Women's Health Flashcards

Question

When prescribing contraception - what criteria should be checked?

Answer 1

``` UKMEC - UK Medical Eligibility Criteria 1 - no restriction for use 2 - advantages > disadvantages 3 - risks outweigh advantage - not recommended 4 - use is unacceptable ```

Answer 2

``` Migraine Smoker HTN Thrombophilia Previous VTE FHx of VTE Hyperlipidaemia BP BMI Exclude pregnancy ``` Start on first day of bleeding (or within 5 days) Drug interactions D&V advice - use alterative protection Need alternative protection for first 7 days

Answer 3

Ovulation is inhibited by varying degrees depending on the drug Delays transport of ovum Cervical mucus thickens Endometrium becomes unsuitable for implantation

Answer 4

``` A Non invasive Easily reversible Avoids CV risk of COCP Less restriction Can be used up to 55 and while breastfeeding ``` D - Amennorhoea and breakthrough bleeds - narrower window - increase risk of cysts - increased risk of ectopic pregnancy if become pregnant - Irregular periods

Answer 5

Every 12 weeks Long acting reversible progesterone only Failure rate 2 in 1000 Thickens mucus Endometrium unsuitable for implantation Can be used 4 weeks post partum

Answer 6

A - Reliable - Infrequent - Low risk - Low failure rate - Decreases bleeding - Used in breast feeding D - not quickly reversible - Decrease bone mineral density - irregular periods - weight gain (up to 3kg)

Answer 7

Etonogestrel subdermal slow release in upper arm Failure rate < 1 in 1000 Inhibits ovulation , thickens mucus, thins endometrium Inserted with local anaesthetic Can be given 21 days post partum Can be given straight after termination

Answer 8

A - No large initial dose or fluctuations - Low failure rate - Reversible after 4 days - Decreased menstrual problems - Safe D - irregular bleeding - weight, mood and libido changes - Changes with bleeding DO NOT SETTLE WITH TIME - Increases risk of congenital malformation

Answer 9

Copper containing Long acting Reversible T shape, sits in fundus of uterus Cytotoxic - inflammatory reaction and is spermicidal Very low failure rate 5-10 years lifespan

Answer 10

A - Effective, reversible - Long acting (up to 10 years) - Can be used as emergency contraception - No hormones D - Spotting - Increased bleeding and pain in first few cycles - Perforation 0.2% - Increased ectopic pregnancy - Uncomfortable insertion

Answer 11

Progesterone releasing Decreased endometrial growth, thickens mucus

Answer 12

A - effective, convenient - reversible - decreased blood loss and dysmenorrhoea - decrease risk of PID - local action only D - common - irregular periods - increase ovarian cysts - increased ectopic pregnancy - expulsion or perforation

Answer 13

acne breast tenderness headache mood changes

Answer 14

Rarely used High failure rate Diaphragms - thin dome 55-100mm. Lie between posterior fornix and pubic bone Caps are smaller and fit over cervix, held by suction Only used if problem with diaphragm Often used with spermicide

Answer 15

Percentage to conceive 16% - diaphragm 32% parous with cap 16% cap in nulliparous 21% female condom

Answer 16

Calendar methods/temperature/mucus thickness/palpating cervix A - no side effects. complies with religious beliefs D - commitment. unreliable. not effective

Answer 17

12-24 hours after ovulation Sperm enter vagina and swim to uterus Prostaglandin in semen stimulate uterine contractility CAPACITATION (increase speed of sperm tail wiggle, removal of proteins/coatings) Acrosomal enzymes aid penetration of corona radiata and zona pellucida ZP3 in zona pellucida acts as sperm receptor and depolarises cell once in contact to prevent polyspermy

Answer 18

Offer antibiotic prophylaxis as 10% get genital tract infection (metronidazole +/- doxycycline or arythromycin) Surgical - Less than 14 weeks, vacuum aspiration + vaginal misoprostol 3 hours prior - 14-24 weeks, dilation and evacuation - Under sedation, local or general Medical - 200mg oral mifepristone followed by misoprostol - NSAID for pain relief

Answer 19

``` Infection (10%) Cervical trauma - surgical only Failed termination <1% Haemorrhage Perforation - surgical Long term psychological consequences ```

Answer 20

Freezing of gametes to preserve fertility Availability if undergoing treatment that may affect fertility like chemotherapy If - will not worsen their condition - enough time is available before the start of treatment

Answer 21

polcystic ovarian syndrome syndrome of polcystic ovaries AND systemic symptoms causing reproductive, metabolic and psychological disturbance infertility, amenorrhoea, acne and hirsuitism

Answer 22

33% of women have polcystic ovaries but not the syndrome affects 5-10% of reproductive age women pre menopausal women onset at age of menarche

Answer 23

unknown but is multifactorial excess androgen so by theca cells of ovary insulin resistance raised LH due to increased production raised oestrogen genetic link but no gene found

Answer 24

``` oligomenorrhoea infertility or subjectivity acne hirsuitism alopecia obesity psychological- mood swings, depression, anxiety sleep apnoea ```

Answer 25

hirsuitism alopecia central obesity acanthosis nigricans (hyperpigmented skin in folds) rarely - increased muscle mass, deep voice

Answer 26

2 out of 3 - polcystic ovaries on US. 12+ peripheral follicles or increased ovarian volume >10cm3 - oligo ovulation or anovulation - clinical and/or biochemical signs of hyperandrogenism

Answer 27

total testosterone - normal or slightly raised free testosterone- may be raised Sex hormone binding globulin - normal or low free androgen index- normal or raised LH - typically raised LH: FSH >2 with normal FSH ultrasound. cysts. raised volume also consider: TFTs, prolactin, cortisol fasting glucose and lipids

Answer 28

advice on weight control if not planning pregnancy - co-cyprinolol for hirsuitism and acne. induces regular bleeds to decrease endometrial cancer - COCP: for menstrual irregularity - metformin - eflornithine for hirsuitism - orlistat for weight loss ``` if planning pregnancy - clomifene - metformin one of both - laparoscopic ovarian drilling or gonadotrophins (if clomifene resistant) ```

Answer 29

``` infertility amenorrhoea increased CV risk sleep apnoea increased type 2 or gestational diabetes increased pre term birth or pre eclampsia ```

Answer 30

Beta-hcg AFP (alpha fetoprotein) Inhibin A UE3 (unconjugated estriol)

Answer 31

``` PAPP-A - lower in Down's beta-hcg - raised in Down's AFP - lower in Down's UE3 - lower in Down's Inhibin A - raised in Down's ```

Answer 32

``` Weight Race IVF Diabetes Smokers Twins ```

Answer 33

- Performed between 11 and 14 weeks - Measure nuchal pad at nape of neck - Increased nuchal translucency = higher change of chromosomal abnormality - 20% false positive rate

Answer 34

- Sample of amniotic fluid to examine foetal cells - Done between 12-18 weeks - Chromosomal, genetic and biochemical analysis - Management of rhesus disease - Estimation of maturity Indicated if: - Mother over 35 - Previous child with chromosomal abnormality - + antenatal screening Procedure - give rhesus prophylaxis where needed - US guided, 22 gauge spinal needle through abdo wall into uterus 10-20ml aspirated 7% loss of pregnancy is done 12-14 weeks

Answer 35

Sampling of developing plancenta late in the first trimester to allow examination of foetal karyotype/genotype - Done transabdominally Indicated if: - advanced maternal age - PHx of chromosomal/genetic abnormality Procedure - between 11 and 13 weeks - US guided needle aspiration First trimester, 2% miscarry, 2nd trimester 3%

Answer 36

FIRST CONTACT - folic acid supplementation - lifestyle advice - smoking, drugs, alcohol - food hygiene - information on all antenatal screening AT BOOKING - nutrition and diet - place of birth - exercises - pregnancy care pathway - discuss mental health issues BEFORE or AT 36 weeks - breastfeeding information - preparation for labour and birth - recognising active labour - care of the new baby - vitamin K prophylaxis

Answer 37

Folic acid 400 micrograms/day ideally before conception Avoid vitamin A (teratogenic) Vitamin D supplementation if darker skin or low Avoid unpasteurised milk, soft cheese, pate (listeriosis) Avoid salmonella risk - no raw or partially cooked eggs Seatbelt placed above and below bump

Answer 38

Anaemia - booking, 28 weeks Blood grouping - blood group and rhesus D status Haemoglobinopathies Foetal anomalies - 18-20 weeks US scan Infection - MSU early pregnancy, BV, chlamydia, hep B, HIV, syphilis, rubella Placenta praevia

Answer 39

Symphysis-fundal height from 24 weeks

Answer 40

external cephalic version

Answer 41

- Vaginal exam plus membrane sweeping - Induction offered after 41 weeks - if declined, twice weekly cardiotocography

