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Women's Health Flashcards

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1
Q

What is a vault prolapse?

A
  • Occurs in women who have undergone a hysterectomy
  • Top of vagina (vault) descends into vagina
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2
Q

What is a rectocele?

A
  • Defect in posterior vaginal wall
  • Rectum prolapses forwards into vagina
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3
Q

What is a cystocele?

A
  • Defect in anterior vaginal wall
  • Bladder prolapses backwards into vagina
  • Urethrocele = prolapse of urethra into vagina
  • Cystourethrocele = prolapse of both bladder and urethra into vagina
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4
Q

What is an enterocele?

A

Prolapse of small bowel through Pouch of Douglas into posterior vault of vagina

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5
Q

What are the clinical features of a pelvic organ prolapse?

A
  • Dragging/heavy sensation in pelvis
  • Lump/mass in vagina
  • Feeling of ‘something coming down’ in vagina
  • Sexual dysfunction
  • Urinary symptoms/recurrent UTIs
  • Faecal loading
  • Bowel symptoms
  • Worse on straining/bending down
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6
Q

What is the investigation for a pelvic organ prolapse?

A

Sim’s speculum:
- U-shaped, single-bladed speculum
- Supports anterior/posterior vaginal wall whilst others are examined

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7
Q

What is the management for a pelvic organ prolapse?

A
  • Physiotherapy (pelvic floor exercises)
  • Weight loss
  • Lifestyle changes (reduced caffeine/incontinence pads)
  • Treat symptoms
  • Topical vaginal oestrogen
  • Vaginal pessary (ring/Shelf and Gellhorn/cube/donut/Hodge)
  • Surgery (mesh repairs/hysterectomy)
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8
Q

What are some causes of overflow incontinence?

A
  • Anticholinergic medications
  • Fibroids
  • Pelvic tumours
  • Neurological conditions (MS/diabetic neuropathy/spinal cord injuries)
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9
Q

What are the investigations for urinary incontinence?

A
  • Urinalysis (MSU)
  • Bladder diary
  • Frequency volume chart
  • Residual urine measurement
  • Symptom questionnaire (urinary/vaginal/bowel/sexual)
  • Urinary stress testing (cough/empty supine stress test)
  • In&Out catheter (CISC)
  • USS KUB
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10
Q

What is the management for stress incontinence?

A
  • Pelvic floor exercises
  • Lifestyle changes (reduce caffeine/lose weight)
  • Pseudoephedrine/topical oestrogen
  • Surgery (tension-free vaginal tape/etc.)
  • Duloxetine
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11
Q

What is the management for urge incontinence?

A
  • Bladder training
  • Anticholinergic medications e.g. oxybutynin/solifenacin
  • Beta-3 agonist e.g. mirabegron
  • Botox
  • Topical oestrogen
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12
Q

What is the management for general urinary incontinence?

A
  • Leakage barriers (pads/pants)
  • Vaginal support (pessaries)
  • Barrier creams
  • HRT
  • Lifestyle changes
  • Bladder bypass (catheters - CISC/suprapubic/urethral)
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13
Q

What are risk factors for urinary tract calculi?

A
  • Previous renal stones
  • Calcium based stones = hypercalcaemia/low urine output
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14
Q

Where do renal calculi most commonly get stuck?

A

Vesico-ureteric junction - most distal part of ureter, at the point where it connects to the bladder

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15
Q

What are staghorn calculi?

A
  • Renal stones that form in the shape of the renal pelvis (appearance of deer stag antlers)
  • Most commonly made of struvite
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16
Q

What can renal calculi be made up of?

A
  • Calcium oxalate (most common)
  • Calcium phosphate
  • Uric acid
  • Struvite (associated with UTIs)
  • Cystine
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17
Q

What are the clinical features of renal calculi?

A
  • Asx
  • Renal colic
  • Haematuria
  • N+V
  • Reduced urine output
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18
Q

What are the investigations for renal calculi?

A
  • Urine dipstick (haematuria)
  • Bloods (calcium)
  • Abdominal x-ray (will only show calcium-based stones)
  • CT KUB
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19
Q

What is the management for renal calculi?

A
  • Supportive (NSAIDs/paracetamol/anti-emetics/abx)
  • Watch and wait (if <5mm)
  • Tamsulosin
  • Surgery (ESWL/ureteroscopy and laser lithotripsy/PCBL)
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20
Q

What medications can be used to reduce the risk of renal calculi?

A
  • Potassium citrate
  • Thiazide diuretics
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21
Q

What are risk factors for vaginal fistulas?

A
  • Prolonged/obstructed childbirth
  • Complications from pelvic surgery
  • Cancer/radiation treatment
  • IBD
  • Infection
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22
Q

What are the clinical features of vaginal fistulas?

A
  • Urinary/faecal leakage
  • Abnormal discharge
  • Offensive urine/discharge
  • Recurrent infections
  • Abdominal pain
  • Rectal/vaginal bledding
  • Fever
  • Weight loss
  • N+V
  • Diarrhoea
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23
Q

What are the investigations for vaginal fistulas?

A
  • Pelvic exam
  • Dye test
  • USS/CT/MRI
  • Colonoscopy
  • Cystourethroscopy
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24
Q

What is the management for vaginal fistulas?

