Womens Flashcards
(289 cards)
1
Q
2 main causes of pelvic organ prolapse
A
- pelvic floor weakness 2. due to raised intra-abdominal pressure (pregnancy, heavy lifting, straining)
2
Q
what are the symptoms of pelvic organ prolapse
A
recurrent UTI
feeling of pelvic fullness
FUNI urinary signs
3
Q
treatment of pelvic organ prolapse 4
A
- pelvic floor exercises
- weight loss if obese
- ring pessary to hold vaginal walls in place
- surgery
cystocele: anterior colporrhaphy
uterine: hysterectomy
rectocele posterior colporrhaphy
4
Q
What are the three classifications of pelvic organ prolapse according to the affected compartment?
A
Anterior compartment: cystocele (bladder prolapse into anterior vaginal wall)
Middle compartment: uterine prolapse (Cervix prolapses into vagina)
Posterior compartment: rectocele (bowels prolapse into vagina)
5
Q
What are fistulas? What are the 2 genital tract fistulas?
A
an abnormal connections between two epithelial surfaces
vaginal fistula (vagina opens into bladder/ rectum)
perianal fistula (anus connects to skin)
6
Q
What are the concerns with genital tract fistulas?
A
- bacterial overgrowth and can lead to infections
7
Q
What is the ix for anal tract fistulas?
A
- DRE
- MRI to identify the course of the fistula
8
Q
What is the mx for anal tract fistulas? 5
A
Management of anal fistula generally involves a combination of surgical, medical, and supportive therapies:
1. analgesia + wound care
2. delineate (define borders of fissure better) using barium + CT
3. control crohns (linked to anal fissures and prevents healing until well controlled)
4. abx for infection
5. fistulotomy, using Goosalls rule
9
Q
What is Androgen insensitivity syndrome
A
X-linked recessive condition
resistance to testosterone
causes children with male genotypes (XY) to have a female phenotype
10
Q
What are the features of androgen insensitivity syndrome 4
A
female with:
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
11
Q
How is Androgen insensitivity syndrome diagnosed 1
A
- buccal smear or chromosomal analysis to reveal 46XY genotype
12
Q
How is androgen insensitivity managed? 3
A
-> bilateral orchidectomy to reduce testicular cancer risk due to undescended testes
-> oestrogen therapy
-> raised child as female
13
Q
What is menopause and what age does this occur and how long do symptoms last for
A
diagnosed when a woman has not had a period for 12 months
40-50 years
7 years, some more, some less, some symptoms can start years after menopause
14
Q
What are the features of menopause 5
A
- change in length of menstrual cycles
- vasomotor sx: hot flushes and night sweats
- vaginal dryness and atrophy
- anxiety and depression
- urinary frequency
15
Q
How is menopause managed?
A
- lifestyle mods: good sleep hygiene, exercise, relaxing to reduce stress
- oral/ transdermal combined HRT (cannot give oestrogen on its own as it can increase risk of endometrial cancer if the woman has a uterus so daily progesterone pill)
- symptom management eg vaginal lubricant for vaginal dryness
- fluoxetine for vasomotor symptoms and depression
- vaginal oestrogen if suffering from urogenital atrophy (can be prescribed alongside HRT)
16
Q
What does oestrogen HRT increase your risk of? 4
A
- venous thromboembolism
- stroke/ CHD
- breast cancer
- ovarian cancer
17
Q
When should contraception be used to be protective during menopause
A
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
18
Q
What is Adenomyosis?
A
presence of endometrial tissue in myometrium (lining of womb grows into muscle of wall of womb)
19
Q
What are the features of adenomyosis 2
A
- dysmenorrhoea
- menorrhagia
20
Q
What is the ix for adenomyosis 2
A
- enlarged, boggy uterus in a bimanual exam
- transvaginal ultrasound
21
Q
What is the mx for adenomyosis 4
A
- IUS/ tranexamic acid to manage menorrhagia (reduce bleeding)
- GnRH agonists
- uterine artery embolisation
- hysterectomy (only definitive tx)
22
Q
What is Asherman’s syndrome and what can it lead to? Features? 3
A
scar tissue forms inside uterus and cervix. This can lead to outflow tract obstruction. Needs to be symptomatic adhesions.