Answer 42

``` 10 weeks 16 weeks 18-20 weeks - US scan NP - 25 weeks (start symphysis-fundal height) 28 weeks - antiD NP - 31 weeks 34 weeks - 2nd dose antiD 36 weeks 38 weeks NP - 40 weeks 41 weeks - for induction ``` All appointments - BP and proteinuria

Answer 43

Loss of pregnancy before 24 weeks of gestation.

Answer 44

Threatened - mild bleeding, little or no pain. Cervical os closed. Ongoing pregnancy Inevitable - heavy bleeding + clots and pain. Cervical os is open. Pregnancy will not continue Incomplete - products of conception partially expelled Missed/silent - foetus is dead but retained. uterus small for dates. Habitual/recurrent - 3+ consecutive miscarriages Septic - complication of incomplete or therapeutic abortion when intrauterine infection occurs

Answer 45

Increases with age 10-15% of pregnancies 85% in the first trimester RFs - increased number of births (parity) - Smoking - Excess alcohol - Illicit drug use - Uterine surgery or abnormalities e.g. incomplete cervix - Connective tissue disorders (SLE, APLS) - uncontrolled diabetes

Answer 46

Often no cause found - Abnormal foetal development - abnormal chromosomes - Genetically balanced parental translocation - Placenta failure - uterine abnormality - bicornuate, fibroids - Incompetent cervix (2nd trimester) - Multiple pregnancy - Autoimmune - SLE, APLS - PCOS 50% unexplained

Answer 47

Vaginal bleeding (heavier bleeding = increased risk) Abdominal pain Passed products of conception/clots 50% with threatened miscarriage will later miscarry - Open cervical os - Uterine size not appropriate for dates - Products of conception in cervical canal

Answer 48

US - TV, if there is no visible heart beat, a 2nd scan should be done in 7-14 days depending on size of sac Serum hcg - levels below 1000 in pregnancy of unknown location or complete miscarriage

Answer 49

Support, follow up and counselling Anti-D to all rhesus negative CONSERVATIVE - Expectant, should resolve naturally 7-14 days - Consider other management if: risk of haemorrhage, late in first trimester, previous adverse miscarriage outcome, infection, coagulopathies - Pregnancy test 3 weeks after - if still positive, medical or surgical management MEDICAL - Vaginal misoprostol, analgesia and anti-emetics - Causes more pain and bleeding than surgical - Pregnancy test 3 weeks after SURGICAL - If persistent bleeding, haemodynamic instability, retained tissue, gestationaltrophoblastic disease - Manual vacuum aspiration under local or surgical under GA - Complications: perforation, cervical tears, adhesions, haemorrhages - Screen for chlamydia

Answer 50

Can be pre-malignant or malignant - due to abnormal proliferation of trophoblastic tissue. Pre-malignant - Complete hydratiform mole - Partial hydratiform mole Malignant - Invasive mole - Choriocarcinoma - Placental site trophoblastic disease - Epitheliod trophoblastic disease

Answer 51

All genetic material comes from the father when an empty oocyte is fertilised - No foetal tissue - 46 XX karyotype - Placental tissue has marked hyperplasia and gross swelling of villi - "bunch of grapes" appearance - 10-15% become malignant, very sensitive to chemo - No embryo

Answer 52

- 3 sets of chromosomes - 2 sperm fertilise at the same time - 69 chromosomes, 46 paternal, 23 maternal - embryo visible on early US - usually diagnosed on histology after miscarriage - <1% malignancy

Answer 53

- Develops form a complete molar pregnancy - Invades into myometrium - Uterine mass with elevated hCG - Responds well to chemo

Answer 54

Synctiotrophoblasts - Often follows a molar pregnancy but can be post normal pregnancy, ectopic or abortion - continued vaginal bleeding post-pregnancy - Often metastasises - lung, brain, GI, liver, kidney - Can occur up to 20 years post pregnancy

Answer 55

GTD - 1 in 714 births Complete molar pregnancy - 1-3 per 1000 pregnancies Partial - 1 per 1000 GTN - 1 in 50,000 live births RFs - over 45 or under 16 - previous molar pregnancy - multiple pregnancy - menarche over 12, light menstruation - COCP of history of use - Asian

Answer 56

Vaginal bleeding in first trimester Hyperemesis Rare - abnormal uterine enlargement - hyperthyroidism - anaemia - respiratory distress - pre-eclampsia

Answer 57

- hCG (best for follow up) - Histology for definitive diagnosis (should be done for all products of conception - US: snowstorm appearance in 2nd trimester, heterogenous mass, no foetal development - CT if staging for metastatic disease

Answer 58

Refer for follow up at a trophoblastic screening centre - Suction curettage - Uterine pregnancy test at 3 weeks - Anti D prophylaxis - SENIOR SURGEON Follow up - 2 weekly until hCG normal - monthly for 6 months after Chemotherapy - if choriocarcinoma, mets, heavy bleeding, plateaued or rising hCG - LOW risk: methotrexate & calcium folinate - HIGH risk: EMA/CO chemotherapy combination

Answer 59

1.1 per 1000 pregnancies 97% in fallopian tubes 2-3% interstitial (not extrauterine part of the tube) RF - IVF - Hx of pelvic infection - Adhesions from inflammation, infection or endometriosis - tubal surgery - IUD/IUD

Answer 60

``` Abdominal or pelvic pain Amenorrhoea or missed period Vaginal bleeding (with or without clots) ``` ``` Dizziness, fainting or syncope Breast tenderness Shoulder tip pain Urinary symptoms Passage of tissue Rectal pain or tenesmus Diarrhoea and vomiting ```

Answer 61

``` Pelvic or abdominal tenderness Adnexal tenderness Rebound tenderness Cervical tenderness Pallor Abdominal distension Enlarged uterus Tachycardia and/or hypotension Shock or collapse ```

Answer 62

Pregnancy test in all women of child bearing age and lower abdominal pain - Transvaginal US most accurate - Need to identify: location of pregnancy, foetal pole, heartbeat - Serial hCG, 48 hours apart

Answer 63

- Admit as emergency - Anti-D prophylaxis in all rhesus negative women - Conservative if hCG declining and patient clinically well MEDICAL - single dose methotrexate - First line if can return for follow up with no significant pain, unruptured, no intrauterine pregnancy on US and hCG <1500 - Contraception for 3-6 months due to methotrexate teratogenicitiy SURGICAL - If can't come for follow up OR - significant pain - adnexal mass >35mm - Foetal heartbeat visible - Serum hCG>5000 - Laparoscopic approach preferable - Salpingectomy - Complications: bleeding, infection, damage to surrounding organs

Answer 64

Falls slightly in 1st trimester due to decreased vascular resistance - Falls in 2nd to lowest point at 22-24 weeks - Increases in 3rd trimester to pre-pregnancy levels - Falls immediately after birth

Answer 65

Abruptio placentae Cerebrovascular accident Disseminated Intravascular Coagulopathy Intrauterine growth restriction Prematurity Intrauterine death

Answer 66

Education on symptoms of pre-eclampsia - US at 34 weeks for foetal growth and amniotic fluid volume - High risk of pre-eclampsia then 75mg aspirin daily PRE-EXISTING - Review medication - Stop ACEi and ARBs - Keep BP <150/110 - Test for proteinuria regularly - US for foetal growth restriction, amniotic fluid volume MILD - 140/90 - Measure BP twice weekly and urine for protein at each visit MODERATE - 150-159/100-110 - Measure BP twice weekly - Start labetalol (alternatives: methyldopa, nifedipine) - Bloods SEVERE >160/110 - Admit, discharge when <150 - Measure BP at least 4 times per day

Answer 67

- Hypertension or pre-eclampsia in past pregnancy - CKD - Autoimmune disease - Diabetes mellitus - Chronic hypertension OR 2 of the following - first pregnancy - aged over 40 - previous pregnancy over 10 years ago - BMI > 35 - FHx of pre-eclampsia - multiple pregnancy

Answer 68

Vaginal bleeding after week 24 of gestation and before 2nd stage of labour

Answer 69

3-5% of pregnancies 20% of very preterm babies are associated with APH RFs depends on causes - Smoking - Cocaine use - Increasing maternal age - Increased parity - Pre-eclampsia - polyhydramnios

Answer 70

No definitive cause found in 50% - Placenta praevia (insertion of placenta, partially or fully, in lower segment of the uterus) - Placental abruption (premature separation of normally placed placenta) - Local causes (vulval, cervical infection, trauma or tumours) - Domestic violence - Vasa praevia (bleeding from foetal vessels in foetal membranes, high risk of foetal haemorrhage) - Uterine rupture - Inherited bleeding problems

Answer 71

``` Bleeding With pain - abruption Without pain - praevia Uterine contractions Malpresentation or failure of head to engage Signs of foetal distress If severe - hypovolaemic shock ```

Answer 72

FBC Group and save Clotting studies ADMIT Urgent US for placenta praevia Foetal monitoring Rhesus negative women should have Kleihauer test - give anti-D after each bleed

Answer 73

Admit, even if only small amount of bleeding Estimate blood loss - Minor <50ml, Major 50-1000ml, massive>1000ml If foetal distress - urgent delivery regardless of gestation If severe bleeding - mother's life takes priority Give corticosteroids if gestation between 24 and 36 weeks

Answer 74

Placenta inserted wholly or partially into the lower segment of the uterus MAJOR - placenta covers internal os of cervix MINOR - leading edge is in lower segment but not covering the os

Answer 75

1/200 births 1/1000 are major Incidence is increasing RFs - Previous history of placenta praevia - Previous C-section - Increased maternal age - Increased parity - Smoking - Cocaine use during pregnancy - Previous spontaneous or induced abortion - Deficient endometrium due to past history of endometritis, manual removal of placenta, curettage - Assisted conception

Answer 76

Painless bleeding after 28th week - sudden, profuse, does not last long - 25% have spontaneous labour in the next few days - Can just have bleeding in labour or membrane rupture - High presenting part or abnormal lie - No foetal distress unless complications - Bleeding provoked by sexual intercourse

Answer 77

Should have high index of suspicion in bleeding after 20 weeks. Diagnosis relies on US - Leading edge may be low on a 20 week scan - Apparent migration occurs during 2nd and 3rd trimester with development of lower uterine segment - Cannot exclude placental abruption (this is a clinical diagnosis) - TV US for all women whose placenta reaches or overlaps cervical os at anomaly scan - Minor - scan again at 36 weeks - major - scan again at 32 weeks Assists in planning and delivery

Answer 78

MINOR - may be able to deliver vaginally. Placental edge <2cm from the os = caesarean section If anterior, reaching os with history of C-section then treat as placenta accrete MAJOR - Deliver by C-section - No penetrative intercourse - Should admit to hospital from 34 weeks - Defer C-section to 38 weeks if possible

Answer 79

Morbidly adherent placenta - high risk if placenta praevia with history of C-section - Requires consultant obstetrician and anaesthetist - Blood products on site - MDT pre-op planning - Deliver baby without disturbing placenta - DO NOT PERFORM VAGINAL EXAM

Answer 80

Light spotting or bleeding Occurs 10-14 days after conception NORMAL Occurs when fertilised egg attaches to lining of uterus

Answer 81

Blue-red colour, discoid shape 450g in weight Maternal surface - divided into lobules or cotyledons with irregular grooves or clefts Foetal surface - smooth, shiny and translucent, choronic plane covered in amniotic membrane

Answer 82

50-60cm long Abundant Wharton's jelly, no true knots 2 umbilical arteries, 1 umbilical vein

Answer 83

Circumvallate - foetal membranes double back on foetal side around edge of placenta, small central chorioic area inside a paler ring of membranes on foetal side Succenturiate lobe - accessory lobes, associated with retained placenta and increased infection Bipartate placenta - bilobed (uncommon) Placenta membranacea - failure of chorion to atrophy during development, placental cotyledons form envelope around greater part of uterine wall

Answer 84

PLACENTA ACCRETA Placenta morbidly attached to uterine wall - chorionic villi penetrate the decidua basalis to attach to myometrium PLACENTA INCRETA villi penetrate deeply into myometrium PLACENTA PERCRETA villi breech myometrium into perioteum

Answer 85

1/2500 deliveries 40% deliver before 38 weeks C-section planned at 36-37 weeks RFs - Previous C-section - Placenta praevia - Increased age

Answer 86

Placenta is left in place with therapeutic uterine artery embolization, surgical internal iliac artery ligation or methotrexate therapy Elective hysterectomy later has less blood

Answer 87

Premature separation of a normally placed placenta before delivery of the foetus with blood collecting between placenta and uterus - 30% of all APH - 6 per 1000 births Concealed (20%) - haemorrhage confined within uterine cavity, more severe as blood loss usually underestimated Revealed (80%) - blood drains through cervix

Answer 88

``` Previous abruption Pre-eclampsia Multiple pregnancy Threatened miscarriage Hypertension Multiparity Past C-section Smoking Non-vertex presentation Cocaine/amphetamines Thrombophilia Intrauterine infections Polyhydramnios Trauma - RTA, domestic violence, iatrogenic ```

Answer 89

``` Vaginal bleeding Continuous abdominal pain Uterine contractions Shock Foetal distress ``` CLINICAL DIAGNOSIS - Tense, tender uterus with woody feel - Foetal hypoxia with HR abnormality on CTG - Low platelet count - Large level of compensation