A
  • May heal on their own alongside a catheter
  • Surgery
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25
Where do most of the female organs develop from?
Upper third of the vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ductus (Mullerian ducts)
26
What is a bicornate uterus?
- Two 'horns' to uterus - Heart-shaped appearance
27
What is an imperforate hymen and how does it present?
- Hymen at the entrance of vagina is fully formed without an opening - Cyclical pelvic pain and cramping ordinarily associated with menstruation but without any vaginal bleeding
28
What is a transverse vaginal septae and how does it present?
- When the septum forms transversely across the vagina - can be perforate or imperforate - Perforate - will still menstruate but difficulty with intercourse/tampon use - Imperforate - similar presentation to imperforate hymen
29
What is vaginal hypoplasia and agenesis?
- Abnormally small/absent vagina - Failure of Mullerian duct to properly develop - May be associated with absent uterus/cervix - Ovaries usually unaffected
30
What are the investigations for abnormal formations of the female organs?
- Examination - Pelvic USS - MRI
31
What is the management for abnormal formations of the female organs?
- Bicornate uterus = no specific management required - Imperforate hymen = surgical incision to create opening - Transverse vaginal septae = surgical correction - Vaginal hypoplasia and agenesis = vaginal dilator over prolonged period/vaginal surgery
32
What are the complications of a bicornate uterus?
Associated with adverse pregnancy outcomes (miscarriage/premature birth/malpresentation)
33
What is a complication of an imperforate hymen?
Untreated --> retrograde menstruation --> endometriosis
34
What are the complications of transverse vaginal septae?
- Infertility - Pregnancy-related complications - Surgical correction complications (vaginal stenosis/recurrence)
35
What is adenomyosis and what are the risk factors?
- Presence of endometrial tissue inside the myometrium - Older age - Multiparous
36
What are the clinical features of adenomyosis?
- 1/3 asx - Dysmenorrhoea - Menorrhagia - Dyspareunia - Infertility/pregnancy-related complications
37
What are the investigations for adenomyosis?
- Examination = enlarged/'boggy' uterus - Transvaginal USS (first-line) - MRI - Transabdominal USS - Histological examination after hysterectomy (gold standard)
38
What is the management for adenomyosis?
- Symptoms tend to resolve after menopause NICE recommend same treatment as for menorrhagia - Tranexamic acid - Mefenamic acid - Contraception (mirena coil/COC pill)
39
What are the complications of adenomyosis?
Associated with pregnancy difficulties (infertility/miscarriage/P-PROM/PPH/etc.)
40
Describe the pathophysiology of androgen insensitivity syndrome
- X-linked recessive - Genetically male - Mutation in androgen receptor gene - Extra androgens converted into oestrogen
41
What are the clinical features of androgen insensitivity syndrome?
- Female phenotype (external genitalia/breast tissue) - Testes in abdomen/inguinal canal (--> inguinal hernias) - Absence of uterus/upper vagina/cervix/fallopian tubes/ovaries - Lack of pubic/facial hair - Tall - Infertile - Primary amenorrhoea
42
What are the investigations for androgen insensitivity syndrome?
- Raised LH - Normal/raised FSH - Normal/raised testosterone - Raised oestrogen
43
What is the management for androgen insensitivity syndrome?
- Bilateral orchidectomy (increased risk of testicular cancer if not removed) - Oestrogen therapy - Vaginal dilators/vaginal surgery - Patients generally raised as female
44
What is Asherman's syndrome?
Symptomatic adhesions (synechiae) that form within uterus following damage to the uterus
45
What are the risk factors for Asherman's syndrome?
- Usually occurs after pregnancy-related dilatation and curettage procedure - Following uterine surgery - Following severe pelvic infection
46
What are the clinical features of Asherman's syndrome?
- Asx adhesions - not Asherman's - Secondary amenorrhoea - Significantly lighter periods - Dysmenorrhoea - Infertility/recurrent miscarriages
47
What are the investigations for Asherman's syndrome?
- Hysteroscopy (gold standard) - Hysterosalpingography (contrast and x-ray) - Sonohysterography (uterus filled with fluid and pelvic USS) - MRI
48
What is the management for Asherman's syndrome?
- Dissection of adhesions via hysteroscopy
49
What is atrophic vaginitis and who does it occur in?
A.k.a genitourinary syndrome of menopause - dryness and atrophy of vaginal mucosa related to lack of oestrogen affecting perimenopausal/menopausal women
50
What are the clinical features of atrophic vaginitis?
- Perimenopausal/postmenopausal woman - Itching - Dryness - Dyspareunia - Bleeding - Recurrent UTIs/stress incontinence/pelvic organ prolapse
51
What is seen on examination in atrophic vaginitis?
- Pale mucosa - Thin skin - Reduce skin folds - Erythema/inflammation - Dryness - Sparse pubic hair
52
What is the management for atrophic vaginitis?
- Topical oestrogen (estriol cream/pessaries, estradiol tablets/ring) - Vaginal lubricants
53
What is the main cause and type of cervical cancer?
- 80% are squamous cell carcinomas - Most common cause if HPV infection (type 16 and 18)
54
What are the risk factors for cervical cancer?
- Risk factors for HPV infection - Non-engagement with screening - Smoking - HIV - COC >5 years - High parity - Fhx - Exposure to diethylstilbestrol during foetal development
55
What are the clinical feature of cervical cancer?
- Asx - Intermenstrual/post-coital/post-menopausal vaginal bleeding - Vaginal discharge - Pelvic pain - Dyspareunia - Abnormal appearance of cervix (ulceration/inflammation/bleeding/visible tumour)
56
What are the investigations for cervical cancer?
- Cervical smear screening - Cervical intraepithelial neoplasia (CIN) grading - Colposcopy (statins + biopsy) - Staging
57
What does colposcopy involve?
- Speculum examination and colposcope to magnify cervix - Stains (acetic acid/iodine) to differentiate abnormal areas (white/not stain) - Punch biopsy or large loop excision of transformational zone (LLETZ a.k.a loop biopsy)
58
What is the staging for cervical cancer?
- Stage 1 = confined to cervix - Stage 2 = invades uterus/upper 2/3 of vagina - Stage 3 = invades pelvic wall/lower 1/3 of vagina - Stage 4 = invades bladder/rectum/beyond pelvis
59
What is the management for cervical cancer?
- Urgent cancer referral for colposcopy - CIN/early stage = LLETZ/cone biopsy - Stage 1B-2A = hysterectomy + removal of lymph nodes + chemotherapy + radiotherapy - Stage 2B-4A = chemotherapy + radiotherapy - Stage 4B = surgery + chemotherapy + radiotherapy + palliative care - Advanced = pelvic exenteration (removal of most/all of pelvic organs) - Bevacizumab (avastin) - monoclonal antibody to be used in combination with chemotherapy
60
What are preventative measures for cervical cancer?
- Cervical smear screening - HPV vaccination in children 12-13 years (against strands 6/11/16/18)
61
When does cervical cancer screening take place?
- Every 3 years in patients 25-49 - Every 5 years in patients 50-64 - HIV patients screened annually - Patients with previous CIN may require additional tests - Certain groups of immunocompromised patients may have additional screening - Pregnant patients due a routine smear should wait until 12 weeks post-partum
62
What is the method for cervical cancer screening?
- Speculum examination and collection of cells from cervix - Liquid-based cytology - ^ Samples initially tested for high-risk HPV before cells examined
63
Describe the results of cytology in cervical cancer screening
- Inadequate - Normal - Borderline changes - Low-grade dyskaryosis - High-grade dyskaryosis (moderate) - High-grade dyskaryosis (severe) - Possible invasive squamous cell carcinoma - Possible glandular neoplasia
64
What are risk factors for dysfunctional uterine bleeding?
- Hormone abnormalities (thyroid/prolactin) - Medications - Excessive exercise/weight loss - Obesity - Stress/illness - Start of menstruation in adolescence - End of menstruation/perimenopause
65
What are the investigations for dysfunctional uterine bleeding?
- Urine/bloods (pregnancy) - Bloods (thyroid/prolactin/oestrogen/iron) - Transvaginal USS - Endometrial biopsy
66
What is the management for dysfunctional uterine bleeding?
- Contraception - Surgical dilatation and curettage - HRT
67
What is the main type of endometrial cancer?
Adenocarcinomas (~80%)
68
What are risk factors for endometrial cancer?
- T2DM - Hereditary nonpolyposis colorectal cancer - Lynch syndrome - Increased exposure to unopposed oestrogen (increased age/earlier onset of menstruation/late menopause/oestrogen only HRT/no pregnancies/obesity/PCOS/tamoxifen)
69
What are protective factors for endometrial cancer?
- COC pill - Mirena coil - High parity - Cigarette smoking (anti-oestrogenic)
70
What is endometrial hyperplasia?
- Precancerous condition - Thickening of endometrium - <5% of cases become endometrial cancer
71
What type of cancer is endometrial cancer?
Oestrogen-dependent - Unopposed oestrogen (oestrogen without progesterone) stimulates endometrial cells
72
What are the clinical features of endometrial cancer?
- Post-menopausal bleeding (MAIN SYMPTOM) - Post-coital/intermenstrual/unusually heavy bleeding - Abnormal vaginal discharge - Haematuria - Anaemia - Raised platelet count
73
What are the investigations for endometrial cancer?
- 2-week-wait referral for patients with postmenopausal bleeding >12 months after last menstrual period - Transvaginal USS - Pipelle biopsy - Hysteroscopy with endometrial biopsy
74
What is the staging for endometrial cancer?
- Stage 1 = confined to uterus - Stage 2 = invades cervix - Stage 3 = invades ovaries/fallopian tubes/vagina/lymph nodes - Stage 4 = invades bladder/rectum/beyond pelvis
75
What is the management for endometrial cancer?
- Hysterectomy - Bilateral salpingo-oophorectomy (BSO - removal of uterus/cervix/adnexa) - Chemotherapy - Radiotherapy - Progesterone - Progestogens (Mirena coil/medroxyprogesterone/levonorgestre/COC pill/cyclical progestogensl)
76
What are polyps?
Overgrowth of cells in the endometrium (endometrial), cervix (cervical), etc.
77
What is the main risk factor for polyps?
Hysterectomy
78
What are the clinical features of endometrial polyps?
- Metrorrhagia (irregular, acyclic, uterine bleeding) - Post-menstrual spotting - Menorrhagia - Post-menopausal bleeding - Breakthrough bleeding during hormonal therapy - Post-coital bleeding - Excessive/discoloured/offensive discharge
79
What are the investigations for polyps?
- USS - Sonohysterography
80
What is the management for polyps?
- Removal (curettage) if symptomatic/post-menopausal/fertility issues
81
What is endometriosis?
Condition in which there is ectopic endometrial tissue outside the uterus
82
What are the clinical features of endometriosis?
- Asx - Cyclical, dull, heavy/burning pelvis pain during menstruation - Blood in urine/stool - Urinary/bowel symptoms - Dyspareunia - Dysmenorrhoea - Adhesions - Infertility
83
What are the investigations for endometriosis?
- Laparoscopic surgery + biopsy/histology (gold standard) - Examination (endometrial tissue visible in vagina/fixed cervix/tenderness)
84
What is the staging for endometriosis?
- Stage 1 = small, superficial lesions - Stage 2 = mild, deep lesions - Stage 3 = deeper lesions, on ovaries with mild adhesions - Stage 4 = large, deep lesions affecting ovaries with extensive adhesions
85
What is the management for endometriosis?
- Analgesia - COC pill/POP/medroxyprogesterone acetate injection/Mirena coil/Nexplanon implant/GnRH agonists - Laparoscopic surgery to excise/ablate endometrial tissue and remove adhesions - Hysterectomy
86
What are fibroids and who are they more common in?