-> reduced menstrual flow
-> abdo pain/ cramps
-> eventual stoppage of menstrual cycles
23
Q
What is the ix and mx Ashermans syndrome
A
ix: hysteroscopy
mx: hysteroscopic surgery to divide adhesions (also GS ix)- high risk of reocurrance
24
Q
What is Lichen sclerosus? features 3
A
inflammatory condition that usually affects the genitalia in elderly females , causing atrophy of epidermis
-> white patches that can scar
-> itch
-> pain on urination/ intercourse
25
What is the mx for lichen sclerosus 4
-> topical steroids- clobestasol
-> emollients to keep area moist
-> 3 monthly follow ups then when conditions settles down then yearly
-> 2ww if suspicious for biopsy
26
What type of cancer is vulval carcinoma and risk factors 3?
squamous cell carcinomas
age: women over 65
HPV infection
lichen sclerosus
27
What are the features of vulval carcinoma 2
1. lump/ulcer on the labia majora
2. inguinal lymphadenopathy
28
What is the mx of vulval carcinoma 3
2ww referral for women with an unexplained vulval lump, ulceration, or bleeding
29
What is prolactinoma and how can prolactinomas be classified
benign tumour of the pituitary gland
size and hormonal status (if secreting and what it is secreting)
30
What are the features of prolactinomas
Females:
-amenorrhoea: absence of menstrual period
-oligomenorrhoea: irregular
Males
-erectile dysfunction
-reduced facial hair
-galactorrhea
Both
-low libido
-infertility
-N/V/ headaches due to increase ICP
31
What is the pathophys of prolactinoma **
1. prolactin hypersecretion inhibits gonadotrophin-releasing hormones
2. therefore this is secondary hypogonadism (hypogonadism is a problem in the pituitary or hypothalamus) because it inhibits gonadotrophin-releasing hormones
3. hypogonadism= gonad sex glands produce little or no sex hormones
32
How is prolactinoma investigated
1. serum prolactin
2. MRI brain diagnoses prolactinoma
33
What is the management for prolactinoma
medical approach is more efficient than surgical, unlike other pituitary adenomas
-> 1st line: dopamine agonists eg oral cabergoline/ bromocriptine (dopamine inhibits prolactin release and will cause shrinkage of the prolactinoma)
-> transphenoidal resection surgery of pituitary gland (for adenoma)
-> hormone replacement therapy to deal with hypogonadism eg oestrogen where fertility and galactorrhea are not an issue
34
What is a molar pregnancy
an abnormal form of pregnancy where a non-viable fertilised egg implants in the uterus- very similar to a tumour so it needs to be removed
35
What are the sx 1 and ix 3 and mx 3 of a molar pregnancy
1. vaginal bleeding
* uterus size greater than expected for gestational age
* abnormally high serum hCG
* ultrasound: 'snow storm' appearance of mixed echogenicity
mx:
refer to secondary care 2ww
surgical removal of molar tissue (dilatation + cutterage
this is sent off to the histologist to confirm molar pregnancy
36
What is the staging for all gynae malignancies? Explain each of the stages. How is staging investigated?