Answer 90

``` Mothers life takes priority ABCD Crossmatch 4 units Kleihauer test for anti-D Left lateral position ``` Delivery - If foetus alive, C-section or artificial rupture of amniotic membranes If foetus dead - vaginal delivery

Answer 91

Physical exam/US History - LMP Naegele's rule - EDD = -3months + 7 days from LMP Uterine size - 6-8weeks = small pear, 8-10 weeks = orange, 10-12weeks = grapefruit 16 weeks = midway pubic symphysis and umbilicus 20 weeks = umbilicus US - gestational sac diameter (until embryo visible) - Crown rump length - After 10 weeks - biparietal diameter and head circumference Foetal biometry - Biparietal diameter - Head circumference - Femur length - Abdominal circumference

Answer 92

``` Amenorrhoea Nausea and vomiting Breast enlargement and tenderness Increased urinary frequency Fatigue ``` ``` Uterine cramping Abdominal bloating Constipation heartburn SOB Mood changes Food cravings/aversions ```

Answer 93

hCG - first secreted 6-8 days post ovulation - doubles every 30-50 hours during the first 30 days - slower rise in abnormal pregnancy - urine requires high levels to detect US - gestational sac at 4-5 weeks - yolk sac from 5 weeks to 10 weeks - foetal pole and cardiac activity 5-6 weeks

Answer 94

operator error (home kits) pregnancy loss soon after implantation interference from hCG from infertility treatment hCG from tumour Pituitary hCG secretion in perimenopausal women

Answer 95

Pregnancy induced hypertension in association with proteinuria +/- oedema Characterised by - Maternal hypertension - Proteinuria - Oedema - Foetal IUGR - premature birth Severe SBP > 160, diastolic >110 Foetus may have neurological damage post-hypoxia

Answer 96

2nd leading cause of direct maternal death - 5 per 1000 - Death rate 0.4 per 100,000 - 20% stillbirths without congenital abnormality is caused by pre-eclampsia - 50% with severe will deliver by 36 weeks ``` RFs HIGH - past pre-eclampsia, eclampsia, hypertension in a previous pregnancy - pre-existing hypertension - Pre-existing CKD - Pre-existing diabetes - SLE or APLS ``` MODERATE - 10+ years since last pregnancy - first pregnancy - aged over 40 - BMI>35 - FHx of pre-eclampsia - multiple pregnancy

Answer 97

Suboptimal uteroplacental perfusion associated with maternal inflammatory response and maternal vascular endothelial dysfunction Phase 1 - Abnormal placentation NORMAL - During 6-18 weeks placentation occurs - Alterations in spiral arteries occur to increase blood supply - Trophoblasts invade spiral arteries to 5x diameter - Coverts low flow, high pressure to low resistance, high flow PRE-ECLAMPSIA - inadequate trophoblast invasion, inadequate placental perfusion - Causes IUGR and pre-eclampsia Phase 2 - endothelial dysfunction - Platelet adhesion and thrombosis - Exaggerated maternal systemic inflammatory response - Decreased organ perfusion - HELLP

Answer 98

Systolic BP>140, diastolic >90 in 2nd half of pregnancy with >1+ of proteinuria - New hypertension - New proteinuria SEVERE - Severe frontal headache - Sudden swelling (oedema) - Liver tenderness - Visual disturbance - Epigastric pain - Vomiting - Low platelet count - Raised ALT and AST - Clonus - HELLP syndrome - Papilloedema - Foetal distress

Answer 99

If patient has any risk factors - increasing frequency of BP and urine measurements Admit if they have: - BP>140/90, >1+ proteinuria - Systolic BP >160 - Diastolic >100 - Any symptoms or signs

Answer 100

- Urinanalysis - microscopy, culture - Frequent monitoring of FBC, LFTs, renal function, electrolytes & urate - Look for HELLP syndrome - Clotting if severe or thrombocytopaenia - 24 hour urine for protein and creatinine - Assessment of foetus - US and amniotic fluid

Answer 101

Haemolysis Elevated Liver enzymes Low Platelets

Answer 102

Conservatively until at least 34 weeks where possible (no HELLP) Delivery of the placenta is the ONLY cure SEVERE - Antihypertensives (labetolol) if BP>160/110 Can also use nifedipine or hydralazine - Magnesium sulphate to prevent seizures - Fluid restruction - to minimise fluid overload which can result in pulmonary oedema - Delivery - If under 34 weeks, give corticosteroids - Method of delivery depends on presentation of foetus, foetal condition and chance of success - IM syntocinon to prevent haemorrhage - Prophylaxis against VTE

Answer 103

``` Resuscitation Magnesium sulphate as anticonvulsant Intubation may be required if repeated seizures IV labetalol or hydralazine Continuous foetal monitoring Monitor fluid intake, and urine output Attempts to prolong pregnancy not of use ``` - it is unsafe to deliver a baby from an unstable mother - Control seizures, reduce HTN and correct hypoxia - c-section

Answer 104

``` Haemolysis HELLP AKI DIC Adult respiratory distress syndrome Cerebrovascular haemorrhage ```

Answer 105

75mg aspirin from 12 weeks if high risk

Answer 106

``` Low nutrition Risk of anaemia Oral hygiene issues Infection from needles Increased risk of mental health problems Increased obstetric complications Increased premature delivery ```

Answer 107

``` IUGR Pre-term delivery Increase perinatal mortality Increased miscarriage Increased placental abruption ```

Answer 108

Maintenance with methadone to stop/minimise illicit use Detox in first trimester has high miscarriage risk Can detox in 2nd or 3rd trimester, small frequent reductions Withdrawal will increase foetal distress and still birth

Answer 109

STOP - no safe prescribed alternative

Answer 110

Increased miscarriage, still birth PROM Placental abruption Preterm labour For baby - stroke - poor growth - deformed limbs - feedbing problems - brain damage - SIDS NO BREAST FEEDING

Answer 111

Increased pre term delivery Still born IUGR Increased neonatal death Neonatal withdrawal syndrome - high pitch cry, poor feeding, tremors, irritability, D&V, sweating, seizures ``` Heroin = NO BREAST FEEDING Opiates = OK to breastfeed ```

Answer 112

60-80% success rate Starting labour by uterine stimulation. Approximately 20% of births. Offer to women in healthy pregnancy over 41 weeks to decrease risk of still birth Offer to diabetic women before term Offer if PROM after 37 weeks - Membrane sweep - Prostaglandin gel or pessary (PV) - Oxytocin +/- artificial rupture of membranes Monitor with CTG for myometrial over-reaction

Answer 113

``` Severe placenta praevia Transverse foetal lie Severe cephalopelvic disproportion Cervix <4 on Bishop's score Active primary genital herpes infection High and floating foetal head (risk of prolapsed cord) ```

Answer 114

Uterine Hyperstimulation - foetal distress, hypoxic damage Uterine rupture Intrauterine infection with prolonged membrane rupture Prolapsed cord if presenting part not engaged Amniotic fluid embolization Atonic PPH

Answer 115

Presence of supporting person with the woman at all times Mother labouring in upright or left lateral position Avoidance of epidurals

Answer 116

Score for ripeness of cervix | >8 = successful delivery

Answer 117

OUTLET - foetal scalp visible, labia separated Foetal skull has reached pelvic floor Rotation required > 45 degrees LOW - leading point (not caput) is at +2, rotation required MIDCAVITY - head 1/5 palpable per abdomen, leading point >2+ but not above ischial spines HIGH = not recommeded

Answer 118

Presumed or diagnosed foetal compromise Protect head during breech delivery ``` MATERNAL Avoid Valsalva manourvre Hypertensive crisis CV disease Myasthenia gravis Spinal cord injury ``` Inadequate progress - Active stage > 2 hours in nulliparous, >1 hour in multiparous - Maternal fatigue

Answer 119

Predisposition to fractures in foetus Bleeding tendency or active bleeding in foetus Face presentation Vacuum extractor should not be used under 34 weeks

Answer 120

``` Fully dilated cervix Occipital-anterior position Ruptured membranes Cephalic presentation Engaged presenting part Pain relief adequate Sphincter (bladder) empty ``` Mediolateral episiotomy before instrumental delivery to reduce tears If unsuccessful with 3 pulls - c-section

Answer 121

``` Rigid perineum preventing delivery Large tear imminent Instrumetnal delivery Shoulder dystocia Vaginal breech delivery ```

Answer 122

Right mediolateral incision with local anaesthetic

Answer 123

1st - injury to vaginal epithelium and vulval skin only 2nd - injury to perineal muscles but not anal sphincter 3rd - injury to perineum, involving anal sphincter 4th - injury to perineum, anal sphincter complex and anal or rectal mucosa

Answer 124

``` uteroplacental insufficiency prolonged pregnancy > 41 weeks IUGR Oligo or anhydramnios Abnormal uterine or umbilical artery Doppler Non-reassuring CTG PROM Severe pre-eclampsia, eclampsia Intrauterine death of foetus APH Chorioamnitis ``` Severe hypertension Uncontrolled diabetes Deteriorating renal function Malignancy

Answer 125

Cervical ripening - Separation of membranes from the cervix - stretch and sweep Amniotomy - Artificial rupture of membranes Prostaglandins - DINOPROSTONE - Intravaginally as tablets or gel - VE after 6 hours - CTG before and after - Only 2 doses as risk of Hyperstimulation Oxytocin infusion - best after rupture of membranes - wait 6 hours after prostaglandins - continuous CTG and want 3-4 contractions in 10 minutes

Answer 126

Begins with regular contractions when the foetal presenting part has reached true pelvis End when the cervix is fully dilated (10 cm) Latent phase - 2-24 hours - Cotnractions not painful, 5-10 minute intervals - Cervix dilating slowily ACTIVE PHASE - Primi - 12-14 hours, multi 6-10 hours - Start when cervix 3-4 cm dilated - Rapid dilation 0.5-1cm per hour - Foetal head descends into maternal pelvis and foetal neck flexes

Answer 127

Hourly temp and HR 4 hourly BP 30 minute monitoring frequency of contractions Foetal HR auscultated for 1 minute immediately after a contraction every 15 minutes Should be 100-160 VE every 4 hours Discuss need for pain relief

Answer 128

Starts when cervix is fully dilated Ends with birth of baby Contractions are stronger, 2-5 minute intervals lasting 60-90 seconds Primigravida 60 minutes, multi 30 minutes Feotal head descends and rotates anteriorly Wants to push After head through, shoulders rotate to allow shoulders through Midwife/doctor present throughout Monitor contractions, and foetal HR ever 5 minutes Push during contractions, relax between If >2 hours nulliparous or > 1 hour multiparous then consider instrumental delivery or c-section

Answer 129

Starts with birth of baby Ends with delivery of placenta and membranes Separation of placenta occurs immediately after birth 20-30 minutes or 5-15 with active management Haemorrhaging prevented by contraction of uterine muscle fibres Separation noted by gush of blood, prominence of fundus in abdomen and lengthening of umbilical cord

Answer 130

Expectant - uterus rubbed up to produce contraction, uterus pushed to vagina to aid expulsion Active - IM oxytocin after birth Controlled traction of umbilical cord to aid expulsion Examine placenta and membranes for completeness

Answer 131

Mild Irregular Non-progressive can occur from 30 weeks, more common after 36 weeks

Answer 132

Criteria <2cm progression in 4 hours - Slowing in progress in parous woman ``` Insufficient uterine activity (power) Malpositions, malpresentation, large baby (passenger) Inadequate pelvis (passage) ```