A.k.a uterine leiomyomas - benign tumours of smooth muscle of uterus - Very common - More common in black women
87
What are the types of fibroids?
Are oestrogen sensitive - Intramural (within myometrium) - Subserosal (below outer layer of uterus) - Submucosal (below endometrium) - Pedunculated (on stalk)
88
What are the clinical features of fibroids?
- Asx - Menorrhagia - Prolonged menstruation - Abdominal pain worse during menstruation - Bloating - Urinary/bowel symptoms - Deep dyspareunia - Reduced fertility
89
What are the investigations for fibroids?
- Abdominal and bimanual examination = palpable pelvic mass/enlarged, firm, non-tender uterus - Hysteroscopy - Pelvic USS - MRI
90
What is the management for fibroids <3cm?
- Mirena coil (1st line) - NSAIDs and tranexamic acid - COC pill - Cyclical oral progestogens - Surgery (endometrial ablation/resection of submucosal fibroids during hysteroscopy/hysterectomy) - GnRH agonists (goserelin/leuprorelin) - used to reduce size of fibroids before surgery
91
What is the management for fibroids >3cm?
- Refer to gynaecology - NSAIDs and tranexamic acid - Mirena coil - COC pill - Cyclical oral progestogens - Surgery (uterine artery embolisation/myomectomy/hysterectomy) - GnRH agonists (goserelin/leuprorelin) - used to reduce size of fibroids before surgery
92
What are complications of fibroids?
- Menorrhagia with iron deficiency anaemia - Reduced fertility - Pregnancy complications - Constipation - Urinary outflow obstruction/UTIs - Torsion - Malignant change - Red degeneration of fibroid (ischaemia/infarction/necrosis of fibroid)
93
What is a hydatidiform mole/molar pregnancy and who is it more common in?
Type of tumour that grows like a pregnancy inside the uterus - Older age - Asian - Previous molar pregnancy
94
Describe the pathophysiology of molar pregnancies
- Complete mole = 2 sperm cells fertilise empty ovum which develops into tumour with no foetal material - Partial mole = 2 sperm cells fertilise normal ovum simultaneously which develops into tumour with some foetal material
95
What are the clinical features of a molar pregnancy?
- Normal pregnancy changes (periods stop/hormonal changes) - Severe morning sickness - Vaginal bleeding - Increased enlargement of uterus - Abnormally high hCG - Thyrotoxicosis (hCG mimics TSH and stimulates excess T3/T4 production)
96
What are the investigations for molar pregnancies?
- Pelvic USS = 'snowstorm' appearance - Histology of mole after evacuation
97
What is the management for molar pregnancies?
- Evacuation of uterus to remove mole - Histology examination to confirm - hCG levels monitored - Chemotherapy if metastsis
98
What is lichen sclerosus?
Chronic inflammatory skin condition (autoimmune) that presents with patches of shiny, 'porcelain-white' skin typically affecting labia/perineum/perianal skin or foreskin/glans penis
99
What are the clinical features of lichen sclerosus?
Typical presentation = woman aged 45-60 complaining of vulvar itching and skin changes in vulva - Asx - Itchy/sore/painful - Skin tightness - Superficial dyspareunia - Erosions/fissures - Koebner phenomenon (exacerbated by friction to skin e.g. tight underwear/scratching) - Skin changes ('porcelain-white'/shiny/tight/thin/raised/papules/plaques)
100
What are the investigations for lichen sclerosus?
- Clinical diagnosis - Vulval biopsy
101
What is the management for lichen sclerosus?
- Symptom management - Potent topical steroids (clobetasol propionate 0.05%) - Emollients
102
What are the complications of lichen sclerosus?
- Squamous cell carcinoma of vulva - Pain/discomfort - Sexual dysfunction - Bleeding - Narrowing of vaginal/urethral openings
103
What is the difference between menopause, postmenopause, perimenopause and premature menopause?
Menopause - the point at which menstruation permanently stops Postmenopause - the period from 12 months after the final menstrual period onwards Perimenopause - the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Includes the time leading up to the last menstrual period, and the 12 months afterwards Premature menopause - menopause before the age of 40 years
104
What is the average age of menopause?
51
105
What are the clinical features of menopause?
Perimenopause: - Hot flushes - Emotional lability - PMS - Irregular periods - Joint pain - Heavier/lighter periods - Vaginal dryness/atrophy - Reduced libido
106
What are the investigations for menopause?
- Retrospective diagnosis (no periods for 12 months) - FSH blood test - Low oestrogen and progesterone, high FSH and LH
107
What is the management for menopause?
- Contraception - HRT - CBT - SRRIs - Testosterone - Vaginal oestrogen/moisturisers
108
What are the complications of menopause?
Lack of oestrogen poses an increased risk of: - CVD/stroke - Osteoporosis - Pelvic organ prolapse - Urinary incontinence
109
What are risk factors for ovarian cancer?
- Age (peak = 60) - BRCA1/BRCA2 gene/fhx - Increased no. of ovulation (early onset menstruation/late menopause/no pregnancies) - Obesity - Smoking - Recurrent use of clomifene
110
What are protective factors for ovarian cancer?
- COC pill - Breastfeeding - Pregnancy
111
What are Krukenberg tumours?
Tumours, usually from GI tract cancer, that metastasis in ovary - have characteristic 'signet-ring' cells on histology
112
What is the most common type of ovarian cancer?
Epithelial cell tumours (serous tumours)
113
What are the clinical features of ovarian cancer?
- Late presentation due to non-specific symptoms - Bloating - Loss of appetite/early satiety - Pelvic pain - Urinary sx - Weight loss - Abdominal/pelvic mass - Ascites - Referred hip/groin pain (press on obturator nerve)
114
What are the investigations for ovarian cancer?
- 2-week-wait referral if ascites/pelvic mass/abdominal mass - Pelvic USS - CA125 (tumour marker >35 = significant - not very specific) - Risk of malignancy index (RMI) - menopausal status/USS findings/CA125 - CT - Histology - Paracentesis (ascitic tap) - Tumour markers (alpha-fetoprotein, human chorionic gonadotrophin)
115
What is the staging for ovarian cancer?
- Stage 1 = confined to ovary - Stage 2 = spread past ovary but inside pelvis - Stage 3 = spread past pelvis but inside abdomen - Stage 4 = spread outside abdomen
116
What is the management for ovarian cancer?
- Surgery - Chemotherapy - Worse prognosis due to late presentation
117
What are risk actors for ovarian cysts?
- Age - Postmenopause - Increased no. of ovulations (early onset menstruation/late menopause/no pregnancies) - Obesity - HRT - Smoking - BRCA1/BRCA2 gene (fhx)
118
What are protective factors for ovarian cysts?
- Breastfeeding - COC pill
119
What are the types of ovarian cysts?
- Functional ovarian - Follicular (most common) - Corpus luteum - Serous cystadenoma - Mucinous cystadenoma - Endometrioma - Dermoid - Sex cord stromal tumour
120
What are the clinical features of ovarian cysts?
- Asx - Pelvic discomfort/pain/delayed menstruation (corpus luteum cysts) - Acute pelvic pain (torsion/haemorrhage/rupture) - Signs of malignancy (pelvic pain/bloating/ascites/palpable mass/reduced appetite/weight loss/urinary symptoms/lymphadenopathy)
121
What are the investigations for ovarian cysts?
- Pelvic USS - Tumour markers (CA125/lactate dehydrogenase/alpha fetoprotein/human chorionic gonadotrophin) - Risk of malignancy index (RMI)
122
What is the management for ovarian cysts?
- 2-week-wait referral if complex cysts/raised CA125 - <5cm = usually resolve on their own - 5-7cm = gynae referral and yearly USS monitoring - >7cm = MRI/surgical evaluation (ovarian cystectomy +/- oophorectomy)
123
What are the complications of ovarian cysts?
- Torsion - Haemorrhage - Rupture - Meig's syndrome (ovarian fibroma + pleural effusion + ascites)
124
What are the clinical features of ovarian torsion?
- Sudden onset, constant, severe, unilateral pelvic pain - N+V - Localised tenderness - Palpable mass - Intermittent pain (if ovary twists and untwists)
125
What are the investigations for ovarian torsion?
- Abdominal examination (localised tenderness/palpable mass) - Transvaginal/pelvic USS ('whirlpool' sign/free fluid in pelvis/oedema of ovary) - Doppler studies = lack of blood flow - Laparoscopic surgery
126
What is the management for ovarian torsion?
Medical emergency - Laparoscopic detorsion/oophorectomy
127
What are the complications of ovarian torsion?
- Delayed treatment --> loss of function --> infertility/menopause (if other can't compensate) - Infection --> abscess --> sepsis - Rupture --> peritonitis --> adhesions
128
What are the main causes of pelvic inflammatory disease (PID)?
- STIs - gonorrhoea/chlamydia/mycoplasma genitalium - Non-STIs (less common) - gardnerella vaginalis/haemophilus influenza/e coli
129
What are the risk factors for PID?
- Lack of barrier contraception - Multiple sexual partners - Younger age - Existing STI - Previous PID - IUD
130
What are the clinical features of PID?
- Pelvic/lower abdominal pain - Abnormal vaginal discharge - Abnormal bleeding (intermenstrual/postcoital) - Dyspareunia - Fever - Dsyuria - Fever/signs of sepsis
131
What are the investigations for PID?
- Examination (pelvic tenderness/cervicitis/purulent discharge) - NAAT swabs/HIV test/syphilis test/high vaginal swab + microscopy (PUS CELLS) - Pregnancy test - Raised CRP/ESR
132
What is the management for PID?
- Contact tracing - Abx (dependent on causative organism) - IM ceftriaxone 1g/doxycycline 100mg/metronidazole 400mg
133
What are the complications of PID?
- Infertility - Chronic pelvic pain - Abscess/sepsis - Ectopic pregnancy - Fitz-Hugh-Curtis syndrome (adhesions between liver and peritoneum)
134
What are risk factors for PCOS?
- Obesity - T2DM - Hypercholesterolaemia - CVD
135
What are the clinical features of PCOS?
- Multiple ovarian cysts - Infertility - Oligomenorrhoea/amenorrhoea - Hyperandrogenism (hirsutism/acne) - Insulin resistance - Acanthosis nigricans (thickened/rough/dark skin with velvety texture)
136
What criteria is used to diagnose PCOS?
Rotterdam criteria - requires at least 2 our of 3 key features: - Oligoovulation/anovulation (presents with irregular/absent menstrual periods) - Hyperandrogenism (hirstusim/acne) - Polycystic ovaries on USS (or ovarian volume >10cm3)
137
What are investigations for PCOS?
Bloods: - Raised testosterone - Sex hormone-binding globulin - Raised LH - FSH - Mildly elevated prolactin - TSH - Raised insulin - Normal/raised oestrogen Transvaginal/pelvic USS: - 'String of pearls' appearance - 12 or more developing follicles in one ovary - Ovarian volume >10cm 2-hour 75g oral glucose tolerance test (diabetes screening)
138
What is the management for PCOS?
Symptom management: - Obesity/T2DM/CVD risks = exercise/diet/weight loss/smoking cessation/statins - Infertility = weight loss/clomifene/laparoscopic ovarian drilling/IVF - Hirsutism = weight loss/hair removal/co-cyprindiol (COC pill)/topical eflornithine/electrolysis/lase hair removal/spironolactone/finasteride/flutamide/cyproterone acetate - Acne = co-cyprindiol (COC pill)/topic adapalene/topic abx (clindamycin + benzoyl peroxide)/topical azelaic acid/oral tetracycline abx (lymecycline) - Increased risk of endometrial hyperplasia/cancer = mirena coil/withdrawal bleeds (cyclical progestogens/COC pill)
139
What is a prolactinoma and who is it more common in?
Tumour of the pituitary gland that secretes excessive prolactin - More common in women - Associated with multiple endocrine neoplasia (MEN) type 1
140
Where is prolactin produced and what does it do?
- Anterior pituitary gland/breast/prostate - Breast milk produced in response to prolactin - Regulates aspects of immune function and metabolism
141
How are prolactinomas defined?
- Microprolactinoma <10mm - Macroprolactinoma >10mm
142
What are the clinical features of prolactinomas?