FIGO stage 1-4
1. only in uterus
2. + cervix
3. + pelvis (lymph nodes)
4. extrapelvic eg mets to bladder/ lung/ liver
MRI
37
What is the MC of endometrial cancer? Risk factors? 4
adenocarcinoma
unopposed oestrogen eg obesity, PCOS, oestrogen only HRT, late menopause/ early menarche
38
What are the symptoms of endometrial cancer? 3
unexplained post-menopausal bleed
pre-menopausal women can get menorrhagia and intramenstrual bleeding
39
What are the ix for endometrial cancer 3
1. first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
2. 2 week wait cancer referral (for all women 55+ with postmenopausal bleeding)
3. GS hysteroscopy and biopsy
40
What is the mx for endometrial cancer 3
1. total abdominal hysterectomy with bilateral salpingo-oophorectomy
2. high risk disease= post op radiotherapy
3. if frail elderly woman that is not suitable for surgery/ yiuong feamle wanting to preserve fertility, give progesterone therapy
41
What is protective against endometrial cancer? 2 What is protective against ovarian cancer?
breastfeeding
IUS (hormonal coil)
pregnancy
|--------------------|
breastfeeding
COCP
pregnancy
42
How is screening done for cervical cancer? Who does not have to do this?
25-49 years every 3 years
50-65 years every 5 years
1. women that have never been sexually active
2. pregnancy- delayed until 3 months post-partum unless prev abnormal/ no smears
43
what is the escalation procedure of cervical cancer?
pap smear for HPV and cytology -> colposcopy biopsy
44
What is the action for different results of cervical screening
1. hrHPV positive with normal cytology= 1 year recall, two repeats of this allowed then send for colposcopy
2. inadequate sample= 3 months, then 3 months, then coloposcopy
3. HIV + patients every year
45
What are the classes of cervical screening results 3
CIN 1= not worrying
CIN 2= little dysplasia (abnormal changes in cervical cells)= risk of cancer
CIN 3= dysplasia= major cervical cancer risk in situ?
46
What are the types of cervical cancer and who is at most risk? 2,5
squamous cell (90), adenocarcinoma (10)
30-45 year old, non-HPV vaccinated, mutliple STIs/ unprotected sexual intercourse/ many sexual partners, first degree relative
47
What are the high risk strains of HPV and why does it cause risk for cervical cancer?
16+18 mainly
inhibits p53 and pRb tumour suppressor genes
48
What are the symptoms of cervical cancer? 5
early= asymptomatic
later: cervicitis symptoms: vaginal discomfort and abnormal discharge, Post coital bleeding, Intermenstrual Bleeding
49
When is HPV vaccine given in UK? Why?
to children 12/13 years old in secondary school or pts engaging in male-male sex up to the age of 45 in sexual health clinics
HPV infections can increase risk of cervical, penile, vulval, vaginal cancer
50
What is the treatment for cervical cancer 4
CIN 2/3 = large loop excision of the transformation zone (this is not cancer, just neoplasia)
Graded cancer management:
1-2a= hysterectomy + lymph node removal
2b-4a= cisplatin chemo +/- radio
4b= cisplatin + bevacizumab (VEGF blocker)- palliative chemo approach
51
What are the types of ovarian cancer and typical location
epithelial carcinomas (MC), then germ call in women under 30
distal end of fallopian tubes= site of origin
52
What are the risk factors for ovarian cancer
BRCA 1 + 2
unopposed oestrogen (all examples same as endometrial eg obesity, PCOS, oestrogen only HRT, late menopause)
53
What are the symptoms of ovarian cancer