Answer 133

Amniotomy and reassess in 2 hours Amniotomy + oxytocin infusion C-section if foetal distress

Answer 134

``` Decreased PPH Decreased length of time in 3rd stage Decrease blood loss Decreased post-natal anaemia Decreased transfusions ```

Answer 135

Contractions of sufficient strength and frequency to effect progressive effacement and dilation of cervix before 37 weeks Very premature is before 32 weeks

Answer 136

``` Multiple pregnancy Genital tract infection P-PROM Antepartum haemorrhage Cervical incompetence Congenital uterine abnormality APLS Diabetes Past pre-term delivery ``` 30% are unexplained and spontaneous

Answer 137

If under 30 weeks with in tact membranes, no investigations If over 30 weeks - TV US to estimate cervical length - Foetal fibronectin: if less than 50 then unlikely to be pre-term labour No VE if ruptured membranes unless confirmed labour Vaginal swabs

Answer 138

Tocolytic drugs - not if P-PROM - Nifedipine - Can delay delivery for up to 7 days Corticosteroids if between 24 and 36 weeks Magnesium sulphate to reduce risk of CP Emergency cervical cerclage if between 16 and 34 weeks with dilated cervix and exposed unruptured membranes Delivery vaginally if cephalic Breech under 32 weeks = C-section Most over 30 weeks survive without lasting abnormality

Answer 139

Maternal support Environment - light diet, keep mobile, soothing music, comfortable position Birthing pool - not within 2 hours of opioids due to drowsiness

Answer 140

Entonox - Inhaled - Patient controlled, works in seconds, wears off quickly, minimal side effects IM opiate - SE nausea, vomiting, drowsiness - Pethidine - Short term respiratory depression and drowsiness - Drowsy neonate Epidural - Central nerve block with local anaesthetic - Most effective, avoids further analgesia for instrumental delivery. - Increases length of 2nd stage, rate of operative delivery - Can cause transient hypotension, dizziness - Severe headache if dural tap - need CTG Local anaesthesia - if tear, episiotomy or instrumental delivery

Answer 141

Epidural - extradural catheter placement - cannula allows top up - patchy analgesia Spinal - subarachnoid injection - 1 off injection, can last 2-4 hours - dense, reliable block

Answer 142

``` Unknown Complication of prematurity Peripartum asphyxia Postnatal (encephalitis, accidents) Perinatal infection (CMV, rubella) Multiple pregnancy Chromosomal abnormality ```

Answer 143

Dizygotic - non identical twins - Foetus has it's own placenta, own amnion and chorion Monozygotic Depends on when the embryo splits - 3 days: 2 chorion, 2 amnion - 4-7 days, 1 placenta, 1 chorion, 2 amnion - 8-12 days: 1 placenta, 1 chorion, 1 amnion - 13 days - conjoined twins

Answer 144

RFs at only for dizygotic twins - monozygotic has no RFs ``` - Past multiple pregnancy FHx on maternal side Increased maternal age West African Assisted conception ```

Answer 145

Refer to obstetrics US as normal at 11-13 wees and 18-20 for abnormality Monitor carefully for IUGR and feto-feto transfusion syndrome Scan Dichorionic - 20, 24, 28, 32 and 26 weeks Monochorionic - 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks Inform - increased risk of Down's and increased risk of false positive on screening - Twins use combined test - Triplets use nuchal translucency Take 75mg aspirin OD from 12 weeks if 1st pregnancy, over 40, pregnancy interval over 10 years, BMI > 35or FHx of pre-eclapmsia

Answer 146

Offer elective birth at 36 weeks (mono-chorionic) after course of steroids Dichorionic - 37 weeks Triplets - 35 weeks If 1st twin is cephalic presentation then trial vaginal delivery, if breech or transverse then C-section - May need IV oxytocin after first child as contractions can decrease - 2nd should be born within 45 minutes

Answer 147

``` Increased miscarriage anaemia pre-eclampsia APH PPH C-section symptoms of pregnancy Polyhydramnios Hyperemesis gravidarum Post natal illness death ```

Answer 148

``` Increased Still birth pre-term birth neonatal mortality morbidity FFTS Umbilical entanglement IUGR congenital abnormality ```

Answer 149

``` Increased blood volume Decreased Hct (due to dilution) - anaemia of pregnancy is physiological Increased RBC Increased stroke volume, cardiac output Decreased peripheral vascular resistance BP stable or decreased ``` Increased tidal volume Decreased functional residual capacity from gravid uterus Decreased total lung capacity Increased clotting Increased renal function increased uterine blood flow Increased uterine weight No autoregularion of uterine blood flow - hypotension can cause foetal distress

Answer 150

Otherwise can have overt caval compression- IVC compression - Hypotension - Sweating - Bradycardia - Pallor - Nausea and vomiting

Answer 151

L3/L4 Pierce the ligamentum flavum before dura Use heavy LA to prevent upwards movement Uterus supply at T10 - block up to nipple line (T4) Phenyepherine - alpha blocker to counteract hypotension Inject bupropripcaine - 20x safer than GA

Answer 152

``` Avoid at all costs Need to neutralise stomach acid with ranitidine and metoclopramide No strong opioids prior to delivery Difficult airway Give +++ oxygen before anaesthesia ``` Only if spinal or epidural contraindicated e.g. raised ICP, coagulopathy, patient refusal or infection

Answer 153

``` MATERNAL Past C-section cardiac problems pre-eclampsia prolonged pregnancy >42 weeks PROM induction of labour Diabetes APH ``` ``` FOETAL IUGR prematurity oligohydramnios abnormal Doppler multiple pregnancy meconium stained liquor breech position ``` ``` INTRAPARTUM oxytocin augmentation epidural anaesthesia intrapartum PV bleed pyrexia > 37.5 fresh meconium bleeding abnormal foetal HR prolonged labour ```

Answer 154

110-160 Bradycardia <110 Tachycardia > 160

Answer 155

Normal 5-25bpm Reduced 0-5 Saltatory >25

Answer 156

Transient rise in FHR > 15 bpm for >15 seconds Transient decrease as above Early decelerations - peaks co-incides with contraction and is due to head compression - 2nd stage of labour Late decelerations - acidosis, if shallow with decrease baseline variability very concerning

Answer 157

``` Position - not left lateral Hypotension VE Emptying bladder or bowels Vomiting Vasovagal episodes Topping up anaesthesia ```

Answer 158

Taken from scalp via needle and speculum Obtain if pathological CTG Woman in L lateral Normal ph>7.25 then repeat in 1 hour if CTG still abnormal Borderline 7.21-7.24, repeat in 30 mins Abnormal <7.20 IMMEDIATE DELIVERY

Answer 159

Smoking Previous pre-term delivery Vaginal bleeding Lower genital tract infection

Answer 160

``` No VE Visualise amniotic fluid draining through cervix Sterile speculum exam US to determine liquor volume 12 hourly temperatures Foetal monitoring ```

Answer 161

Refer to hospital, admit for first 48 hours Prophylactic antibiotics Antenatal steroids if between 24 and 35 weeks Consider delivery post-34 weeks

Answer 162

``` prematurity Sepsis Pulmonary hypoplasia Umbilical cord prolapse Placental abruption Oligohydramnios Increased retained placenta and PPH ```

Answer 163

As common as depression Most common in first few weeks post-natally 10-15% ``` MAJOR RF Previous history of MH problems Psychological disturbance in pregnancy Poor social support Poor relationship with partner Baby blues Recent major life events ``` ``` Other RF Unplanned pregnancy Not breast feeding Unemployment Antenatal parental stress Depression in father 2+ children Neonatal illness/death/SIDS Substance misuse Low family outcome History of abuse ```

Answer 164

``` Low mood Anhedonia Anxiety Disturbed sleep Decreased appetite Poor concentration Decreased self-esteem Decreased energy Decreased libido Suicidal thoughts ```

Answer 165

``` Hx or FHx or MH problem Physical wellbeing Alcohol and drug misuse Mother-baby relationship Relationships, social networks, isolation Domestic violence, abuse, sexual abuse, trauma Housing Employment Economic and migration status ```

Answer 166

Mild-moderate = consider self-help strategies Mild + history of severe depression = consider antidepressant Moderate-severe = CBT, antidepressants or combination Psychological therapies are first line Women can breastfeed unless taking = lithium, sodium valproate, carbamazepine, clozapine Higher threshold for pharmacological therapy due to risk

Answer 167

Adverse effects in the children Poorer cognitive, emotional, social and behavioural development Post-partum psychosis 1/1000 - first few weeks - psychiatric emergency - paranoia, delusions, hallucinations, loss of inhibition Most resolves in 3-6 months Course of illness widely variable

Answer 168

81% of mothers, increasing 1/3 are still breast feeding at 6 months Only 1% are exclusive breast feeding at 6 months More likely to breast feed if... - From ethnic minority group (Chinese, black) - managerial and professional occupation - aged over 30 - Live in England (vs. rest of GB) - First time mother - Left full time education over 18

Answer 169

``` Free No preparation Immunity Infection protection (decreased LRTI, otitis media, gastroenteritis) May protect against asthma and eczema Decrease SIDS Protection from future Type 2 diabetes (in mother and child) Decrease breast and ovarian cancer Contraception - lactational amenorrhoea ```

Answer 170

issues with feeding in public low in vitamin D (may need supplements) transmission of HIV and hep C Can transmit maternal infection - N. gonorrhoea, H. influenza, group B strep, staph cracked/sore nipples blocked ducts and breast engorgement mastitis thrush

Answer 171

Nipple soreness is very common in the first few weeks Caused by - improper positioning of baby - alter - improper feeding technique - incomplete suction release - improper nipple care - excessively dry or moist

Answer 172

caused by poor drainage of the breast swollen, hard, painful, redness nipples can protrude to allow baby to latch causes by pressure on breast and prolonged gaps between feeds nurse 8+ times in 24 hours for 15+ minutes can develop in mastitis if persists

Answer 173

occurs in 20% Increased if: nipple damage, over supply of milk, S.aureus Engorgement can lead to mastitis which can lead to abscess Treat with flucloxacillin

Answer 174

Should begin within an hour of birth It should be on demand - when baby wants it Avoid pacifiers or bottles Baby head and body in line Hold baby close Place baby nipple to nose - baby will tip head back Milk released by oxytocin

Answer 175

Infant born to mother addicted to opioids at the risk of withdrawal. - Heroin - Methadone

Answer 176

CNS - tremors - irritability - increased wakefulness - high pitched cry - hypertonicity - hyperactive reflexes - seziurs - yawning, sneezing GI TRACT - poor feeding - uncoordinated, constant sucking - vomiting - regurgitation - loose, watery stools - dehydration AUTONOMIC - increased sweating - nasal stuffiness - fever - temperature instability - tachypnoea - mottling of skin Starts within 24 hours if heroin or 24-72 days if methadone

Answer 177

Decrease sensory stimulation Small frequent feeding Increased calorie dense formula MONITOR Pharmacology if seizures, poor feeding, fever, significant D&V Opioid therapy - morphine/methadone/buprenorphine Adjunct therapy if multiple drug exposure = phenobarbital

Answer 178

Normally discussed at 6 week GP check ``` Contraceptive needs Future child plans Any periods Breastfeeding Any medical conditions ```

