Week 1 - Core clinical problems Flashcards by Rachel Gordon

Before starting assisted conception treatment, what lifestyle advice would you give your patient?

Limit alcohol intake to 4 units per week 
Weight -  19-29 BMI 
Stop smoking 
Folic acid - 0.4mg day 
Go for a cervical smear

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What are the indications for Intra-uterine insemination? (IUI)

Couple have sexual problems

Same sex relationships

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What are the indications for In Vitro-Fertilisation? (IVF)

Couple have been trying for >2 years
Pelvic disease
Failed IUI

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Give the overview steps of IVF

Down regulation
Ovarian Stimulation 
Semen retrieval 
Oocyte retrieval 
Fertilisation 
Embryo transfer 
Luteal Support

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What are the indications for Intra-cytoplasmic sperm injection

Severe male factor infertility

Previous failed IVF

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Name 3 potential complications of assisted conception treatment

Over-stimulating the ovaries (leads to lots of yuck symptoms such as N&V)
Multiple pregnancies
Ectopic pregnancy

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What 2 hormones do the male testes secrete?

Testosterone and Mullerian Inhibiting Factor

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Name 2 genital tracts and whether they belong in males or females

Wolffian ducts - males

Mullerian ducts - females

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Medical term for undescended testes?

Cryptorchidism

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Treatment of cryptorchidism?

<14 years - Orchidopexy

Adults - Orchidectomy

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Where does spermatogenesis occur?

Seminiferous tubules

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Where is testosterone produced?

Leydig cells

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Role of Sertoli cells?

Basically - ASSISTS in spermatogenesis:

Form a blood testes barrier - protects the sperm from antibody attack

Provides nutrients for developing cells

Produces seminiferous tubule fluid

Secretes androgen binding globulin - binds to testosterone

Secrete inhibin and activin hormones - they regulate FSH which enhances spermatogenesis

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Causes of Male Infertility

Idiopathic

Obstructive (vasectomy, cystic fibrosis)

Non-obstructive - endocrine (pituitary tumours), infection, Kleinfelder’s syndrome, genetic, anorexia

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How would you go about assessing male infertility?

History, Examination, Semen analysis, Endocrine profile (LH, FSH, TSH etc)

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Would the endocrine profile be abnormal or normal in:

a) obstructive
b) non-obstructive

a) Normal

b) Abnormal (high LH/FSH, low testosterone)

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Name a bacteria that you would EXPECT to find in normal vaginal flora

Lactobacillus spp.

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Symptoms of bacterial vaginosis

Discharge containing bubbles

Fishy odour

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What infections of the vagina are NOT STIs

Bacterial vaginosis and Candida Albicans

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Woman comes in complaining of an intense itch alongside white discharge which looks pussy/cheesy in appearance

Candida Infection (most common form = candida albicans)

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Where in the body can both gonorrhoea and chlamydia affect?

Urethra, rectum, throat, eyes, endocervix

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Symptoms of gonorrhoea

Discharge + Pain on urination

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Symptoms of chlamydia

pain or burning while peeing.
pain during sex.
lower abdo pain
abnormal vaginal discharge (may be yellowish and have a strong smell)
bleeding between periods.
pus or a watery/milky discharge from the penis.
swollen or tender testicles

What does gonorrhoea look like on gram stain?

2 kidney beans (diplococci)

What does chlamydia look like on gram stain?

HA, trick question. | It does not gram stain due to it having no peptidoglycan in its cell wall

How do you diagnose Gonorrhoea and Chlamydia - what tests and what samples in: a) Males b) Females

NAATs PCR a) Males - first pass urine b) Females - high vaginal swab or Vulvo-vaginal swab (can be self taken)

Advantage of using culture as your diagnostic test

Can test antibody sensitivities | Can track antibody resistance

What 2 STIs are MSM most at risk of?

HIV - most common group | Gonorrhoea - MSM are also more likely to have gonorrhoea just isolated to the pharynx or rectum compared to other groups

What is proctitis? And when is it seen?

Inflammation of the lining of the rectum Can occur in gonorrhoea & other STIs - herpes, syphilis, chlamydia It can also occur in non-STI situations such as Crohn's, anal fissures, rectal lacerations, UTIs (esp if elderly)

Patient presents with proctitis, tenesmus and blood, what could this be?

Lymphogranuloma Venereum

At what stage does a chancre appear in syphilis

Primary stage

What happens in the secondary stage of syphilis?

Bacteriuria Snail track mouth ulcers Generalised rash Flu like symptoms

Screening test for syphilis?

Dark ground microscopy - look for spirochetes Enzyme linked immunosorbent assay (ELISA) - IgG & IgM Swab lesions for PCR

Tests to monitor response to syphilis medication?

VDLR | RPR

Transmission of herpes

Genital-Genital | Oropharyngeal-genital

What is herpes caused by?

Herpes simplex virus type 1 & 2

Where does the herpes simplex virus 'hide' from the immune system?

Sacral root ganglion

Diagnosis of Herpes?

PCR

How is trichomonas vaginalis transmitted?

Sexual contact

Symptoms of trichomonas vaginalis: | Males and Females

Females - Vaginal discharge & Irritation | Urethritis in males

Name a few causes for bleeding in early pregnancy

``` Implantation problems Miscarriage Chronic haematoma Ectopic pregnancy Cervical or vaginal causes - infection, malignancy, polyp ```

What substance do you need to administer to the women after a miscarriage?

Anti-D

Give reasons for a women having recurrent miscarriages

Antiphospholipid syndrome Thrombophilia Uterine abnormality Age

By taking what drug, is said to lower the chances of women having a miscarriage?

Progesterone

How do the symptoms of a miscarriage compare to that of an ectopic pregnancy?

Miscarriage - LOTs more bleeding. Pain is cramp like | Ectopic - PAIN > bleeding. Includes heart & lung symptoms such as dizziness, SOB

What investigations do you perform for both miscarriage and ectopic

FBC, G&S, betaHCG, USS

Management of ectopic pregnancy

Medical - if women is stable, low betaHCG . Give Methotrexate

How does a chronic haematoma form?

Due to separation of the embryo from the endometrium and a layer of blood forms in between

End result of a haematoma

Some may be resolve | Others can result in a miscarriage

Organic causes of menorrhagia

Local - polyps, fibroids, malignancy, pelvic inflammatory disease Systemic - Endocrine disorder, Von Willebrand's disease Pregnancy - Miscarriage, Ectopic etc

Non-organic causes of menorrhagia

Dysfunctional uterine bleeding

Investigations of Dysfunctional uterine bleeding

``` FBC Cervical smear TSH, Coagulation screen, Renal/Liver function tests - to rule out any organic causes of menorrhagia Transvaginal ultrasound scan Endometrial sampling - pipelle biopsies ```

Management of DUB (Medical & Surgical)

Medical - Progesterone, COP, GnRH analogues, NSAIDs, Anti-fibrinolytics, Danazol Surgical - Endometrial resection (more minor procedure) or Hysterectomy (more major procedure)

Common causative organisms of BV ?

Anaerobes such as: | Gardnerella

Risk factors of getting candida?

Recent antibiotic therapy High oestrogen levels (e.g. during pregnancy) Poorly controlled diabetes Immunocompromised