1. 50+ year old with first time presentation of IBS/ GI symptoms (bloating, contipation, indigestion, vague abdo pain)
2. malignancy red flag sx: unintended weight loss
54
How is ovarian cancer investigated? 4
1. CA125 bloods
2. **urgent transvaginal and abdominal pelvic USS** if CA125 over 35
3. if physical exam shows abdo mass or US suggests malignancy then 2WW referral
3. GS tissue biopsy
55
How is ovarian cancer treated? 2
1. hysterectomy with bilateral salpingo-oophorectomy
2. When there is spread outside the uterus, treatment often consists of a combination of surgery, radiotherapy, and chemotherapy
56
Name the types of carcinomas for each female pelvic organ malignancy
vulval + cervical= squamous cell
endometrial + breast= adenocarcinoma
ovarian= epithelial
57
What is the pathophys of ovarian cysts
1. follicle underdevelopment= follicle becomes a fluid filled sac
58
What are ovarian cyst symptoms 3
-> bloating
-> dysmenorrhoea
-> dysuria
59
What are the 4 types of ovarian cysts
1. functional
-> follicular cyst (due to dominant follicle not rupturing)
-> corpus luteum cyst (due to corpus luteum not degrading)
2. endometrioma- chocolate cyst- because it is filled with brown fluid, start of endometriosis
3. non functional: PCOS
4. germ cell tumours (benign epithelial cell tumour, benign sex cord stromal tumour)- MC in women under 30
60
What are complications of ovarian cysts 3
cyst rupture (causing SBP + shock)
cyst haemorrhage
ovarian torsion
61
What is the action for ovarian cysts 1
Complex ovarian cysts should be biopsied to exclude malignancy
complex: filled with blood/ walls inside of them/ solid
Ovarian enlargement: management
The initial imaging modality for suspected ovarian cysts/tumours is ultrasound. The report will usually report that the cyst is either:
simple: unilocular, more likely to be physiological or benign
complex: multilocular, more likely to be malignant
Management depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as 'simple' then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Postmenopausal women
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
1st line: US
for complex cysts + post menaupausal women, ararnge biopsy
for simple cysts, repeat US in 2 months
62
What is the sx 3 1 ix 3 and mx 2 for a ruptured ovarian cyst
sx:
acute onset unilateral lower abdo pain, N/V, fever
ix:
pregnancy test to exclude ectopic pregnancy
Ultrasound may identify the ruptured cyst
Diagnostic laparoscopy may be needed in an unstable patient
mx:
supportive: analgesia
if necessary/ complications then laproscopic surgery
63
compare ovarian ruptured cyst to ovarian torsion
torsion: pain is worse, more likely to get n/v and will show whirlpool sign + free fluid
ruptured cyst: onyl free fluid on US
64
What is ovarian torsion and RF 2
ovary twists around itself on a longitudinal axis
cysts, pelvic surgery
65
What is the sx for ovarian torsion 3
1. severe unilateral colicky RIF/ LIF pain
2. N/V
3. painful walking
66
What are the ix 1 and mx 1 for ovarian torsion
ix:
IVUSS doppler= whirlpool sign + free fluid around ovary
mx:
laproscopic detorsion, if ovary is nectrotic then needs oophrectomy
67
What is the management for menorrhagia 3
first line IUS
tranexamic acid (reduces bleeding, but does nothing for pain)
first line for dysmenorrhea:
mefenamic acid/ naproxen (NSAIDs to reduce bleeding and reduce pain)
68
What are fibroids? Why do they appear? How common is it?