- Headaches - Bitemporal hemianopia - N+V - Galactorrhoea - Breast tenderness - Decreased libido - Infertility - Menstruation stops - Gynaecomastia - Impotence
143
What are the investigations for prolactinomas?
- CT/MRI pituitary/brain - Testosterone levels - Prolactin levels - TFTs
144
What is the main differential diagnosis for prolactinomas?
Pseudoprolactinoma - underactive thyroid mimics prolactinoma
145
What is the management for prolactinomas?
- Dopamine agonists (bromocriptine/cabergoline) - Transphenoidal surgery - Radiation
146
What is the average age of menarche?
10-16 (average = 12)
147
What is precious puberty?
Puberty before the age of 8 (girls) and 9 (boys)
148
What are risk factors for delayed puberty?
- Low birth weight - Chronic disease - Eating disorders - Athletes
149
What are the clinical features of puberty?
Girls: - Development of breast buds - Development of pubic hair - Menarche Boys: - Increase in testicular volume (gonadarche) - Development of pubic hair - Increase in penis length
150
What is used to stage puberty?
Tanner staging I-IV
151
What is the most common type of vulval cancer?
- Rare - ~90% are squamous cell carcinomas
152
What are the risk factors for vulval cancer?
- Advanced age (>75) - Immunosuppression - HPV infection - Lichen sclerosus - Vulvar intraepithelial neoplasia (VIN)
153
What is vulvar intraepithelial neoplasia (VIN)?
Precancerous condition affecting squamous epithelial of skin
154
What are the clinical features of vulval cancer?
- Vulvar lump - Ulceration/pain/bleeding - Itching - Lymphadenopathy in groin - Irregular mass - Fungating lesions
155
What are the clinical features of vulval cancer?
- Incidental on catheterisation - Biopsy - Sentinel node biopsy - CT
156
What is the management for vulval cancer?
- 2-week-wait referral - Wide local excision - Groin lymph node dissection - Chemotherapy - Radiotherapy - VIN = imiquimod cream/laser ablation
157
What is the most common cause of bacterial vaginosis?
Gardnerella vaginalis
158
What are the risk factors for bacterial vaginosis?
- Multiple sexual partners - Excessive vaginal cleaning - Recent abx use - Smoking - Copper coil
159
Describe the pathophysiology of bacterial vaginosis
- Loss of lactobacilli (friendly bacteria) in vagina - Keep vaginal pH low (<4.5) - Alkaline environment enables anaerobic bacterial growth
160
What are the clinical features of bacterial vaginosis?
- Asx - Fishy-smelling, watery, grey/white vaginal discharge
161
What are the investigations for bacterial vaginosis?
- Speculum examination - Vaginal pH (normal = 3.5-4.5) - Charcoal vaginal swab + microscopy = 'clue cells' (epithelial cells from cervix that have bacteria stuck inside them)
162
What is the management for bacterial vaginosis?
- May resolve without treatment - Abx = metronidazole/clindamycin
163
What are the complications of bacterial vaginosis?
- Increased risk of developing STIs - Pregnancy complications
164
What is balanitis and who is it more common in?
- Inflammation of glans penis - More common in uncircumcised men
165
What are the causes of balanitis?
- Intertrigo (inflammation due to rubbing of skin against each other) - Infection (candida/staph/group B strep/anaerobes/gardnerella vaginalis/trichomonas) - Irritation/contact dermatitis (wet nappy/poor hygiene/soap/condoms)
166
What are the risk factors for balanitis?
- Uncircumcised - Diabetes mellitus - Abx use - Poor hygiene - Immunosuppression - Chemical/physical irritation
167
What are the clinical features of balanitis?
- Sore, inflamed, swollen glans/foreskin - Non-retractile foreskin (phimosis) - Ulceration/plaques/lesions - Purulent discharge - Dysuria - Impotence/dyspareunia
168
What are the investigations for balanitis?
- Blood/urine test - Swab + microscopy
169
What is the management for balanitis?
- Encourage daily cleaning with lukewarm water and gentle drying (avoid irritants) - Topical hydrocortisone 1% (dermatitis) - Imidazole cream/clotrimazole 1% cream/miconazole 2% cream/oral fluconazole 150mg (candida) - Oral flucloxacillin/clarithromycin (bacteria)
170
What is chancroid?
STI caused by gram -ve bacterium Haemophilus ducreyi
171
What are the clinical features of chancroid?
- May be asx - Painful genital ulcers on foreskin/glans/corona/labia/vaginal entrance/cervix/perineum/perianal area - Painful inguinal lymphadenopathy - Dysuria - Vaginal discharge - Dyspareunia
172
What are the investigations for chancroid?
- Microscopy/PCR/serology
173
What is the management for chancroid?
- Abx (azithromycin/ciprofloxacin/ceftriaxone/erythromycin) - Drain buboes by aspiration - Avoid sex until lesions completely healed
174
What is the main complication of chancroid?
Increases risk of HIV
175
What is the cause of chlamydia?
Gram -ve bacteria chlamydia trachomatis
176
What are the clinical features of chlamydia?
- 70% (women) and 50% (men) are asx - Abnormal discharge - Dysuria - Testicular pain - Dyspareunia - Abnormal vaginal bleeding - Epididymo-orchitis - Reactive arthritis - Anorectal discharge/bleeding/discomfort - Change in bowel habit
177
What are the investigations for chlamydia?
- Charcoal swab - NAAT swab
178
What is the management for chlamydia?
- Avoid sex until treatment finished - Contact tracing - National chlamydia screening programme (everyone <25) - Uncomplicated = doxycycline 100mg BD for 7 days - Alternatives (pregnancy/breastfeeding) = azithromycin/erythromycin/amoxicillin
179
What causes genital herpes?
Herpes simplex virus - HSV-1 strain = most associated with cold sores - Trigeminal nerve ganglion = cold sores - Sacral nerve ganglia = genital herpes
180
What are the clinical features of genital herpes?
- Asx - Aphthous ulcers - Ulcers/blistering lesions - Herpes keratitis (inflammation of cornea) Herpetic whitlow (painful lesions on fingers) - Neuropathic pain - Flu-like sx - Dysuria - Inguinal lymphadenopathy
181
What is the investigation for genital herpes?
Viral PCR swab
182
What is the management for genital herpes?
- Aciclovir - Valaciclovir/famciclovir - Paracetamol - Topical lidocaine 2% gel - Clean with warm salt water - Topical vaseline - Avoid sex whilst having symptoms - Contact tracing
183
What is the management for genital herpes in pregnancy?
Contracted before 28 weeks: - Aciclovir and regular prophylactic aciclovir from 36 weeks - Vaginal delivery (asx)/c-section (sx) Contracted after 28 weeks: - Aciclovir and immediate regular prophylactic aciclovir - C-section
184
What is the main complication of genital herpes in pregnancy?
Neonatal herpes simplex infection (contracted during labour/delivery - high morbidity/mortality)
185
What are the main causes of genital warts?
Human papilloma virus (HPV) - HPV6 and HPV11 most common
186
What are the clinical features of genital warts?
- Most are asx - Warts on penis/scrotum/vulva/vagina/cervix/perianal skin/anus - Painless, fleshy lesions that can be soft or hard - Extra-genital lesions (oral cavity/larynx/conjunctivae/nasal cavity)
187
What are the investigations for genital warts?
- Examination - Colposcope - Proctoscopy - Speculum examination - Biopsy (if atypical lesions/suspected intraepithelial neoplastic lesions)
188
What is the management for genital warts?
- Most resolve spontaneously - Topical podophyllotoxin/imiquimod/catephen/trichloroacetic acid - Physical ablation (excision/cryotherapy/electrosurgery/laser surgery) - Vaccination (12-13)
189
What is the cause of gonorrhoea?
Gram -ve diplococcus bacteria neisseria gonorrhoea
190
What are the clinical features of gonorrhoea?
- 50% (women) and 10% (men) asx - Odourless purulent discharge - Dysuria - Pelvic/anal/rectal pain - Epididymo-orchitis - Urinary sx - Prostate tenderness - Erythema
191
What are the investigations for gonorrhoea?
- Charcoal swab - NAAT swab
192
What is the management for gonorrhoea?
- Avoid sex until treatment finished - Contact tracing - Uncomplicated = single dose of IM ceftriaxone 1g or single dose of oral ciprofloxacin 500mg - Pregnancy/breastfeeding = single dose of IM ceftriaxone 1g or single dose of oral cefixime 400mg - High level of abx resistance = test of cure (72 hours, 7 days, 14 days after)
193
What are complications of gonorrhoea?
- Gonococcal conjunctivitis in neonate - Disseminated gonococcal infection - Fitz-Hugh-Curtis syndrome
194
Describe the epidemiology and pathophysiology of HIV
- HIV-1 most common (HIV-2 rare outside West Africa) - RNA retrovirus that enters and destroys CD4 T helper cells
195
What are AIDS-defining illnesses?
End-stage HIV infection where CD4 count has dropped so low that unusual opportunistic infection/malignancies can appear: - Kaposi's sarcoma - PCP - CMV infection - TB
196
What are the investigations for HIV?
- Antibody blood test - P24 antigen test - PCR testing for HIV RNA levels
197
How is HIV monitored?
- CD4 count (normal = 500-1200) - Viral load (undetectable < 50-100)
198
What is the management for HIV?
- Antiretroviral therapy - High active anti-retrovirus therapy (protease inhibitors/integrase inhibitors/nucleoside reverse transcriptase inhibitors/non-nucleoside reverse transcriptase inhibitors/entry inhibitors) - Prophylactic co-trimoxazole - Yearly cervical smears - Up to date vaccines - Statins
199
What are the complications of HIV?
- Increased risk of developing CVD - Predisposed to HPV infection and cervical cancer
200
What is lymphogranuloma venereum?
STI caused by specific strain of chlamydia trachomatis bacteria
201
What are the clinical features of lymphogranuloma venereum?
- Most asx - Lymphadenopathy - Ulcer/sore on penis/vagina/anus - Blood/pus from anus - Pain on defecation/anal sex - Constipation/painful straining/diarrhoea
202
What are the investigations for lymphogranuloma venereum?
- NAAT swab - Urine
203
What is the management for lymphogranuloma venereum?
- Avoid sex until treated - Contact tracing - Abx = doxycycline/erythromycin - Surgical management for fistulas/strictures
204
What are pubic lice also known as?
Pthirius pubis
205
What are the clinical features of pubic lice?
- Itching in genital region/pubic hair - Red/blue dots on skin (bites) - White/yellow dots in hair (eggs) - Dark red/brown spots in underwear (poo) - Crusted/sticky eyelashes
206
What is the management for pubic lice?
- Avoid sex until treatment finished - Contact tracing - Medicated creams/shampoos (aqueous malathion 0.5% liquid/permethrin 5% dermal cream) - Wash clothes/bedding - Vacuum mattress
207
What is the cause of syphilis?
Treponema pallidum - spiral-shaped bacteria
208
What are the clinical features of syphilis?
Primary: - Painless ulcer (chancre) - resolves over 3-8 weeks - Local lymphadenopathy Secondary: - Maculopapular rash - Condylomata lata (grey, wart-like lesions) - Fever/lymphadenopathy - Oral lesions - Resolve after 3-12 weeks Tertiary: - Affects organs - Gummas (granulomatous lesions) - Aortic aneurysms - Neurosyphilis (headache/altered behaviour/paralysis/impairment/etc.)
209
What are the investigations for syphilis?
- Antibody testing (T. pallidum) - Dark field microscopy - PCR - Rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)
210
What is the management for syphilis?
- Avoid sex until treatment finished - Contact tracing - Single IM dose of benzathine benzylpenicillin - Alternatives = ceftriaxone/amoxicillin/doxycycline
211
What is thrush?
Vaginal candidiasis - vaginal infection with yeast (candida albicans most common)
212
What are the risk factors for thrush?
- Increased oestrogen - Poorly controlled diabetes - Immunosuppression - Broad-spec abx
213
What are the clinical features of thrush?
- Thick, white discharge - Vulval/vaginal itching/irritation/discomfort - Erythema - Fissures - Dyspareunia/dysuria
214
What are the investigations for thrush?
- Vaginal pH <4.5 (normal) - Charcoal swab with microscopy
215
What is the management for thrush?