Answer 179

Barrier methods POP Progesterone only injectable and implants

Answer 180

COCP Barrier methods POP Progesterone only injectable and implant IUS over 6 weeks

Answer 181

Lactational amenorrhoea methods POP Progesterone only implants Barrier methods

Answer 182

``` LAM POP Progesterone injectable and implant IUS - from 6 weeks IUD Barrier methods Sterilisation ``` No COCP until after 6 months

Answer 183

Under 6 months post partum Amennorhoeic Full daily breast feeding

Answer 184

From the time of birth to expulsion of placenta

Answer 185

Prolonged if not completed in: 30 minutes - active 60 minutes - physiological

Answer 186

Active management - routine use of uterogenic drugs - oxytocin IM with birth of anterior shoulder - deferred clamping and cutting of cord (between 1 minutes to 5 minutes) - controlled cord traction Physiological - delivery of placenta by maternal effort

Answer 187

Apgar score at 1 minute and 5 minutes Record time from birth to regular respirations Skin to skin contact Avoid separation of mother and baby for 1 hours Encourage breast feeding within 1st hour Record head circumference, body temp and weight

Answer 188

``` Assess uterine contraction and lochia Examine placenta and membranes Assess emotional and physical condition Successful voiding of bladder Assess for genital trauma If genital trauma then rectal exam If required perineal repair ```

Answer 189

Excessive bleeding post-delivery Primary - loss of blood >500ml within 24 hours of delivery MINOR - 500-1000ml MAJOR - over 1000ml Secondary - abnormal bleeding between 24 hours and 6 weeks

Answer 190

Tone - uterine atony (most common), distended bladder Trauma - lacerations of uterus, cervix or vagina Tissue - retained placenta, clots Thrombin - pre-existing or acquired coagulopathy

Answer 191

5-10% Severe less than 1% Increased in Asians Increased in over 40s Antenatal RF - APH - Placenta praevia (x12) - Placental abruption - Multiple pregnancy (x5) - Uterine over-distension (polyhydramnios, macrosomia) - pre-eclampsia - multi parity > 4 - previous PPH or retained placenta - increased if BMI > 35 Delivery RFs - emergency section (x4) - elective seciont (x2) - Retained placenta (x5) - episiotomy (x5) - induction of labour - instrumented delivery - labour > 12 hours - Baby > 4kg - Maternal pyrexia in labour Clotting disorders

Answer 192

Resusciattion - Minor = 14G cannula and crystalloid infusion - Major = ABCs, high flow O2, 2x14G cannula, transfuse bloods ASAP and Hartmanns until blood available Monitor and investigate - Minor = blood group, coag screen - Major = FBC, coag, U&E, LFTs, crossmatch 4 units. Consider arterial line and ITU transfer, MEOWS charts Stop bleeding - If uterine atony: - bimanual uterine compression - empty bladder - oxytocin infusion - ergometrine - carboprost or misoprostol - balloon tamponade - haemostatic brace suturing - bilateral ligation of uterine or internal iliac arteries - selective arterial embolization Hysterectomy - should be a 2 consultant decision

Answer 193

``` Hypovolaemic shock DIC AKI Liver failure Acute respiratory distress syndrome Death in 1 in 100,000 deliveries ```

Answer 194

Infection - endometritis | Retained products of conception

Answer 195

1-3% of vaginal deliveries ``` C-section prolonged rupture of membranes severe meconium staining in liquor long labour with multiple examinations manual removal of placenta extremes of maternal age decreased socio economic status maternal anaemia prolonged surgery ```

Answer 196

``` fever abdominal pain offensive smelling lochia abnormal vaginal bleeding abnormal vaginal discharge dyspareunia dysuria malaise ```

Answer 197

``` fever rigors tachycardia tenderness of suprapubic area and adnexa elevated boggy uterus if retained products of conception ```

Answer 198

``` FBC Blood cultures MSU High vaginal swab - gonorrhoea, chlamydia US if ?RPOC ```

Answer 199

Urgent referral if any red flags (sepsis) - pyrexia >38 - sustained tachycardia >>90 - RR >20 - abdominal and chest pain - D+V - uterine or renal angle pain - IV antibiotics (for endometriits) - piperacilin/taxobactam (tazocin)

Answer 200

``` Increased in developing countries 30% detected through screening 13th most common cancer in females 1 per 10,000 Peak age 25-29 ``` RF - HPV 16 and 18 - Heterosexual - multiple sexual partner - Smoking - Lower social class - Immunosuppression - COCP

Answer 201

70% squamous carcinoma 15% adenocarcinoma 15% mixed CIN - CIN1 - disease confined to lower 1/3 epithelium - CIN2 - confined to lower and middle 1/3 of epithelium - CIN3 - full thickness of epithelium

Answer 202

``` Abnormal vaginal bleeding vaginal discharge bleeding - post coital, on micturition or defaecation Vaginal discomfort Urinary symptoms ``` Late symptoms - painless haematuria - chronic urinary frequency - painless fresh rectal bleeding - altered bowel habit - leg oedema, pain, hydronephrosis If any suspicion refer on 2 week wait, do not do a smear

Answer 203

``` White patches on cervix Abnormal cervical appearance - erosion, ulcer, tumour Mass on rectal exam Pelvic bulkiness or mass peripheral oedema Hepatic/pulmonary mets ```

Answer 204

Pre-menopausal - STI screen Post-menopausal - urgent gynae referral ``` Colposcopy - cleaned with acetic acid - Insepction +/- biopsy +/- treatment Cone biopsy FBC, U&Es, LFTs ```

Answer 205

``` FIGO staging Based on tumour size Vaginal or parametrial involvement Bladder or rectum involvement Mets ``` Most are diagnosed in early stages

Answer 206

Surgery, radiotherapy, chemotherapy or combination Fertility sparing treatment may be important If pregnant may delay for a few weeks or abort Surgery - If fertility sparing, removal with margins - Or hysterectomy - Radical: Wertheim's hysterectomy: tumour + main lymph nodes + upper 1/3 vagina Radiotherapy - external beam or internal brachytherapy Chemo - cisplatin

Answer 207

``` 1 = 90% survival at 5 years 2 = 60-90% 3 = 30-50% 4 = <20% ```

Answer 208

HPV vaccine 16 and 18 or 16, 8, 6 and 11 (includes for warts) - Given in females aged 11 to 13 2 doses

Answer 209

From 25 Every 3 years until 50 After 50 every 5 years until 65

Answer 210

Mainly adenocarcinoma from lining of uterus | OESTROGEN DEPENDENT

Answer 211

90% are over 50 Increased with age Most common in Western societies 3% of total cancer cases RF - prolonged periods of unopposed oestrogen - Nulliparous - Post menopausal - Obesity - Endometrial hyperplasia - PCOS - HNPCC - Diabetes - Tamoxifen

Answer 212

POST MENOPAUSAL BLEEDING IS endometrial cancer unless proven otherwise

Answer 213

TV US - 3mm cut off for endometrial cancer Endometrial biopsy - pipelle - done as outpatient and offers definitive diagnosis - hysteroscopy and biopsy

Answer 214

TAH and BSO for all If stage 2 - TAHBSO and systematic pelvic node clearance If stage 3/4 - debulking surgery - surgery/radio/chemotherapy

Answer 215

Epithelial (85-90%) - In over 50s - Serous is most common subtype (40-60 years) - Endometroid - Clear cell tumour - Mucinous tumour Germ cell (2-10%) - derived from germ cells of embryonic gonad - <35 - Curable - Rapid enlarging, bloating, pain, rupture, torsion - Dysgerminoma, endodermal sinus tumours, teratoma, embryonal carcinoma, choriocarcinoma Sex cord stromal tumour (<5%) - derived from connective tissue cells Borderline (10-15%) - Not benign or malignant - Do not respond well to chemotherapy

Answer 216

2% lifetime risk 17 per 100,000 Peaks in 70-80s RF - Increasing age - Smoking - Obesity - Decreased exercise - Talcum powder use pre 1975 (asbestos) - Hx of infertility or treatment - Nulliparous - FHx - BRCA1 or 2 - Endometriosis - HRT Protective factors - COCP, child bearing, breastfeeding, early menopause

Answer 217

``` 58% present with stage 3 or 4 Insidious onset - Abdominal discomfort Distension Bloating Urinary frequency Dyspepsia Pelvic or abdominal mass associated with pain Abnormal uterine bleeding Ascites Pleural effusion ```

Answer 218

Refer with any mass or ascites Test over 50s if symptomatic with multiple attendances Test over 50s with new IBS CA125 If raised then US and refer CT pelvis and abdo for staging If aged under 40, alpha fetoprotein (endodermal sinus tumours) - beta hCG for dysgerminomas, embryonal carcinoma, choriocarcinoma Biopsy prior to chemotherapy

Answer 219

1 limited to ovaries 2 one or both ovaries with pelvic extension 3 microscopically confirmed peritoneal deposits outside pelvic 4 distant mets

Answer 220

Explorative laparotomy for staging and tumour debulking TAH and BSO Conservative if fertility sparing Chemo post surgery - Paclitaxel and carboplatin Relapses are treated with chemotherapy CA125 useful for monitoring

Answer 221

``` Torsion Rupture Infection Malnutrition Electrolyte imbalance Bowel obstruction Ascites Pleural effusion ``` 10 year survival 35% Better outcome if under 40

Answer 222

Irregular and frequent periods

Answer 223

``` Infection Cervical ectropion Cervical or endometrial polyps Vaginal cancer Cervical cancer Trauma ``` No specific cause is found in 50%

Answer 224

``` Pregnancy related - ectopic, GTD Physiological - 1-2% spot around ovulation Vaginal - adenosis, vaginitis, tumour STI Cervical cancer Cervical/endometrial polyps Ectropion Fibroids Endometrial cancer Adenomyosis Enodmetritis Oestrogen secreting ovarian cancers ``` Tamoxifen Missed oral contraceptive Drugs altering clotting - anticoagulants, SSRIs, steroids Dysfunctional uterine bleeding

Answer 225

``` LMP Usual cycle length and regularity Duration of abnormal bleeding Menorrhagia? Associated symptoms - abdo pain, fever, vaginal discharge, dyspareunia, aggravating factors ``` Previous pregnancies and deliveries Risk of current pregnancy RF for ectopic - PID, IVF, IUCD, POCP Current contraception Smear history Past gynae investigations or surgery Sexual history - STIs Medical history - diabetes, bleeding disorders Current medications

Answer 226

red ring around external os due to extension of endocervical columnar epithelium over ectocervix More common in young people on COCP

Answer 227

red, congested oedematous cervix May have purulent discharge with tender cervix on palpation Chlamydia or gonorrhoea

Answer 228

Trichomonas vaginalis infection Cervix is friable Prominent papillae Punctate haemorrhages

Answer 229

Women with abnormal looking cervix Suspicious looking cervical polyp Pelvic mass High risk of endometrial cancer (Fhx, prolonged or irregular cycles, on tamoxifen Over 45 + IMB Under 45 with persistent symptoms or RFs for endometrial cancer