benign smooth muscle tumours in uterus (leiomyoma)
develop in response to oestrogen
common in Afro-Caribbean women (50%)
69
What are the features of fibroids 5
-> menorrhagia
-> bloating
-> bad cramps during menstruation
-> urinary frequency (if large fibroids)
-> subfertility
FIBRoid
Frequency of urine (if large)
IBS like bloating
Bad cramps during menstruation
Really heavy periods
70
What is the ix for fibroids 3
bimanual exam: large irregular cervix
abdo exam: palpable mass
transvaginal US
71
What is the mx for fibroids 4
1. manage menorrhagia: LNG-IUS if wants contraception, otherwise tranexamic acid
2. GnRH agonist to reduce size of fibroid (short term eg for before surgery)
3. surgery: myomectomy or hysterectomy (former for subfertile female who wants to have a child)
4. uterine artery embolisation
72
What are the complication of fibroids? 2
-> red degeneration- fibroid grows very fast and outgrows blood supply (severe abdo pain, N/V, fever in a woman with hx of severe bleeding due to fibroids)
-> infertility
73
Explain the menarche cycle in terms of ovarian and uterine cycles, what is the variation in cycle length
ovarian:
1. follicular (1-13)- LH surge day 12/13 so 36 hours= preovulation
2. ovulation (14)
3. luteal (15-28)- LH stimulates corpus luteum to release progesterone
uterine/ hormonal:
menses (1-5): decreased oestrogen + progesterone= breakdown of lining
proliferative (6-14): increased oestrogen= build up of lining
secretory (15-28): increased progestrone- peaks on 21st day= maintenance of lining
23-35 day
FOL ovarian
MPS uterus
74
What is a marker for ovulation 1
midluteal progesterone, 7 days before end of cycle eg if ycle is 28 days long then on day 21 and if cycle is 35 days long then on day 28
positive resut is progesterone over 5= ovulation has occured and entered into luteal phase
75
What are the causes of menorrhagia 5
dysfunctional uterine bleed (idiopathic cause- MC)
fibroids
copper IUD
hypothyroidism
adenomysosis
76
How is menorrhagia investigated? 3
1. bimanual/ speculum exam
2. bloods: FBC, clotting screen, ferratin, TFT
3. TVUSS
77
How is postnatal depresseion screened for and explain the scale
-> The Edinburgh Postnatal Depression Scale
-> out of 30
-> asks about how the mum has felt over the previous week, including self harm
-> over 13 indicates a depressive illness of varying severity
78
Compare onset of baby blues, postpartum depression and postpartum psychosis
baby blues: seen within a week of giving birth and is most common in primips (giving birth for first time)
postpartum depression: seen within a month and peaks at 3 months
postpartum psychosis: seen 2/3 weeks after giving birth
79
Compare symptoms of baby blues, postpartum depression and postpartum psychosis
baby blues: mums are anxious, tearful and irritable
postpartum depression: typical depression symptoms
postpartum psychosis: mood swings (like bipolar) and disordered perception (eg auditory hallucinations)
80
Compare management of baby blues, postpartum depression and postpartum psychosis
baby blues: reassurance and support from health visitor
postpartum depression: reassurance and support from health visitor, CBT, if mod- severe, prescribe SSRI eg sertaline/ paroxetine
postpartum psychosis:
admission to hospital to mother and baby unit
81
what are the two main complications of urolithiasis and nephrolithiasis
1. Obstruction leading to acute kidney injury
2. Infection with obstructive pyelonephritis
82
What are the MC types of nephrolithiasis/ urolithiasis composition
1. Calcium oxalate (MC)
2. Uric acid – these are not visible on x-ray
83
What is the presentation of nephrolithiasis 5
1. Unilateral colicky loin to groin pain
2. haematuria
3. reduced urine output
4. N/V
5. fever
typical triad + 2 urinary sx
84
What are the ix for nephrolithiasis 2
1. urine dipstick for haematuria
2. non contrast CT KUB **within** 24 hours of presentation
85
What are causes of nephrolithiasis 3
1. hypercalcaemia: due to calcium supplements, hyperparathyroidism and cancer
2. dehydration and high salt diet
3. oxolate rich foods in calcium stones (spinach, black tea, nuts) and purin rich foods in uric stones (kidney/ liver, oily fish, spinach)
86
What is the management for nephrolithiasis 5
1. NSAID-diclofenac for pain, IV if admitted and if not fixing issue, IV paracetomol
2. watchful waiting if less than 5mm
3. tamsulosin to aid spontaneous passage of stones if <10mm for ureteric stones only
4. surgical interventions: lithotripsy or Percutaneous nephrolithotomy if over 20mm
5. reduce reoccurrence- potassium citrate (reduces uric acid) and thiazide diuretics (reduces calcium), encourage water and low salt diet (sorts out dehydration)
87
What is endometriosis?