Antifungal medication: - Single dose of intravaginal clotrimazole cream (5g of 10%) at night - Single dose of clotrimazole pessary (500mg) at night - 3 doses of clotrimazole pessaries (200mg) over 3 nights - Single dose of fluconazole (15mg)
216
What is trichomonas vaginalis?
Protozoan spread through sexual activity
217
What are the clinical features of trichomoniasis?
- Asx - Frothy, yellow-green, fishy discharge - Itching - Dysuria/dyspareunia - Balanitis
218
What are the investigations for trichomoniasis?
- 'Strawberry cervix' - Vaginal pH >4.5 - Charcoal swab with microscopy
219
What is the management for trichomoniasis?
- Avoid sex until treatment complete - Contact tracing - Oral metronidazole 400-500mg BD for 5-7 days - Single dose of oral metronidazole 2g (not suitable for pregnancy/breastfeeding)
220
What are the complications of trichomoniasis?
Increased risk of: - Contracting HIV (damages vaginal mucosa) - BV - Cervical cancer - PID - Pregnancy-related complications
221
What are common causes of breast abscesses?
- Staph aureus (most common) - Strep bacteria - Enterococcal bacteria - Anaerobic bacteria - Obstruction in ducts/accumulation of milk
222
What are the risk factors for breast abscesses?
- Smoking - Damage to nipple (eczema/candidal infection/piercings) - Underlying breast disease
223
What are the clinical features of breast abscesses/mastitis?
- Swollen, fluctuant, tender lump within breast - Nipple changes - Purulent nipple discharge - Localised pain - Tenderness/warmth/erythea - Hardening of skin/breast tissue - Swelling
224
What is the management for breast abscesses?
- Abx - USS - Drainage (needle aspiration/surgical incision and drainage) - Continue breastfeeding and regularly express breast milk
225
What is the management for lactational mastitis?
- Abx - Continue breastfeeding/expressing milk - Breast massage - Heat packs/warm showers/analgesia
226
What is the management for non-lactational mastitis?
- Abx - Analgesia
227
What antibiotics are used for breast abscesses/mastitis?
- Penicillins e.g. flucloxacillin = effective against gram +ve bacteria (staph aureus/strep/enterococcal) - Broad-spec e.g. co-amoxiclav, erythromycin/clarithromycin + metronidazole = against anaerobic
228
What are the complications of breast abscesses/mastitis?
Candidal infection of nipple: - Treat with topical miconazole 2% to nipple after each breastfeed - Oral miconazole gel/nystatin for baby
229
What are common causes of benign breast lumps?
- Fat necrosis triggered by localised trauma/radiotherapy/surgery - Galactocele (lactation after stopping breastfeeding - lactiferous duct blocked)
230
What are fibroadenomas?
- Common benign tumours of stromal/epithelial breast duct tissue - Respond to oestrogen and progesterone
231
What are fibrocystic breast changes?
- Generalised lumpiness to breast - Considered variation of normal - Connective tissue (stroma), ducts and lobules of breast respond to oestrogen and progesterone - Become fibrous and cystic - These changes fluctuate with menstrual cycle - Benign, non-cancerous condition
232
What is a lipoma?
Benign tumour of adipose tissue
233
What are Phyllodes tumours?
- Rare tumours of connective tissue (stroma) of breast - Large and fast-growing - Can be benign/borderline/malignant
234
What are the clinical features of fibroadenomas?
- Small (up to3 cm) and mobile - Painless - Smooth/round/well circumscribed - Firm
235
What are the clinical features of fibrocystic breast changes?
- Symptoms occur prior to menstruation and resolve once menstruation begins - Lumpiness - Mastalgia - Fluctuation of breast size
236
What are the clinical features of breast cysts?
- Smooth/well circumscribed - Mobile - May be painful - Possibly fluctuant
237
What are the clinical features of fat necrosis?
- Painless - Firm/irregular/fixed in local structures - Skin dimpling/nipple inversion
238
What are the clinical features of lipomas?
- Soft - Painless - Mobile
239
What are the clinical features of galactoceles?
Firm, mobile, painless lump usually beneath areola
240
What is the management for benign breast lumps?
Triple assessment: - Clinical assessment (history/examination) - Imaging (USS/mammography) - Histology (fine needle aspiration/core biopsy)
241
What is the management for fibrocystic breast changes?
Symptom management - mastalgia: - Supportive bra - NSAIDs - Avoid caffeine - Apply heat to area - Hormone treatment e.g. danazol, tamoxifen
242
What is the management for breast cysts?
Aspiration
243
What is the management for fat necrosis?
- Conservative management - may resolve spontaneously - Surgical excision
244
What is the management for lipomas?
- Conservative management - Surgical removal
245
What is the management for galactoceles?
- Usually resolve spontaneously - Drainage with needles - Abx (if infected)
246
What is the management for Phyllodes tumours?
- Surgical removal of tumour and surrounding tissue (wide excision) - Chemotherapy
247
Describe the epidemiology of Paget's Disease of the Nipple
Majority of patients also have underlying neoplasm
248
What are the clinical features of Paget's Disease of the Nipple?
- Roughening/scaling, ulcerating, eczematous change to nipple - Itching/inflammation - Flaky skin around nipple - Pain - Flattened nipple with/without yellow/bloody discharge
249
What are the investigations for Paget's Disease of the Nipple?
- Biopsy - Mammogram/USS/MRI
250
What is the main differential for Paget's Disease of the Nipple?
Eczema: - Paget's = nipple always affected and sometime areola - Eczema = areola nearly always affected and nipple usually spared
251
What is the management for Paget's Disease of the Nipple?
- Surgical removal of nipple and areola - Radiotherapy
252
What are intraductal papillomas?
Benign tumours that grow within one of the ducts in the breast as a result of proliferation of epithelial cells
253
What are the clinical features of intraductal papillomas?
- Often asx - Clear/blood-stained nipple discharge - Tenderness/pain - Palpable lump
254
What are the investigations for intraductal papillomas?
Triple assessment
255
What is the management for intraductal papillomas?
Complete surgical excision and tissue examined for atypical hyperplasia/cancer
256
What is ductal ectasia, who does it most commonly occur in and what is a risk factor?
- Dilation of large ducts in breasts - Perimenopausal women - Smoking
257
What are the clinical features of ductal ectasia?
- White/grey/green nipple discharge - Tenderness/pain - Nipple retraction/inversion - Breast lump
258
What are the investigations for ductal ectasia?
- Triple assessment - Ductography (contrast injected + mammogram) - Nipple discharge cytology - Ductoscopy
259
What is the management for ductal ectasia?
- May resolve spontaneously - Symptomatic management (supportive bra/warm compress) - Abx - Surgical excision of affected duct (microdochectomy)
260
What are the most common forms of invasive breast cancer?
- Invasive ductal carcinoma (80%) - Invasive lobular carcinoma (10%)
261
What are the risk factors for breast cancer?
- Female - Increased oestrogen exposure - Fhx/genetics (BRCA1/BRCA2) - More dense breast tissue - Obesity - Smoking/alcohol - HRT/COC
262
What is a ductal carcinoma in situ (DCIS)?
- Pre-cancerous/cancerous epithelial cells of breast ducts - Localised to single area (may spread locally) - Can become invasive breast cancer
263
What is lobular carcinoma in situ?
Pre-cancerous condition typically occurring in pre-menopausal women
264
What are the clinical features of breast cancer?
- Hard/irregular/painless lumps that are fixed in place - Lumps that are tethered to skin/chest wall - Skin dimpling/oedema (peau d'orange) - Lymphadenopathy (particularly axilla) - Nipple discharge/retraction
265
What is the pathway for investigations for breast cancer?
Two week wait referral if: - Unexplained breast lump in patients >= 30 - Unilateral nipple changes in patients >= 50 - Unexplained lump in axilla in patients >= 30 - Skin changes suggestive of breast cancer
266
What is breast cancer screening?
- Ages 50-70 - Dual view mammogram every 3 years - If higher risk = secondary care breast clinic/specialist genetic clinic/genetic counselling/pre-test counselling/annual mammograms
267
What are the investigations for breast cancer?
Triple assessment: - Clinical assessment (history/examination) - Imaging (USS - younger women (<30)/mammography - older women/MRI/USS of axilla) - Histology (fine needle aspiration/core biopsy = look for oestrogen receptors/progesterone receptors/human epidermal growth factor (receptors that can be targeted)/USS-guided biopsy of abnormal nodes/sentinel lymph node biopsy)
268
What is a sentinel lymph node biopsy?
- Performed during breast surgery - Isotope contrast and blue dye injected in tumour area - Contrast and dye travel through lymphatics to first lymph nodes (sentinel node) - First node in drainage of tumour area shows up blue and on isotope scanner - Biopsy performed on node and if cancer cells found, lymph nodes removed
269
What is triple negative breast cancer?
Breast cancer where the cells do not express any of the common receptors (oestrogen/progesterone/human epidermal growth factor) - carries a worse prognosis and limits treatment options
270
What is gene expression profiling?
- Assessing which genes are present within breast cancer on histology sample - Helps to predict the probability that breast cancer will reoccur as distal metastasis and whether to give additional chemotherapy - Recommended for women with early breast cancers that are ER positive but HER2 and lymph node negative
271
What is used to stage breast cancer?
- Triple assessment - Lymph node assessment/biopsy - MRI breast/axilla - USS liver - CT thorax/abdomen/pelvis - Isotope bone scan - TNM staging
272
What are the surgery options for breast cancer?
- Breast-conserving surgery (usually coupled with radiotherapy) - Mastectomy (potentially with immediate/delayed breast reconstruction) - Removal of axillary lymph nodes (risk of lymphoedema)
273
What can be done to manage complications of axillary lymph node removal?
- Massage techniques to drain lymphatic system - Compression bandages - Specific lymphoedema exercises to improve drainage - Weight loss
274
What are the chemotherapy options for breast cancer?
- Neoadjuvant therapy (shrink tumour before surgery) - Adjuvant therapy (given after surgery to reduce recurrence) - Treatment of metastatic/recurrent breast cancer
275
When can hormone treatment be used in patients with breast cancer?
- Patients with ER positive breast cancer (oestrogen receptors) - Tamoxifen (premenopausal women) = selective oestrogen receptor modulator, blocks oestrogen receptors in breast tissue (increases risk of endometrial cancer) - Aromatase inhibitors (postmenopausal women) = enzyme found in adipose tissue, converts androgens into oestrogen, inhibitors block creation of oestrogen
276
What are other treatment options for breast cancer?
- Bisphosphonates - Monoclonal antibodies (trastuzumab/pertuzumab) - Tyrosine kinase inhibitor (neratinib) - PARP inhibitors (new targeted agents) - Chemoprevention/risk-reducing bilateral mastectomy
277
What are the options for breast reconstruction?
- Breast implants - Flap reconstruction (lattissimus dorsi flap/transverse rectus abdominis flap/deep inferior epigastric perforator flap)
278
When do mood disorders occur following delivery?
- Baby blues = first week - Postnatal depression = peaks around 3 months - Puerperal psychosis = a few weeks
279
What are the clinical features of baby blues/postnatal depression/puerperal psychosis?
Baby blues: - Mood swings/low mood/anxiety/irritability/tearfulness Postnatal depression: - Low mood + anhedonia + low energy Puerperal psychosis: - Delusions/hallucinations/mania/confusion/thought disorder
280
What is the investigation for postnatal depression
Edinburgh postnatal depression scale = score out of 30 - score of 10 or more suggests postnatal depression