Answer 230

``` Always exclude pregnancy Exclude STI Smears only if due FBC, clotting, TFT, FSH/LH TV US is investigation of choice (best to do immediately post-menstrually as thinnest and cysts and polyps most obvious) Endometrial biopsy using Pipelle Colposcopy ```

Answer 231

Bleeding at intervals <21 days

Answer 232

Abnormal uterine bleeding without any structural or systemic pathology Usually menorrhagia Diagnosis of exclusion

Answer 233

``` 40-60% have no pathology 20% anovulatory cycles Fibroids Endometrial polyps Endometriosis Adenomyosis PID Endometritis Endometrial hyperplasia/carcinoma Systemic disease - hypothyroid, liver or kidney disease, obesity, bleeding disorder IUCD Anticoagulants ```

Answer 234

``` FBC Haemotinics (iron deficiency) TFTs Assessment of bleeding disorders US to assess underlying pathology ```

Answer 235

Pharmacological 1. Mirena IUS 2. Tranexamic acid, NSAIDs (mefamic acid), COCP 3. Progestogens - POP or depot 4. 3-4 months of gonadotrophin releasing hormone (GnRH) 5. Hysterectomy/myomectomy Surgical - Endometrial ablation if not enlarged utuerus (not if large fibroids) - Radiofrequency/microwave etc. - Uterine artery embolization (if wish to keep uterus) - Hysteroscopic myomectomy - Hysterectomy

Answer 236

``` Vaginal discharge Increased period pain Need for additional surgery Infection Perforation ```

Answer 237

Bengin monoclonal tumours of smooth muscle cells of uterine myometrium with disordered collagen Growth is stimulated by oestrogens and progesterone

Answer 238

Intramural (most ) Submucosal (growing into uterine cavity) Subserosal - growing outwards from uterus

Answer 239

77% of women Increased in Africans 30-40 years old FHx (x2.5 if first degree relative) RF - Obesity - Early menarche Protective factors: increased parity, smoking and exercise

Answer 240

50% are asymptomatic 30-50 years old Excessive or prolonged heavy periods IMB Pelvic pain (especially in pregnancy due to pressure and resultant fibroid degeneration) Constipation/ urinary symptoms from pressure Recurrent miscarriage or infertility (only if submucosal) Palpable mass Enlarged irregular firm non-tender uterus Iron deficiency anaemia

Answer 241

``` Pregnancy test FBC and haematinics TV US MRI if US not definitive Endometrial sampling with pipelle for other causes Hysteroscopy and biopsy ```

Answer 242

- NSAIDs to reduce blood loss - Transexamic acid - COCP - Mirena coil - GnRH agonists decrease size but will regrow when stopped - Surgery: if pressure symptoms, increased uterine size, medical treatment insufficient or fertility affected - Myomectomy (recurrence rate 3%) - Hysteroscopic endometrial ablation - Laparoscopic hysterectomy

Answer 243

``` Iron deficiency anaemia Bladder frequency Constipation Infertility Problems in pregnancy - miscarriage, premature labour and PPH, IUGR. ```

Answer 244

Chronic oestrogen dependent condition characterised by growth of endometrial tissues in sites other than the uterine cavity

Answer 245

``` Pelvic cavity including ovaries Uterosacral ligaments Pouch of Douglas Rectosigmoid colon Bladder and distal ureter Rare sites - umbilicus, scar sites, pleura, pericardium, CNS ```

Answer 246

Invasion of myometrium by endometrial tissue

Answer 247

10-15% of women of reproductive age Exclusive to reproductive age Diagnosed in 30s ``` RFs - Infertile - Early menarche - Delayed child bearing - Long duration of menstrual flow - Obstruction to vaginal flow (hydrocolpos) - FHx (6x with first degree relative) Chromosomes 7 and 10 ``` Protective; multiparity and use of oral contraceptives

Answer 248

``` Dysmenorrhoea (painful periods) Dyspareunia Cyclical or chronic pelvic pain Subfertility Bloating Lethargy Constipation Lower back pain ``` ``` Less common: cyclical rectal bleeding menorrhagia diarrhoea haematuria ``` Severity of symptoms increase with age Worsening of symptoms at the time of menstruation or just prior to it

Answer 249

``` Examination often normal Posterior fornix or adenexal tenderness Palpable nodules Bluish haemorrhagic nodules in posterior fornix Chocolate cysts on ovaries ```

Answer 250

Lapararoscopy is gold standard Symptoms and laparoscopic findings do not always correlate TV US to exclude ovarian pathology ``` FBC, Urinalysis Cervical swabs beta hCG MRI may be useful ```

Answer 251

Medical treatment may decrease symptoms in 80-90% - Try suppressing ovarian function for 6 months - COCP, danazol, oral or depot progesterone, IUS - NSAIDs for pain - or GnRH analogues with add back therapy Surgery - Laparoscopic excision or ablalation - Endomeriomata (large cysts from endometriosis) need stripping out - Hysterectomy as last resort

Answer 252

Increased breast and ovarian cancers Infertility due to tubal damage Adhesions post-op Increased IBD

Answer 253

Decreased oestrogen Vaginal mucosa thins, drier, decreased elasticity Can become inflamed and lead to urinary symptoms Changes in vaginal pH and flora can predispose to UTIs

Answer 254

``` Natural menopause or oophorectomy Anti-oestrogen treatments: tamoxifen. aromatase inhibitors Radiotherapy Chemotherapy Post partum Breastfeeding ```

Answer 255

``` Vaginal dryness Burning/itching of vagina or vulva Dyspareuunia Vaginal discharge (white/yellow) Vaginal bleeding Post coital bleeding Urinary symptoms: frequency, nocturia, dysuria, recurrent UTI, stress incontinence ``` ``` Decreased pubic hair Narrow introitus Thin mucosa Diffuse erythema Dryness Lack of vaginal folds ```

Answer 256

Exclude other causes of PCB/infection/UTI Vaginal pH testing - alkaline Vaginal cytology - lack of maturation of vaginal epithelium Often a clinical diagnosis

Answer 257

Lubricants - short term relief Water or silicone based Moisturisers - regular use Hormonal treatments: - HRT topical Restores pH, thickens epithelium, improves lubrication Very effective in long term, minimal side effects

Answer 258

12 months of spontaneous amenorrhoea | Early menopause is between 40-45

Answer 259

``` Menstrual irregularity Hot flushes - head, face, neck, chest Sweats Urogenital symptoms - dyspareunia, vaginal discomfort, dryness, recurrent UTI, incontinence Sleep disturbance Mood changes - anxiety, nervousness, irritability Loss of libido Brittle nails, thinning skin, hair loss ```

Answer 260

Generally clinical Lab requirements only if under 45 Raised FSH Check TFTs Blood glucose cholesterol Check up to date with cervical and breast screening

Answer 261

Amennorhoea Raised gonadatrophins Oestrogen deficienct Women under 40

Answer 262

Decreased ovarian follicles at birth, accelerated follicle atresia or follicular dysfunction Mutations in FSH receptor Iatrogenic - surgery, radio or chemotherapy X linked chromosomal abnormality - Turners Autoimmune lymphocytic oophritis Infections - mumps, TB, malaria, chicken pox, CMV

Answer 263

Raised FSH - on 2 occasions, 4 weeks apart Decreased oestrodiol TFTs and prolactin DEXA scan Anti-Mullerian hormone as a measure of decreased ovarian reserve Test - adrenal antibodies, autoimmune, hypothyroid, diabetes, addison's

Answer 264

Manage depression and anxiety Lifestyle advice to decrease CV risk Adequate vitamin D and calcium HRT until 51 (no risks of HRT as under 50s)

Answer 265

``` Decreased vasomotor symptoms in 4 weeks Increased quality of life Increased sleep Increased mood Decreased vaginal atrophy Decreased osteoporosis risk Decreased CV disease (doesn't increase if started under 60) Decreased colorectal risk Decreased aging ```

Answer 266

``` VTE PE Stroke Breast and endometrial cancer (If BMI normal) Gallbladder disease ```

Answer 267

``` Breast tenderness Leg cramps Bloating Nausea Headache PMS Backache Depression Pelvic pain ```

Answer 268

``` Check personal and FHx of VTE Confirm no sinister pathology No maximal duration Transdermal has fewer risks Continuous combined Erratic bleeding common for first 3-6 months ```

Answer 269

Follicular phase - follicles are stimulated due to rise of FSH Ovulation - ovarian follicles mature, egg released, rise in oestrogen causes rise of LH. LH surge causes release of egg Luteal phase - corpus luteum forms and produces progesterone which causes decrease in FSH and LH. When corpus luteum dies, decrease in progesterone which causes menstruation

Answer 270

LH remains at baseline until day 12-14 where there is very large LH surge There is a corresponding increase in FSH during this period but much lower than LH

Answer 271

oestrogen peaks just before ovulation | progesterone is low until after ovulation at which is steadily rises before dropping just before mensturation

Answer 272

Thought to be due to excess or imbalance of prostaglandins and leukotrienes in the menstrual fluid Causes vasoconstriction in uterine vessels Causes uterine contractions and pain

Answer 273

Low anterior pelvic pain which occurs in association with menstruation

Answer 274

Primary - Occurs in young females with no pelvic pathology - Often begins 6-12 months after menarche - Pain begins with onset of period and lasts for 24-72 hours Secondary - Occurs in association of pelvic pathology - Can precede period by several days and last for the whole period - May be associated with dyspareunia

Answer 275

``` Endometriosis Adenomyosis PID Fibroids Adhesions Developmental abnormalities IUD ```

Answer 276

Invasion of myometrium with endometrial tissue Causes inflammation, pain and adhesions Chronic pelvic pain, dyspareunia and infertility

Answer 277

Very common, incidence unknown RFs - Longer duration of periods - Early menarche - Smoking - Alcohol - Obesity - Depression Severity decreases with age Incidence decreases with childbirth

Answer 278

Pain is usually suprapubic, but may be felt in the lower back/ back of legs May have pathological features: discharge, IMB or PCB, dyspareunia Dyschezia/rectal pain - endometriosis Hx features - age at menarche, cycle length, regularity, duration of period, timing of pain, smoking, sexual activity, obstetric and contraceptive history

Answer 279

``` Speculum High vaginal swab/chlamydia screen Smear (if due) Pelvic US/TV US MRI Laparoscopy ```

Answer 280

``` Lifestyle - smoking cessation TENS and locally applied heat NSAIDs - all are equally effective COCP POP Depo-medroxyprogesterone The above only if not trying to conceive ``` If trying to conceive then Danazol (only under specialist) Surgery - laparoscopic uterine nerve ablation or hysterectomy (only in refractory)

Answer 281

``` UTI Miscarriage Ectopic pregnancy Torsion or rupture of ovarian cysts PID In late pregnancy - premature labour, placental abruption, uterine rupture Ovulation Dysmenorrhoea Degeneration of fibroid Pelvic tumour Pelvic vein thrombosis ``` Appendicitis, IBS, adhesions, prostatitis, strangulated hernia

Answer 282

Associated post partum or in malignancy Pelvic pain Fever Abdominal mass

Answer 283

``` Urinalysis MSU High vaginal swab and endocervical swab Pregnancy test FBC Urgent US - if ?ectopic or miscarriage Laparoscopy (if severe) ```

Answer 284

Intermittent or constant pain in lower abdomen for >6 months. Does not occur exclusively with menstruation or sex Not associated with pregnancy

Answer 285