* endometrial cells growth and form linings outside of the uterus eg ovaries, fallopian tubes, uterosacral ligaments
* these cells in the endometrium respond the the mentrual cycle each month and bleed
* but with nowhere for the blood to go, there is inflammation and scar tissue formation which is painful
88
What are the ix for endometriosis 2
1. first line: transvaginal USS- may see Chocolate cyst
2. gold standrad- laproscopy for diagnosis and treatment
89
What are the symptoms of endometriosis 6
chronic pelvic pain (gets worse a few days before period)
1. dysmenorrhoea
2. dysuria
3. dyspareunia
4. decreased fertility
5. defecation is painful
1C and 5Ds
90
What is the mx for endometriosis 4
1. paracetamol/ NSAIDs
2. hormonal eg COCP or progesterone only pill
3. if these don't work, refer to secondary care
4. surgery: ablation if wanting to keep fertility, otherwise hysterectomy
pain-> pill-> referral-> ablation/ hysterectomy
Pretty people relax after hardships
91
What is pelvic inflammatory disease? Pathophys?
infection/ inflammation of female pelvic organs (uterus, fallopian tubes, ovaries)
MC due to ascending infection from endocervix
92
What are the causes of pelvic inflammatory disease 3
Chlamydia trachomatis (MC)
Neisseria gonorrhoeae (MC)
Mycoplasma genitalium
93
What are the symptoms of pelvic inflammatory disease? 4
-> lower abdo pain
-> intermenstrual bleeding
-> deep dyspareunia
-> unusual vaginal discharge eg yellow/ green/ smelly
PeLViC
Pain with sex
Lower abdo pain
Vaginal discharge
Continous bleeding (intermenstrual bleed)
94
What are the ix for pelvic inflammatory disease 3
1. pregnancy test to exclude extopic
2. tenderness on cervical examination (speculum + bimanual)
3. screen for chlamydia + gonorrhoea (NAAT swabs)
95
What is the mx for pelvic inflammatory disease 3
1. A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
2. Doxycycline for 14 days (to cover chlamydia and Mycoplasma genitalium)
3. Metronidazole for 14 days (to cover anaerobes such as Gardnerella vaginalis)
96
What is a complication of pelvic inflammatory disease, explain sx and ix and mx
1. Fitz-Hugh-Curtis Syndrome (due to inflammation + infection of liver which causes adhesions between liver and peritoneum.
-> sx: RUQ pain which refers to right shoulder if diaphragm irritated
-> ix: laparoscopy
-> mx: laparoscopy + adhesiolysis
97
How is Polycystic ovarian syndrome diagnosed
Rotterdam criteria (need to have 2+/3)= clinical diagnosis
hirsutism
menstrual changes
polycystic ovaries
98
What is the pathophys of PCOS 4
1. No increase in progesterone from corpus luteum= increase in GnRH
2. this causes high levels of androgens (LH mainly)
3. high androgen levels promote hirsutism and insulin resistance
4. therefore, there are high levels of insulin produced, which increases LH production
99
What are the symptoms of PCOS 6
subfertility
hirsutism (acne, facial hair)
oligo/ amenorrhoea
mood swings
insulin resistance
acanthosis nigricans
| SHOMIA
100
What are the investigations for PCOS 2
1. bloods:
FBC, UE, TFT, LFT
testosterone, oestrogen, progesterone 17-OH, sex hormone binding globulin (SHBG) , raised LH: FSH
2. gold standard: TVUSS (positive results are:
**-String of Pearls appearance
-12 or more developing follicles in one ovary.
Ovarian volume of more than 10cm3**
101
What is the mx of PCOS 3
1. lose weight and increase exercise
2. COCP to decrease hirsutism, if family planning then clomifene (to induce ovulation)
3. metformin to increase peripherla insulin sensitivity
102
What are the complications of PCOS 4
1. fertility is significantly reduced
2. endometrial hyperplasia and cancer
4. obstructive sleep apnoea
5. DM
| FEDS
103
What is ectopic pregnancy and risk factors 3
Implantation of a fertilized ovum outside the uterus
Rfx: anything that slows the ovum's passage to the uterus eg PID, endometriosis, IUD/S and previous ectopic pregnancies
104
Where are most ectopic pregnancies located?
in ampulla (in fallopian tubes)
105
What is the ix for ectopic pregnancy?