281
What is the management for baby blues/postnatal depression/puerperal psychosis?
- Baby blues = no treatment - Postnatal depression (mild) = additional support/self-help/follow up with GP - Postnatal depression (moderate) = SSRIs + CBT - Postnatal depression (severe) = psychiatric referral - Puerperal psychosis = admission to mother and baby unit/CBT/medications/ECT
282
What is a complication of antidepressant use in pregnancy?
SSRI use --> neonatal abstinence syndrome - Presents in first few days after birth - Irritability/poor feeding - Supportive management
283
Describe anaemia in pregnancy
Physiological anaemia due to increased plasma volume - normal MCV
284
Describe anaemia screening in pregnancy
Booking clinic at 28 weeks - haemoglobinopathy screening for thalassaemia and sickle cell disease
285
What are normal haemoglobin ranges in pregnancy?
- Bookings bloods >110g/l - 28 weeks >105g/l - Postpartum >100g/l
286
What are the investigations for anaemia in pregnancy?
- Haemoglobin - MCV - Bloods (ferritin/B12/folate)
287
What is the management for anaemia in pregnancy?
- Iron = ferrous sulphate 200mg TDS - B12 = IM hydroxocobalamin/oral cyanocobalamin - Folate = folic acid 400mcg OD + folic acid 5mg OD - Thalassaemia/sickle cell anaemia = high dose folic acid (5mg), close monitoring, transfusions
288
What is cephalopelvic disproportion and what are the causes?
Head of foetus is too large for pelvis - Large baby (hereditary/post maturity/diabetes/multiparity) - Abnormal position (brow presentation( - Small pelvis - Abnormality of genital tract (fibroids/congenital rigidity of cervix/surgical scarring of cervix/congenital septum of vagina)
289
How is cephalopelvic disproportion diagnosed?
Labour does not progress and use of medical therapy e.g. oxytocin has not worked
290
What are the complications and therefore management for cephalopelvic disproportion?
- Obstructed labour/failure to progress - Shoulder dystocia - C section
291
What is cord prolapse?
When the umbilical cord descends below presenting part of the foetus and through the cervix into the vagina, after rupture of foetal membranes
292
What is a risk factor for cord prolapse?
Abnormal lie after 37 weeks e.g. unstable/transverse/oblique
293
What are the investigations for cord prolapse?
- Foetal distress on CTG - Vagina/speculum examination
294
What is the management for cord prolapse?
DO NOT PUSH CORD BACK IN - C section - Cord kept warm and wet and minimal handling - Push presenting part of baby upwards to prevent compression cord - Mother lies in left lateral position (uses gravity to draw foetus away from compressing cord) - Tocolytic medication e.g. terbutaline (used to minimise contractions)
295
What is the main complication of cord prolapse?
Presenting part of foetus compresses cord --> foetal hypoxia
296
What are the delayed labour timings?
First stage = cervical dilatation of <2cm in 4 hours Second stage (nulliparous) = >2 hour duration Second stage (multiparous) = >1 hour duration Third stage (actively managed) = >30 minutes Third stage (physiological) = >60 minutes
297
What are the stages of labour?
First stage: - Latent phase (0-3cm dilation, 0.5cm/hour, irregular contractions) - Active phase (3-7cm dilation, 1cm/hour, regular contractions) - Transition phase (7-10cm dilation, 1cm/hour, strong/regular contractions) Second stage: - From 10cm dilation to delivery of baby Third stage: - Delivery of baby to delivery of placenta
298
What are causes of delayed labour?
3 P's - power/passenger/passage - Power = deviation from normal uterine contractions - Passenger = size of foetus head/foetal presentation/foetal position - Passage = cephalopelvic disproportion
299
What is the management for delayed labour?
First stage: - Amniotomy (if membranes intact) - Oxytocin infusion Second stage: - Oxytocin infusion - Expedited delivery (e.g. instrumental/c-section) Third stage: - Controlled cord traction - IM oxytocin/ergometrine
300
What features suggest gestational diabetes?
- Large for date foetus - Polyhydramnios - Glucose on urine dipstick
301
What are the investigations for gestational diabetes?
- Pre-existing diabetes = retinopathy screening - Oral glucose tolerance test = 24-28 weeks, fasting glucose measured and glucose measured 2 hours after 75g glucose drink - Normal fasting <5.6mmol/l - Normal after 2 hours <7.8mmol/l - Urine dipstick = glucose
302
What is the management for pre-existing diabetes in pregnancy?
- Insulin + metformin - 5mg folic acid from preconception until 12 weeks - 4 weekly USS to monitor foetal growth and amniotic fluid volume from 28-38 weeks
303
What is the management for gestational diabetes?
- Fasting glucose <7mmol/l = diet/exercise/metformin/insulin - Fasting glucose >7mmol/l = insulin +/- metformin - Fasting glucose >6mmol/l + macrosomia = insulin +/- metformin - Glibenclamide (sulfonylurea) if cannot have insulin/metformin - 4 weekly USS to monitor foetal growth and amniotic fluid volume from 28-38 weeks
304
What are the blood sugar target levels in diabetes in pregnancy?
- Fasting = 5.3 - 1 hour post-meal = 7.8 - 2 hour post-meal = 6.4 - Avoid 4 or below
305
What is the delivery management for diabetes in pregnancy?
- Pre-existing diabetes = planned between 37 and 38 + 6 weeks - Gestational diabetes = up to 40 + 6 weeks
306
What are the complications of gestational diabetes?
- Large for date foetus/macrosomia --> shoulder dystocia - Longer term risk of developing chronic T2DM - Pre-eclampsia - Increased CVD risk - Neonatal hypoglycaemia - Childhood obesity - Polycythaemia - Jaundice - CHD - Cardiomyopathy
307
What medications should be stopped in HTN in pregnancy?
- ACE inhibitors (ramipril) - Angiotensin receptors blockers (losartan) - Thiazide and thiazide-like diuretics (indapamide)
308
What is the management for HTN in pregnancy?
- Oral labetalol (first line) - Nifedipine (first line if asthmatic) - Hydralazine - Doxazosin - Aspirin 75mg OD from 12 weeks until birth (if at risk of developing pre-eclampsia)
309
What is pre-eclampsia?
Pregnancy-induced HTN associated with end-organ dysfunction, notably proteinuria
310
What is eclampsia?
Seizures that occur as a result of pre-eclampsia
311
What are the clinical features of pre-eclampsia?
- HTN - Proteinuria - Oedema - Headache - Visual disturbances/blurriness - N+V - Upper abdominal/epigastric pain - Reduced urine output - Brisk reflexes
312
What are the investigations for pre-eclampsia?
- Systolic BP >140mmHg - Diastolic BP >90mmHg - Proteinuria = 1+ or more on dipstick - Urine protein:creatinine ratio >30 - Urine albumin:creatinine ratio >8
313
What is placental growth factor?
- Protein released by placenta that functions to stimulate development of new blood vessels - Low in pre-eclampsia
314
What is the management for pre-eclampsia?
- Aspirin prophylaxis from 12 weeks until birth - Labetolol/nifedipine/hydralazine/magnesium sulphate - Planned early birth if complications/poorly controlled BP
315
What are some complications of pre-eclampsia?
- Maternal organ damage - Foetal growth restriction - Eclampsia - Premature labour - HELLP syndrome
316
What are risk factors for an ectopic pregnancy?
- Previous ectopic - Previous PID - Previous surgery to fallopian tubes - IUD - Older age - Smoking
317
What are the clinical features of an ectopic pregnancy?
- Presents around6-8 weeks - Missed period - Constant RIF/LIF pain - Vaginal bleeding - Lower abdominal/pelvic tenderness - Cervical motion tenderness - Dizziness/syncope - Shoulder tip pain
318
What are the investigations for an ectopic pregnancy?
- Transvaginal USS - Serum hCG
319
What is the management for an ectopic pregnancy?
Not viable - must be terminated: - Expectant management (awaiting natural termination) - Medical management (methotrexate) - Surgical (salpingectomy/salpingotomy)
320
What is the main complication of an ectopic pregnancy?
Rupture of fallopian tube --> severe bleeding/infection/death
321
What are risk factors for multiple pregnancies?
- Use of fertility treatment - Fhx - Older age - High parity - African American
322
What are the types of multiple pregnancies?
- Monozygotic/dizygotic - Monoamniotic/diamniotic - Monochorionic/dichorionic - Diamniotic, dichorionic = best outcomes (own nutrient supply)
323
What are the investigations for multiple pregnancies?
USS: - Dichorionic, diamniotic twins = membrane between twins, with lambda sign/twin peak sign - Monochorionic, diamniotic twins = membrane between twins with T sign - Monochorionic, monoamniotic twins = no membrane between twins
324
What is the management for multiple pregnancies?
- Additional monitoring - Planned birth
325
What is the main complication of multiple pregnancies?
Twin-twin transfusion syndrome: - Occurs when foetuses share a placenta - Recipient receives majority of the blood and donor is starved of blood - Recipient becomes fluid overloaded with HF/polyhydramnios - Donor has growth restriction/anaemia/oligohydramnios - Management = laser treatment to separate blood supplies
326
What is the criteria for termination of pregnancy?
1967 Abortion Act and 1990 Human Fertilisation and Embryology Act - Can be performed before 24 weeks if continuing pregnancy involves greater risk to the physical/mental health of the women and/or existing children of the family - Can be performed at any time if continuing the pregnancy is likely to risk the life of the women - Can be performed at any time if terminating the pregnancy will prevent 'grave permanent injury' to the physical/mental health of the woman - Can be performed at any time if there is substantial risk that the child would suffer physical or mental abnormalities making it seriously handicapped - 2 registered medical practitioners must sign to agree abortion is indicated - Must be carried out by a registered medical practitioner in an NHS hospital or approved premise
327
What is a medical abortion?
- Earlier in pregnancy - Mifepristone (anti-progestogen) + misoprostol (prostaglandin analogue)
328
What us a surgical abortion?
- Medications given before for 'cervical priming' (mifepristone/misoprostol) - Cervical dilatation and suction of contents of uterus (up to 14 weeks) - Cervical dilatation and evacuation using forceps (14-24 weeks)
329
Describe post-abortion care
- Intermittent vaginal bleeding/abdominal cramps for up to 2 weeks after procedure - Urine pregnancy test performed 3 weeks after to confirm it is complete - Contraception - Support and counselling
330
What are risk factors for recurrent miscarriages?
- Antiphospholipid syndrome (secondary to SLE) - Hereditary thrombophilias (factor V Leiden/factor II/protein S deficiency) - Uterine abnormalities (septum/unicornuate/bicornuate/didelphic/fibroids)
331
What are risk factors for miscarriages?
- Older age - Previous miscarriage(s) - Previous ectopic - Smoking - Obesity
332
What are the clinical features of miscarriages?
- Abdominal/pelvic pain - Vaginal discharge - Lack of pregnancy symptoms
333
What are the investigations for miscarriages?
Transvaginal USS - 3 main features looked for in early pregnancy: - Mean gestational sac diameter - Foetal pole + crown-rump length - Foetal heartbeat)
334
What is the management for miscarriages?
- <6 weeks = expectant management - >6 weeks = USS/expectant management/medical management (misoprostol)/surgical management
335
What is the main complication of miscarriages?
Incomplete miscarriage - Retained products of conception remain in uterus - Risk of infection - Medical (misoprostol) or surgical (vacuum aspiration and curettage) management
336
What are risk factors for VTE in pregnancy?
- Smoking - Parity of 3 or more - Age >35 - BMI >30 - Reduce mobility - Multiple pregnancy - Pre-eclampsia - Gross varicose veins - Fhx - Thrombophilia - IVF prgenancy
337
What are the clinical features of VTE in pregnancy?