``` Endometriosis Adhesions IBS Interstitial cystitis MSK Pelvic organ prolapse Nerve entrapment Psychological and social issues - depression, physical or sexual abuse as children ```

Answer 286

``` Rectal bleeding New bowel symptoms in over 50s New pain after menopause Pelvic mass Suicidal ideation Excessive weight loss Irregular vaginal bleeding in over 40s PCB ```

Answer 287

``` STI screen] FBC, CRP CA125 if ?ovarian Ca (new IBS >50 is suspicious) Urinalysis and MSU TV US MRI if ?adenomyosis Diagnostic laparoscopy is gold standard ```

Answer 288

Treat cause and psychological causes Challenging as pain often continues after treatment without diagnosis Treat underlying disorder Most managed in primary care If cyclical pain can use COCP or GnRH agonists or mirena

Answer 289

Functional (24%) Benign (70%) Malignant (6%) Benign epithelial neoplastic cysts (60%) - Serous cystadenoma (40-50 years, papillary growths can appear solid, 20% malignant) - Mucinous cystadenoma (20-40 years - filled with mucinous material, become enormous, 5% malignant) Benign neoplastic cystic tumours of germ cell origin - Benign cystic teratoma (rarely malignancy, may contain well differentiated tissue, common in young women) Benign neoplastic solid tumours - Fibroma (<1% malignant, small solid, benign fibrous tumours - associated with Meig's syndrome and ascitets) - Thecoma - Adenofibroma - Brenner's tumour

Answer 290

30% of females with regular periods 50% of females with irregular periods Occur in premenopausal women Uncommon pre-menarche and post-menopausal RF - Obesity - Tamoxifen - Early menarche - Infertility - Dermoid can run in families

Answer 291

Asymptomatic Dull ache or pain in lower abdomen/back If rupture/torsion - severe abdominal pain and fever Dyspareunia Swollen abdomen, palpable mass Pressure effects - urinary frequent, peripheral oedema Torsion - severe pain, can be intermittent Rupture - peritonitis, shock, mucinous cystadeomas can continue to secrete mucin causing build up and death (psudomyxoma peritonei) Ascites

Answer 292

Ascites Pleural effusion Benign ovarian tumour (fibroma, fibrothecoma, Brenner tumour)

Answer 293

``` Pregnancy test FBC - infection, haemorrhage Urinalysis TV US CT or MIR if US inconclusive Diagnostic laparoscopy CA125 (do not do if premenopausal with cyst on US) - it is not reliable in distinguishing malignant/benign in fertile women LDH, AFP, beta - HCG for germ cell tumours ```

Answer 294

For suspected ovarian cancer Not to be used pre-menopausally Uses CA125, menopausal status and US score RMI = U x M x Ca125 US - 1 point each for: multilocular cysts, solid area, mets, ascites, bilateral lesions RMI > 200 = CT abdo pelvis

Answer 295

<50mm, expectant management 50-70mm = yearly US follow up >70mm = MRI/surgery Do not use COCP Laparoscopic removal If torsion may need oophorectomy and uncoiling Immediate surgery if haemorrhagic - more common in R ovary

Answer 296

More common in women 9% of all women Increase in 20s-30s and over 60s RFs - Sexually inexperienced - peri or post-menopausal

Answer 297

Superficial (felt at introits) OR deep (felt with thrusting and deep in pelvis) tightening of vaginal muscles on penetration - vaginismus When/where/duration Is intercourse possible? Desired? Any evidence of sexual abuse, rape or trauma Any FGM STI risk

Answer 298

Pain with arousal - Hymenal ring bands - Swelling of Bartholin's gland cyst Sensitive external genetalia - Vulvodynia - Chronic vulvitis - allergy, candida, herpes, trichomonas - Lichen planus/sclerosis Pain at introitus on penetration - Painful episiotomy scar - rigidity of hymenal ring - Inadequate lubrication - atrophic vaginitis - vaginitis - vaginismus - insufficient foreplay - congenital abnormality Mid vaginal pain - Acute/chronic cystitis - Urethritis - Shortened vagina Deep pain - PID - Vaginiits - Cervicitis - Malposition of IUS/IUD - Endometrisosis/adenomysosis - Fibroids - Fixed retroverted uterus - IBS - IBD - Pelvic mass - Interstitial cystitis

Answer 299

Swab for STIs Urine dip &; MSU US

Answer 300

``` Functional Stress Urge Mixed Overactive bladder syndrome Overflow True ```

Answer 301

Patient is unable to reach the toilet in time e.g. poor mobility or unfamiliar surroundings

Answer 302

Involuntary leakage of urine on effort or exertion e.g. sneezing or coughing. Due to incompetent sphincter May be associated with GU prolapse

Answer 303

Involuntary urine leakage accompanied or preceded by urgency of micturition Detrusor instability or hyper-reflexia leading to involuntary detrusor contraction Idiopathic or neurological

Answer 304

Involuntary leakage associated with both urgency and exertion

Answer 305

Urgency that occurs with or without urge incontinence and usually with frequency and nocturia

Answer 306

Usually due to chronic bladder outflow obstruction e.g. prostatic disease Can cause obstructive nephropathy

Answer 307

Fistulous track between vagina and ureter or bladder and urethra. Continuous urine leakage

Answer 308

``` Very common ~ 8%, up to 40% Increase in females Most common = stress incontinence Increases with age Increased if in institution ``` RFs - Pregnancy, vaginal delivery especially with forceps - Diabetes - Oral oestrogen therapy - Raised BMI - Hysterectomy (RF for stress) - Increased parity (RF for stress) - Frequent UTIs - Neurological disease - stroke, dementia, Parkinson's - Cognitive impairment

Answer 309

Leakage on sneezing, coughing, exercise, standing Urgency LUTS - dribbling, frequency, dysuria, incomplete emptying Sexual dysfunction Full obstetric history Bladder chart

Answer 310

Urine dipstick + MSU Assessment of residual volume (bladder scan for post-void volume) Urinary flow rates Urodynamic studies Refer - any haematuria - prolapse below introitus - neurological disease - persisting pain - faecal incontinence

Answer 311

Temporary containment products only until specific diagnosis and management plan. STRESS - Pelvic floor exercises for 3 months, 8 contractions TDA - Duloxetine - Retopubic mid-urethral tape - Colopsuspension - Autologous rectal fascial sling MIXED - pelvic floor exercises and bladder taining - Oxybutinin (anitmuscarinic) - Annual review OVERFLOW - relieve obstruction - intermittent self-catheterisation if persistent retention - botulinum toxin A - desmopressin if troublesome nocturia

Answer 312

Urgency Often with frequency Nocturia Sometimes urge incontinence Often associated with detrusor muscle over activity

Answer 313

2nd most common cause of female urinary incontinence Increases with age Associated with Parkinson's, spinal cord injury, diabetic neuropathy, MS, dementia, stroke

Answer 314

``` Sudden urge to urinate Hard to delay Frequency of micturition Nocturia Abdominal discomfort Urge incontinence ```

Answer 315

Lifestyle - decrease caffeine, increase fluid intake, lose weight if BMI > 30 Bladder tainting - 1st line, minimum of 6 weeks. Scheduled voiding, regular intervals, increasing time intervals Drugs - anticholinergics (oxybutynin, propiverine) Decreases involuntary contractions to increase bladder capacity Intravaginal oestrogens in vaginal atrophy Botulinum A toxin Nerve stimulation - sacral nerve Surgery - only for severe

Answer 316

Increased in women 3 per 100,000 Increases with age ``` RFs diarrhoea anal problems - obstetric injury, rectal or pelvic organ prolapse, pelvic radiotherapy Urinary incontinence Frail elderly patients Neuro problems/spinal disease Vaginal delivery Severe cognitive impairment ```

Answer 317

``` Child birth Obstetric trauma Anal surgery Chronic anal fissure Degeneration of smooth muscle in internal anal sphincter Neurological disease Dementia Congenital disorders - Hirschprung's, spina bifida Constipation Rectal prolapse IBD ```

Answer 318

``` Treat underlying cause Diet Encourage bowel opening after a meal Sitting or squatting to avoid straining Antidiarrhoeal medications - loperamide or codeine ``` Continence produces Skin care Odour control If faecal loading - clear bowel Pelvic floor training Bowel retraining Electrical stimulation Rectal irrigation

Answer 319

Pudendal nerve is under our control - when activated causes contraction of external sphincter to contract ``` Hypogastric nerve (sympathetics) - NA causes contraction of external sphincter ``` Sympathetics cause urinary retention Parasympathetic causes voiding Parasympathetic pelvic nerve causes detrusor contraction Empty bladder - no stretching - slow impulse along sensory pelvic nerve - this activates hypogastric nerve - causes relaxation of detrusor Full bladder - stretching - increasing fast signals to sacral region - bypass straight to pontine micturition centre - inhibits sympathetics (hypogastric nerve) - Relaxation of external sphincter - contracts detrusor

Answer 320

``` Physiological - New born infants - from maternal oestrogens - Reproductive age: normal Low oestrogen = mucus thick and sticky High oestrogen = mucus clearer, wetter - Cervical ectopy and polyps - Foreign bodies e.g. retained tampon - Vulval dermatitis - Erosive lichen planus - Genital tract malignancy - Fistulae ``` Infection - BV - Thrush. Candidiasis - Chlamydia trachomatis - Neisseria gonorrhoea - Trichomonas vaginalis

Answer 321

BV - thin, profuse, fishy smelling. No soreness, no itch. Candidiasis - thick, curd like, white, non-offensive. Vulval itch, soreness. Mild dyspareunia and dysuria. Chlamydia - copious purulent discharge. Asymptomatic in 80% Trichomonas - offensive, yellow discharge. profuse and frothy. Vulval itch, soreness, dysuria, abdo pain, superficial dyspareunia Gonorrhoea - purulent vaginal discharge. asymptomatic in 50% Retained foreign body - foul smelling seroanguinous discharge Fistulae - foul or faeculent discharge

Answer 322

``` Discharge heavier than normal Discharge thicker than normal Pus like discharge White and clumpy discharge Grey/green/yellow/blood tinged Foul smelling Accompanied by itching, burning, rash or soreness ```

Answer 323

BV - poor perinatal outcomes Candida - No harm to foetus Chlamydia - doesn't affect pregnancy outcome but mother baby transmission can occur - opthlamia neonatorum 15-25% - pneumonitis 5-15%

Answer 324

If typical BV or candidia, can be treated without testing STI screening and swabs - Vulvovaginal/ endocervical swabs - Urine chlamydia testing - Blood tests for HIV and syphilis Vaginal pH testing - BV pH>4.5

Answer 325

5-12% of normal population 30% undergoing termination of pregnancy Increased in sexually active women RFs - Sexual activity - New sexual partner - Other STIs - Increased in Afro-Caribbean - IUCD (copper) - Vaginal douching - Bubble baths - Receptive oral sex - Smoking Protective - COCP - Condoms - Circumcised partner

Answer 326

Overgrowth of anaerobic organisms Most common - Gardnerella vaginalis, prevotella, mycoplasma hominis, mobiluncus They replace the lactobacilli Raised pH from 4.5 to 6 (becomes alkaline)