1. pregnancy test= positive
2. transvaginal US (adnexal mass that moves separately to the ovary)
106
What is the mx for ectoptic pregnancies 3
1. CONSERVATIVE: if asymptomatic, size <35mm, no fetal heartbeat, hCG under 1000
= regular hcg monitoring
**monitor over 48 hours to check B hcg- but no admission, only trips to hopsital for blood tests in expectation that it will spontaneously resolve**
2. MEDICAL: if some pain, size <35mm, no fetal heartbeat, hCG under 1500
= give methotrexate and attend follow up to monitor hcg, can give another dose of methotrexate if fails to treat ectopic pregnancy. **Advise not to get pregnant within 3 months due to tetarogenic nature of methotrexate**
**only do this if patient can attend follow up in 4 days and after thsi get weekly b hcgs until back to normal**
3. SURGICAL: if lots of pain, size >35mm, fetal heartbeat present, hCG over 5000
=salpingectomy (fallopian tube containing the ectopic pregnancy is removed which reduces risk of future ectopics reoccuring)
**only surgical needs anti-D immunoglobulin (not even methotraxate)**
107
Explain the types of miscarriage 5
1. Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred (transvaginal US dx no foetal heart activity and CRL >7mm, give Mifepristone then 48 hours later misoprostol then within 48 hours bleeding should start)
2. Threatened miscarriage – painless vaginal bleeding with a closed cervix and a fetus that is alive in first 24 weeks of gestation, goes on to produce a viable baby
3. Inevitable miscarriage – heavy vaginal bleeding, painful, clots with an open cervix which is a sign of physiological expulsion of the pregnancy from the uterine cavity- will progress to complete/ incomplete miscarriage
4. Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage (US shows mixed echos in uterine cavity)
5. Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus (US shows empty uterus, pregnancy test in 3 weeks to confirm)
108
What is miscarriage, when does this usually occur and why and risk factors 4
spontaneous abortion
first trimester before 12 weeks
50% are due to chromosomal abnormalities
Rfx: 35+, previous miscarriage, poor lifestyle eg smoking/ alcohol, med conditons eg uncontrolled diabetes
109
What is recurrent miscarriage and causes 4
3+ consecutive losses
-> smoking
-> chromosomal abnormalities
-> poorly controlled diabetes
-> PCOS
110
What is mx for incomplete miscarriage? 5
miscarriage cannot be stopped/ prevented so mx is to completely remove foetal material
1. wait for a spontaneous miscarriage (wait 1-2 weeks for completion)
2. if incomplete then single dose misoprostol vaginally/ oral (prostaglandic analogue= softens and dilates the cervix)
3. analgesia and antiemetics
4. surgery: vacuum aspiration
5. pregnancy test at 3 weeks
111
What are the symptoms of a miscarriage 3 and ix 1
1. vaginal bleeding
2. uterine cramps
3. vaginal discharge (tissue)
transvaginal US
112
How is gestational diabetes managed? 4
1. lifestyle advice (diet, exercise)
2. regular self monitoring of blood glucose and targets required to meet: fasting 5.3, 1 hour postprandial 7.8, 2 hours 6.4
3. just diagnosed seen within a week at diabetes and antenatal clinic
4. if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
113
What are the trimesters of pregnancy 3
first trimester – conception to 12 weeks
second trimester – 13 to 27 weeks. third trimester – 28 to 40 weeks.