DVT = unilateral calf/leg swelling, tenderness, dilated superficial veins, oedema PE = SOB, cough with/without blood, pleuritic chest pain, hypoxia
338
What are the investigations for VTE in pregnancy?
- Doppler USS - Chest x-ray - ECG - CT pulmonary angiogram (CTPA) - Ventilation-perfusion (VQ) scan
339
What is the management for VTE in pregnancy?
- VTE prophylaxis = LMWH (enoxaparin/dalteparin/tinzaparin)/mechanical prophylaxis - Thrombolysis/surgical embolectomy
340
What are risk factors for Group B Strep Infection?
- Prematurity - Prolonged rupture of membranes - Previous baby with GBS infection - Fever during labour - Positive GBS urine/swab test during pregnancy - Waters broken >24 hours before birth
341
What is the management for GBS?
Intrapartum abx prophylaxis (IAP) - benzylpenicillin: - Women who have had GBS detected in previous pregnancy - Women with previous baby with early/late onset GBS disease - Women in preterm labour regardless of GBS status - Women with pyrexia during labour
342
What is puerperal pyrexia and what are common causes?
Temperature of >38 in the first 14 days following delivery - Strep. pyogenes - Staph bacteria - Anaerobic strep bacteria - E coli
343
What are the risk factors for puerperal pyrexia?
- Endometritis (most common) - UTI - Wound infections (perineal tears/c-section) - Mastitis - VTE
344
What is the management for puerperal pyrexia?
IV abx - clindamycin + gentamicin until afebrile for >24 hours
345
What is the management for varicella zoster in pregnancy?
Exposure: - Oral aciclovir or valaciclovir given at day 7-14 after exposure - Injection of varicella zoster immune globulin (VZIG) Infection: - Oral aciclovir if >= 20 weeks and presents within 24 hours of onset of rash - If <20 weeks = aciclovir considered with caution
346
What is the management of UTIs in pregnancy?
- Nitrofurantoin (first line) - Alternatives = amoxicillin/cefalexin DO NOT GIVE TRIMETHOPRIM
347
What are the complications of UTIs in pregnancy?
Increased risk of: - Preterm labour - IUGR - Pre-eclampsia - Kidney infection --> sepsis
348
What is the main complication of varicella zoster in pregnancy?
Foetal varicella syndrome: - Skin scarring - Eye defects (microphthalmia) - Limb hypoplasia - Microcephaly - Learning disabilities
349
What are the clinical features of HELLP syndrome?
- N+V - RUQ pain - Lethargy - HTN - Oedema - Proteinuria
350
What are the investigations for HELLP syndrome?
- Bloods = Haemolysis, Elevated Liver enzymes, Low Platelet count - Proteinuria
351
What are the complications and therefore management for HELLP syndrome?
- Premature labour - Seizures - Deliver baby
352
Describe obstetric cholestasis
- Pruritus of palms/soles/abdomen - Clinical detectable jaundice (in some patients) - Raised bilirubin - Induction of labour at 37-38 weeks - Ursodeoxycholic acid - Vitamin K supplementation
353
What are risk factors for placental insufficiency?
- Maternal hypertensive disorders - Smoking/alcohol/drug use - Primiparity - Advanced maternal age - History of IUGR neonate - Medications e.g. valproic acid
354
What is the investigation and management for placental insufficiency?
- Doppler USS - Low dose aspirin - Heparin
355
What are the complications of placental insufficiency?
- Pre-term labour - Pre-eclampsia - IUGR - Stillbirth
356
What are reasons patients might feel reduced foetal movements?
- Posture - Distraction - Anterior placental/foetal position - Medication (alcohol/opiates/benzodiazepines) - Obesity - Oligohydramnios/polyhydramnios - SGA foetus
357
What is quickening?
First onset of recognised foetal movements - Usually occurs around 18-20 weeks (16-18 weeks in multiparous women) - Increase until 32 weeks and then plateaus
358
What are the investigations for reduced foetal movements?
- <10 movements within 2 hours in pregnancies past 28 weeks = indication for further assessment - Doppler USS to confirm foetal heartbeat --> CTG (heartbeat)/USS (no heartbeat)
359
What are the complications of reduced foetal movements?
Increased risk of: - Stillbirth - Foetal growth restriction
360
What is the main risk factor for an instrumental delivery?
Epidural
361
What are the clinical features that indicate an instrumental delivery may be required?
- Failure to progress - Foetal distress - Maternal exhaustion - Control of head in various foetal positions
362
What are the types of instrumental delivery?
- Ventouse = suction cup on baby's head - Forceps = curved metal either side of baby's head
363
What is recommended after an instrumental delivery?
Single dose of co-amoxiclav to reduce risk of maternal infection
364
What nerves can be affected in instrumental deliveries?
- Femoral = weakness of knee extension/loss of patella reflex/numbness of anterior thigh and medial lower leg - Obturator = weakness of hip adduction/rotation and numbness of medial thigh Usually resolves over 6-8 weeks
365
What nerves can be affected in normal deliveries?
- Lateral cutaneous nerve of thigh = due to prolonged flexion at hip whilst in lithotomy position = numbness of anterolateral thigh - Lumbosacral plexus = compressed by foetal head during 2nd stage of labour = foot drop/numbness of anterolateral thigh, lower leg and foot - Common peroneal nerve = compressed on head of fibula whilst in lithotomy position = foot drop/numbness of lower lateral leg
366
What are some complications of instrumental delivery to the baby?
- Cephalohematoma - Caput succedaneum - Facial nerve palsy/facial bruises - Intracranial haemorrhage - Skull fracture - Subgaleal haemorrhage - Spinal cord injury
367
What are some malpresentations?
- Breech (most common) = legs/bottom are presenting - Shoulder = baby in transverse lie - leading part is arm/shoulder/trunk - Face = foetal head/neck are hyperextended so face presents first - Brow = foetal head is midway between full flexion and hyperextension - presenting part is between orbital ridge and anterior fontane
368
What are the investigations for malpresentations?
- Abdominal examination = palpate lower uterus, if head feels hard and round = cephalic - USS
369
What is the management for breech presentation?
Attempt external cephalic version (ECV): - Rotate baby from breech position - Salbutamol given to relax muscles - Press on abdomen to encourage foetus to roll - 36 weeks - If unsuccessful --> vaginal breech delivery or c-section
370
What is the management for other malpresentations?
- Shoulder = c-section - Face = c-section (normal labour possible if chin is anterior but likely to be prolonged/complicated) - Brow = c-section
371
What are the complications of malpresentations?
- PROM - Premature labour - Prolonged/obstructed labour - PPH
372
What is oligohydramnios/polyhydramnios?
Oligohydramnios = abnormally low volume of amniotic fluid Polyhydramnios = abnormally high volume of amniotic fluid
373
What is the most common cause of oligohydramnios?
Preterm prelabour rupture of membranes
374
What are some causes of polyhydramnios?
- 50-60% of cases are idiopathic - Any condition preventing foetus from swallowing (oesophageal atresia/muscular dystrophies) - Duodenal atresia - Anaemia - Twin-to-twin transfusion syndrome
375
What is a normal amount of amniotic fluid?
- Will increase throughout pregnancy - Peak around 33 weeks at 1000ml and plateaus until 38 weeks
376
What are the clinical features of oligohydramnios?
- Often asx - Clear/light pink fluid leaking from vagina (indicates ROM) - Abdominal palpation = foetus easier to palpate/feels more firm
377
What are the clinical features of polyhydramnios?
- Breathlessness - Indigestion/heartburn - Constipation - Swelling in legs/feet
378
What are the investigations for oligohydramnios?
- USS - Symphyseal-fundal height = uterus appears small for dates - Amniotic fluid volume via ultrasonography - Fluid analysis (Ferning test/amnisure/actim-PROM)
379
What are the investigations for polyhydramnios?
- USS - Amniotic fluid volume via ultrasonography
380
What measurements are taken for amniotic fluid in ultrasonography?
- Maximum vertical pocket (MVP) - normal = 2-8cm - Amniotic fluid (AFI - uterus divided into quadrants and MVP from each added together) - normal = 5cm-25cm2 ^ Oligohydramnios/polyhydramnios = <5th/>95th centile for gestational age
381
What is Ferning test?
- Tests cervical secretions for amniotic fluid - Placed on slide and dried - Amniotic fluid forms fern-like patterns of crystals
382
What is amnisure?
- Vaginal swab that checks for rupture of membranes - Screens for presence of placental alpha microglobulin-1 (PAMG-1) - found in high conc. in amniotic fluid
383
What is actim-PROM?
- Swab that checks for premature rupture of membranes - Screens for insulin-like growth factor binding protein (IGFBP-1) which is found in high conc. in amniotic fluid
384
What is the management for oligohydramnios?
- Therapeutic amnioinfusion (saline/Ringer's lactate infused into amniotic cavity under USS) - Induction of labour between 36-38 weeks
385
What is the management for polyhydramnios?
- No medical intervention required in majority of cases - Amnioreduction (if severe) - Indomethacin (enhances water retention to reduce foetal urine output) - NG tube passed when baby born to rule out tracheoesophageal fistula/oesophageal atresia
386
What are some complications of oligohydramnios?
- Limb deformities due to foetal compression e.g. muscle contractures/talipes (club foot) --> physiotherapy - Pulmonary hypoplasia
387
What are some complications of polyhydramnios?
- Better prognosis than oligohydrmanios - Amnioreduction associated with infection and placental abruption - Indomethacin associated with premature closure of ductus arteriosus (should not be used beyond 32 weeks) - PPH
388
What is placental abruption?
Obstetric emergency - when the placenta separates from the wall of the uterus during pregnancy
389
What are some risk factors for placental abruption?
- Previous placental abruption - Pre-eclampsia - Bleeding early in pregnancy - Trauma - Multiple pregnancy - Polyhydramnios
390
What are the types of placental abruption?
- Concealed abruption = cervical os remains closed so bleeding remains in uterine cavity - Revealed abruption = cervical os open so bleeding observed via vagina
391
What are the clinical features of placental abruption?
- Sudden onset severe continuous abdominal pain - Vaginal bleeding - Shock (hypotension/tachycardia) - Pain between contractions - Abnormalities on CTG - 'Woody' abdomen on palpation
392
What are the investigations for placental abruption?
- Clinical diagnosis - Severity = spotting/minor haemorrhage (<50ml)/major haemorrhage (50-1000ml)/massive haemorrhage (>1000ml)
393
What is the management for placental abruption?
- C-section - Corticosteroids (between 24 and 34 + 6 weeks) - 2 x grey cannula - Bloods (FBC/U&Es/LFTs/coag) - Crossmatch 4 units of blood - Fluid/blood resus - CTG monitoring - Monitor mother
394
What is the main complication of placental abruption?
Antepartum haemorrhage
395
What is placenta accreta spectrum?
When the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of baby
396
What are some risk factors for placenta accreta spectrum?
- Previous placenta accreta - Previous endometrial curettage procedure - Previous c-section - Multigravida - Increased maternal age - Low-lying placenta/placenta praevia
397
What are the layers of the uterus?
- Endometrium = inner layer (contains stroma/epithelial cells/blood vessels) - Myometrium = middle layer (contains smooth muscle) - Perimetrium = outer (contains serosa)
398
What are the types of placenta accreta spectrum?
- Superficial placenta accreta = implants in surface of myometrium - Placenta increta = attaches deeply into myometrium - Placenta percreta = invades past myometrium and perimetrium, potentially reaches other organs e.g. bladder
399
What are the clinical features of placenta accreta spectrum?