Answer 327

Offensive, fishy smelly discharge No soreness or irritation 50% are asymptomatic Thin wall of white discharge on vaginal walls

Answer 328

Amsel's criteria (3+ of) - Homogenous offensive discharge - Microscopy - large numbers of bacilli "clue cells" on vaginal epithelial cells - pH>4.5 - Fishy odour on adding 10% potassium hydroxide - Cannot use isolation of G. vaginalis as it is normal flora in 40% Often treated empirically Examine and swab Vaginal pH

Answer 329

Avoid vaginal douching Avoid shower gel and bubble bath Do not need treatment if asymptomatic Oral metronidazole +/- clindamycin

Answer 330

Endometritis and PID Increased risk of acquiring HIV and STIs Late miscarriage, pre-term delivery, PROM, decreased birth weight 70% relapse in 3 months

Answer 331

Small, obligate, intracellular Gram negative Infected columnar and transitional epithelium Can cause - Ocular infections - GU infections - Proctitis - Sexually acquired reactive arthritis - Lymphgranuloma venerum - STI tropical infection, genital ulcer and inguinal lymphadenopathy

Answer 332

Most common STI in UK Most common preventable cause of infertility worldwide Prevalence dependent on age Increased in under 25s Decreasing numbers presenting to screening RFs - Age < 25 - Sexual partner chlamydia positive - 2+ sexual partners in 1 year - Recent change in sexual partner - Non barrier contraception - Infection with another STI - decreased socio-economic status

Answer 333

Most cases are asymptomatic Female - Vaginal discharge - Dysuria (sterile pyuria) - Lower abdominal pain - Fever - IMB, PCB - Deep dyspareunia Male - Urethritis - Dysuria - Urthethral discharge - Epididymo-orchiditis - Fever Reiter's syndrome - urethritis, arthritis, conjunctivitis. Associated with HLAB27 Proctitis with mucopurulent discharge if anal chlamydia

Answer 334

Female - Friable, inflamed cervix - Mucopurulent discharge - abdominal tenderness - adnexal tenderness - cervical excitation Males - epididymal tenderness - mucopurulent discharge - perineal fullness

Answer 335

Samples for nucleic acid amplification tests (NAATs) Vulvovaginal swabs Can do endocervical swab or first catch urine Opportunistic screening at GP Test when - Symptoms suggest infection - Sexual partners of chlamydia positive patients - All sexually active under 25 annually or with change of partner - Termination of pregnancy - At GUM clinic

Answer 336

Antibiotics - doxyxyxline 100mg BD 7/7 or azithromycin 1g stat Screen for other STIs Partner notification - If asymptomatic: back to 6m - If symptomatic 4/52 before symptoms No need to retest after treatment unless pregnant, persistent symptoms, non-compliant or re-exposed

Answer 337

``` PID Female infertility Ectopic pregnancy Perihepatitis (Fitz-Hugh and Curtis syndrome) Reactive arthritis (Reiter's syndrome) ```

Answer 338

Gram negative diplococcus Infects mucus membranes Transmission via direct inoculation of infected secretions - sexually or perinatally

Answer 339

Increasing prevalence Most causes in homosexual men Most diagnosed in GUM clinics Increased in younger ages RFs - History of previous STI - Co-existent STIs - New or multiple sexual partners - Recent sexual activity abroad - Inconsistent condom use - Anal intercourse and frequent insertive oral sex - Drug use or commercial sex work

Answer 340

Symptomatic in most men (90-95%) Asymptomatic in 50% of women Male - urethral discharge - dysuria - rectal infection (anal discharge) - pruritus - urthethral discharge Female - discharge - abdominal pain - dysuria - rare cause of IMB - pelvic tenderness - mucopurulent discharge

Answer 341

Culture - for resistant strains NAAT - urine or urthethral swabs Vulvovaginal swab is superior in women

Answer 342

Check for other STIs Partner notification Ceftriaxone 500mg IM stat + azithromycin 1g stat Resistance is an ongoing issue

Answer 343

male - urethral scarring and stricture (BOO), acute epididymitis, prostatitis, peri-urethral abscess ``` Female PID Infetrilty Peri-hepatitis (Fitz-Hugh Curtis syndrome) Bartholin's abscess Ectopic pregnancy Premature labour miscarriage ``` Can have haematogenous dissemination <1% Skin lesions, Reiter's syndrome, arthralgia, meningitis, endocarditis

Answer 344

``` Flagellated protozoan Most curable STI worldwide Urethral infection in 90% Most are women Underdiagnosed and undertreated ```

Answer 345

FEMALE - vaginal discharge, frothy and yellow - Vulval itching - dysuria - offensive odour - lower abdominal discomfort - cervicitis - 10-50% have no symptoms - 5-15% have normal exam MALE - usually asymptomatic - dysuria - urethral discharge - most have no signs

Answer 346

``` High vaginal swab Refer to GUM clinic Wet microscopy Test for other STIs Urethral culture or urine culture NAATs are being gold standard ```

Answer 347

Treat both partners at the same time Avoid sex 7/7 post-treatment Metronidazole 2g stat

Answer 348

``` Pre term delivery Low birth weight Increased maternal post partum sepsis Prostatis in men Persistent and recurrent infections ```

Answer 349

``` 6000 new UK diagnoses per year Increased in males Increased in men who have sex with men (MSM) Increased in Blacks Increased if born abroad ```

Answer 350

``` Seroconversion illness Asymptomatic infection Persistent generalised lymphadenopathy Symptomatic infection AIDS ```

Answer 351

``` 1-6 weeks post infection 20-60% present at this time Glandular fever like illness Fever, malaise, myalgia, headaches, diarrhoea, lymphadenopathy, maculopapular rash Viral p24 antigen positive High HIV RNA levels Antibody tests negative ```

Answer 352

Nodes>1cm in diameter at 2 extra inguinal sites | Persists for longer than 3 months

Answer 353

Non specific constitutional symptoms - fever, night sweats, diarrhoea, weight loss Minor opportunistic infections: oral candida, herpes zoster, recurrent herpes simplex, seborrheic dermatitis - Prodrome to AIDS

Answer 354

anti-HIV IgG antibody tests (not reliable in under 18m old) HIV DNA PCR and virus culture In acute infection will be p24 positive IgG and IgM to HIV 4 weeks to get test results back HIV counselling before and after testing

Answer 355

CD4 grade 1. CD4 > 500 cells/mm3 or 29% 2. CD4 200-499 cells/mm3 or 14-28% 3. CD4<200 cells/mm3 or <14% Clinical grade A. Documented HIV infection. Asymptomatic or persistent lymphadenopathy B.. Symptomatic but no category C conditions C. AIDs indicator condition. Cannot move out of category C Receive both clinical and CD4 grading Clinical Grade

Answer 356

``` Candidiasis - lung/trachea/oesophagus Invasive cervical carcinoma Coccidiodomycosis. Crytococcosis. CMV (not liver or spleen) Encephalopathy Herpes simplex Histoplasmosis Kaposi's sarcoma Lymphoma - Burkitt's, primary brain or immunoblastic TB Pneumocystis jirovecci Recurrent pneumonia Progressive multifocal leukoencephalopathy Toxoplasmosis of brain Wasting syndrome due to HIV ```

Answer 357

Support Anti retroviral therapy for all patients HAART - combination of 3 drugs to decrease resistance Efaurenz + tenofovir + lamivudine Chemoprophylaxis to prevent infection

Answer 358

``` Promote lifelong safer sex Barrier contraception Decrease number of partners Condom program in brothels Warn heterosexuals the dangers of sex tourism Treat other STIs Don't share needle - needle exchange programs Decrease unnecessary blood transfusions Encourage HIV tests in pregnancy Pre-exposure prophylaxis in high risk ```

Answer 359

Multiple echhymotic skin nodules, macules or papules. Skin or mucosal surfaces Can have visceral disease e.g. lungs and GIT

Answer 360

``` Brain involved in most late HIV Decreased concentration and memory Gradual decrease in intellect Increased motor problems and weakness Hyper-reflexia Extensor plantars ```

Answer 361

HPV infection Sexually transmitted 60% transmission rate between partners 95% caused by HPV 6 or 11

Answer 362

Most common viral STI Numbers should decrease with HPV vaccination 35% of those being screened for chlamydia ``` RF Smoking Multiple sexual partners Early age of first intercourse History of other STIs Anoreceptive intercourse Immunosuppression ```

Answer 363

Painless lesions Can be disfiguring or embarrassing Can cause itching, bleeding or dyspareunia Urethral lesions may distort urinary stream Pelvic or scrotal pain

Answer 364

``` Often multiple lesions Can become confluent (huge in immunocompromised) Can be keratinsed or non-keratinised May be broad based or pedunculated may be pigmented ``` In women on: labia, clitoris, urethral meaturs, introitus, vagina or cervix Men - frenulum, corona, glans penis, shaft, scrotum, urethral meatus both - perineum, groin, pubic, perianal area, anal canal

Answer 365

Biopsy and viral typing not usually required | Only biopsy if anything suspicious e.g. over 35 with minimal risk factors

Answer 366

cervical cancer Vaginal, penile and vulval cancer Anal cancer Oral and oropharyngeal cancer

Answer 367

Explain long term latency - does not mean infidelity Advise condom use until resolved Advise HPV persists long after warts 20% have concurrent STIs = SCREEN Assess current and past partners - last 6 months Non-smokers have better response to treatment No treatment, 1/3 regress spontaneously in 6 months Podaphylotoxin cream or imiquimod 5% Can use ablation. cryotherapy or excision if resistant Treatments cause itching, burning, pain. Recurrence occurs after all treatmetns.

Answer 368

HSV Type 1- usual cause of cold sores. Now most common cause of genital herpes HSV type 2 - causes genital infection. transmission: Contact with infected secretion Close contact Vaginal, anal and oral sex

Answer 369

Herpes simplex - type 1 and 2

Answer 370

``` 7% of new STIs Numbers are increasing Highest in 15-24s Lifelong disease 80% are not aware they have it 20% of population ``` ``` Rf Sexual promiscuity Previous history of STIs Early age of first intercourse MSM HIV infection Females ```

Answer 371

``` Primary infection Commonly asymptomatic Febrile flu like prodrome 5-7 days Myalgia. Fever Tingling neuropathic pain in genital area Extensive painful crops of blisters/ulcers in genital area Usually bilateral Tender inguinal lymph nodes Dysuria/ Vaginal or urethral discharge ``` ``` Secondary infection After latency, reactivation Episodes are shorter e.g. 10 days Mild and self-limiting Lesions unilateral ``` HSV type 1 less recurrence (1/year) 2 = 4 per year

Answer 372

Viral culture DNA detection using PCRR Serology testing - takes 12 weeks

Answer 373

Refer to GUM clinic Swab Supportive management Saline bathing Oral analgesia Topical lidocaine Micturation sitting in bath to prevent urinary retention Increase fluid intake to dilute urine to decrease pain Antivirals not recommended unless within 5 days, aciclovir

Answer 374

``` Autonomic neuropathy e.g. urinary retention aseptic meningitis Spread to extra-genital areas 2y infection with candida or strep Perinatal transmission psychological or psychosexual problems ```

Women's Health Flashcards

(399 cards)