- Asx - Bleeding in 3rd trimester - Difficulty delivery placenta
400
What are the investigations for placenta accreta spectrum?
- USS - MRI
401
What is the management for placenta accreta spectrum?
- Uterine surgery - Blood transfusion - Planned delivery between 35 to 36 + 6 weeks - ^ C-section + hysterectomy/uterus preserving surgery/expectant management (leave placenta to be reabsorbed)
402
What are some complications of placenta accreta spectrum?
- PPH - Expectant management - bleeding/infection
403
What is placenta praevia?
Placenta attached in lower portion of uterus, lower than presenting part of foetus and over the internal cervical os (covers cervix)
404
What are some risk factors for placenta praevia?
- Previous c-section - Previous placenta praevia - High parity - Older maternal age - Maternal smoking
405
What are the clinical features of placenta praevia?
- Asx - Painless vaginal bleeding
406
What are the investigations for placenta praevia?
20 week anomaly scan = assess position
407
What is the management for placenta praevia?
- Repeat transvaginal USS at 32 weeks and 36 weeks - Corticosteroids - Planned c-section between 36 and 37 weeks
408
What are the complications of placenta praevia?
- Antepartum haemorrhage/placental abruption/vasa praevia - PPH - Emergency c-section/hysterectomy required - Maternal anaemia/transfusions - Preterm birth/low birth weight - Stillbirth
409
What are the causes of postpartum haemorrhages?
4 Ts: - Tone = uterine atony (most common) - Trauma = e.g. perineal tear - Tissue = retained placenta - Thrombin = bleeding disorder
410
What are some risk factors for postpartum haemorrhages?
- Previous PPH - Multiple pregnancy - Obesity - Large baby - Failure to progress in 2nd stage of labour/prolonged 3rd stage - Pre-eclampsia - Placenta accreta/retained placenta - Instrumental delivery/general anaesthesia - Retained products of conception/infection
411
What are the clinical features of postpartum haemorrhages?
- Bleeding - Decreased BP - Tachycardia - Decreased RBC count
412
What is the diagnostic criteria for postpartum haemorrhages?
- Blood loss of 500ml after vaginal delivery - Blood loss of 1000ml after c-section
413
What are the types of postpartum haemorrhages?
- Minor = <1000ml - Major = >1000ml (moderate = 1000-2000ml/severe = >2000ml) - Primary = within 24 hours of birth - Secondary = from 24 hours to 12 weeks after birth
414
What are the investigations for postpartum haemorrhages?
- Blood loss - Bloods (FBC/U&Es/clotting) - USS (RPOC) - Endocervical/high vaginal swab (infection)
415
What is the management for postpartum haemorrhages?
- Resuscitation - Lie woman flat/keep warm - 2 x large-bore cannulas - Bloods - Group/cross match 4 units - Warmed IV fluid/blood resuscitation - Oxygen - Fresh frozen plasma - Major haemorrhage protocol
416
What are some methods of stopping bleeding in postpartum haemorrhages?
- Mechanical = rub uterus through abdomen to stimulate contractions/catheterisation - Medical = oxytocin/IV or IM ergometrine/IM carboprost/SL misoprostol/IV tranexamic acid - Surgical = intrauterine balloon tamponade/B-lynch suture/uterine artery ligation/hysterectomy
417
What is vasa praevia?
Foetal vessels are exposed outside umbilical cord/placenta
418
What are the risk factors for vasa praevia?
- Low lying placenta - IVF pregnancy - Multiple pregnancy
419
What are the clinical features of vasa praevia?
- Often asx - Antepartum haemorrhage
420
What are the types of vasa praevia?
- Type I = foetal vessels exposed as velamentous umbilical cord - Type II = foetal vessels exposed as they travel to accessory placental lobe
421
What are the investigations for vasa praevia?
- USS - Vaginal examination = pulsating foetal vessels seen in membranes through dilated cervix - Foetal distress - Dark-red bleeding following ROM
422
What is the management for vasa praevia?
- Corticosteroids from 32 weeks - Planned c-section for 34-36 weeks
423
What are the complications of vasa praevia?
- Antepartum haemorrhage - Foetal blood loss - Death
424
What is prematurity?
Birth before 37 weeks gestation
425
What are some risk factors for prematurity?
- Previous prematurity - Short cervix - Past gynae conditions/surgeries - Pregnancy complications - Multiple pregnancy - Infection/smoking/dietary deficiencies - <17/>35 years
426
What are the types of prematurity?
- Extreme = <28 weeks - Very = 28-32 weeks - Moderate to late = 32-37 weeks
427
What are the investigations for prematurity?
- Speculum exam + transvaginal USS (if >30 weeks) to access cervical length - Foetal fibronectin (alternative to transvaginal USS) = >50ng/ml indicates preterm labour is likely
428
What is the management for prematurity?
- CTG - Maternal corticosteroids (IM betamethasone) - IV MgSO4 - Delayed cord clamping/cord milking (increase circulating blood volume)
429
What is prophylaxis management for prematurity?
- Vaginal progesterone (gel/pessary) - Cervical cerclage (stitch added to cervix) - Tocolysis with nifedipine/atosiban (stop uterine contractions)
430
What are some risk factors for premature rupture of membrane (PROM)?
- Infection - Previous preterm birth - Vaginal bleeding - Smoking
431
What are the investigations for PROM?
- Speculum = pooling of amniotic fluid in vagina - Insulin-like growth factor binding protein 1 (IGFBP-1)/placental alpha-microglobin-1 (PAMG-1) = high conc. in amniotic fluid
432
What is the management for PROM?
- Prophylactic abx (prevent chorioamnionitis) = erythromycin 250mg QDS for 10 days or until labour is established - Induction of labour
433
What are the complications of PROM?
- Chorioamnionitis - Placental abruption - Compression of umbilical cord - C-section - Postpartum infection
434
What is uterine rupture?
Complication of labour in which myometrium layer of uterus ruptures
435
What are some risk factors for uterine rupture?
- Previous c-section - Vaginal birth after c-section - Previous uterine surgery - Increased BMI - High parity - Increased age - Induction of labour - Use of oxytocin
436
What are the types of uterine rupture?
- Incomplete = a.k.a uterine dehiscence - perimetrium remains intact - Complete = perimetrium also ruptures - contents of uterus released into peritoneal cavity
437
What are the clinical features of uterine rupture?
- Acutely unwell mother - Abdominal pain - Vaginal bleeding - Ceasing of uterine contractions - Shock (hypotension/tachycardia) - Collapse
438
What are the investigations for uterine rupture?
Abnormal CTG
439
What is the management for uterine rupture?
- Resuscitation/transfusion - Emergency c-section - Hysterectomy
440
What is rhesus disease of newborn?
Mother is rhesus-D negative and baby is rhesus-D positive so pregnant woman produces antibodies that destroy RBCs of baby
441
What is the investigation for rhesus disease of newborn?
Kleinhauer test: - 20 weeks - Sees how much foetal blood has passed into mother's blood during sensitisation - Determines whether further doses of anti-D are required - Acid addle to sample of mother's blood --> foetal Hb more resistant to acid so will not be destroyed --> no. of cells still containing Hb
442
What is the management for rhesus disease of newborn?
Prophylaxis - prevention of sensitisation: - IM anti-D injections to rhesus-D negative women (attach to antigens on foetal RBCs so antibodies are not created) - Given at 28 weeks/birth/within 72 hours of sensitisation event (antepartum haemorrhage/amniocentesis/abdominal trauma)
443
What is the main complication of rhesus disease of newborn?
Haemolytic disease of newborn
444
What are some risk factors for shoulder dystocia?
- Macrosomia (>4.5kg) secondary to gestational diabetes - Previous shoulder dystocia - High maternal BMI - Induction of labour/prolonged labour
445
What are the clinical features of shoulder dystocia?
- Difficulty delivering face/head/shoulders - Failure of restitution (head remains face downwards) - Turtle-neck sign (head delivered by retracts)
446
What is the first line management for shoulder dystocia?
- Discourage pushing - McRoberts manoeuvre (hyperflexion of mother at hip) - Pressure to anterior shoulder (press on suprapubic region of abdomen)
447
What is further management for shoulder dystocia?
- Episiotomy (enlarge vaginal opening) - Rubins manoeuvre (reach into vagina and put pressure on anterior aspect of baby's posterior shoulder) - Zavanelli manoeuvre (push baby's head back in for c-section)
448
What are the complications of shoulder dystocia?
- Foetal hypoxia --> cerebral palsy - Brachial plexus injury and Erb's palsy - Perineal tears - PPH
449
Describe the combined contraceptive pill
- Daily method - Recommended in women with moderate to severe PMS - Takes 7 days to become effective - Combination of oestrogen and progesterone - inhibits ovulation/thickens cervical mucus/inhibits proliferation of endometrium
450
What are the benefits of the combined contraceptive pill?
- Usually makes periods regular/lighter/less painful - Reduced risk of ovarian/endometrial/colorectal cancer
451
What are contraindications with the combined contraceptive pill?
- Breastfeeding - Women >35 years who smoke >15 cigarettes per day - Migraines with aura - Surgery (stop 4 weeks before and restart 2 weeks after)
452
What are the side effects of the combined contraceptive pill?
- Headache - Nausea - Breast tenderness - Increased risk of VTE/stroke/IHD - Increased risk of breast/cervical cancer
453
Describe the progestogen only pill
- Daily method - Can be started at any time postpartum - Takes 48 hours to become effective - Thickens cervical mucus/inhibits ovulation
454
What is the main side effect of the progestogen only pill?
Irregular bleeding
455
Describe implantable contraceptives
- Long acting methods of reversible contraception - Suitable for young women if chaotic lifestyle - Can be used if past history of thromboembolism/migraine - Can be inserted immediately following termination of pregnancy - Takes 7 days to become effective - Last 3 years - Does not contain oestrogen - etonogestrel inhibits ovulation/thickens cervical mucus
456
What is the main benefit/side effect of implantable contraceptives?
- Most effective form of contraception - Irregular bleeding
457
Describe injectable contraceptives
- Long acting methods of reversible contraception - Suitable for women taking enzyme-inducing drugs e.g. carbamazepine - Takes 7 days to become effective - Lasts 12 weeks - Medroxyprogesterone acetate inhibits ovulation/thickens cervical mucus
458
What are the main side effects/contraindications of injectable contraceptives?
- Weight gain - Irregular bleeding - Current breast cancer
459
Describe the intrauterine system (Mirena)
- Long acting methods of reversible contraception - First line for menorrhagia - Suitable for women taking enzyme-inducing drugs e.g. carbamazepine - Takes 7 days to become effective - Levonorgestrel (progesterone releasing coil) - prevents endometrial proliferation/thickens cervical mucus
460
What is the main side effect of IUS?
Irregular bleeding within 6 months of insertion
461
Describe the intrauterine device
- Long acting methods of reversible contraception - Suitable for women taking enzyme-inducing drugs e.g. carbamazepine - Effective immediately - Copper coil - toxic to sperm
462
What is the main side effect of the intrauterine device?
Heavier/longer/more painful periods
463
Describe the contraceptive patch
- Change patch weekly with 1 week break after 3 patches - Oestrogen and progesterone - inhibits ovulation
464
What are the benefits of the contraceptive patch?
- Usually makes periods regular/lighter/less painful - Reduced risk of ovarian/endometrial/colorectal cancer
465
What are the side effects of contraceptive patch?
- Bleeding between periods - Increased risk of VTE

Phase 3a (21 decks)

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