114
What is the law on termination of pregnancy
1967 abortion act
24 weeks and under (23 +6) with risk to mums physical or mental health or foetus would likely be handicapped
2 registered medical practitioners need to sign a legal document
115
When is a pregnancy considered viable
when a fetal heartbeat is visible arond 5-6 weeks after conception
116
What is important to note about rhesus D negative women who have a termination of pregnancy or miscarriage
if after 10 weeks, then give anti-D prophylaxis, otherwise no need
117
What is the mx for terminatin of pregnancy
1. mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions.
**-> Give analgesia and anti-emetics too
-> before 10 weeks can be done at home, after 10 weeks, done in hospital**
2. pregnancy test in 2 weeks to confirm pregnancy has ended
3. alternatively, they can choose a surgical method= manual vacuum aspiration
women are free to choose the method of termination
118
What are the risk factors of gestational diabetes? 2
molaBMI over 30
first degree relative with diabetes
119
How is gestational diabetes screened for?
oral glucose tolerance test (24-28 weeks)
diagnosis if: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L
120
What is the management for pre-existing diabetics who have become pregnant? 3
1. weight loss if over 27
2. 5mg folic acid daily
3. stop all medications apart from metformin and start insulin
121
What are risks of gestational diabetes to the mother and child 2, 3
mother: increased risk future T2DM and HTN
child: Macrosomia, neonatal hypoglycaemia, pre-term birth
122
What is a complication of pre-eclampsia: sx 3 and ix results 3 and mx 3
HELLP syndrome
sx:
Hypertensive pregnant woman with RUQ pain +/- N/V
ix:
haemolysis
elevated liver enzymes
low platelets
mx:
give magnesium sulfate to decrease risk of eclampsia
give dexamethasone
deliver the baby asap
123
What is and how is pre-eclampsia diagnosed
1. new-onset blood pressure ≥ 140/90 mmHg AFTER 20 weeks of pregnancy, AND 1 or more of the following:
-> proteinuria
-> severe headache
-> other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver: abnormal liver enzymes/ liver tenderness, neurological: visual disturbances/ severe headache
-> high blood pressure during pregnancy
124
What are the risk factors of pre-eclampsia 5 and how is this risk reduced?
1. T1/T2DM
2. chronic HTN
3. CKD
4. pre-eclampsia in previous pregnancy
5. autoimmune condition eg SLE or antiphospholipid syndrome
women take aspirin 75mg from 12 weeks gestation to birth if 1+ of these Rfx
125
What is pre-eclampsia mx? 3
1. emergency secondary care assessment if suspected and observation when admitted for BP >160/110
2. oral labetalol or nifidipine if asthmatic
3. fluid restriction 80ml per hour and monitor urine output
126
What is eclampsia?
development of seizures in a woman with pre-eclampsia
127
What is the mx for eclampsia? And SE and tx?
magnesium sulphate for prevention and treating seizures whilst they're happening
SE: respiratory depression which is managed with calcium gluconate
128
What is the mx for VTE in pregnant women
if 4+ risk factors then immediately give LMWH dalteparin until 6 weeks postnatal
if 3+ then from 28 days gestation until 6 weeks postnatal LMWH eg dalteparin
35+ years
BMI 30+
smoker
pre-eclampsia
VTE family hx
parity >3
to remember non common sense ones- four 3s
35+ age, 30+ BMI, pr3-3clampsia, 3+ kids
129
What is puerperal pyrexia and what are the causes 5 and appropriate mx
temp >38 in the first 14 days after delivery
causes:
endometritis (MCC)
UTI
wound infections
mastitis
VTE
if endometritis then emergency to hospital and give IV clindamycin and gentamicin until fever subsided for 24 hours
130
What is the guidance on maternal group B strep infections and why?
-> women who've had GBS in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IV benzylpenicillin during labour)
-> women who have fever during labour should be given IV benzylpenicillin too
-> woomen in preterm labour should be offered this too
-> this is not given to all mums, even if it is requested
-> baby is monitored for 12 hours if mum has had previous GBS with other births
GBS is contained in many mothers bowel/ vaginal flora and infants can be exposed to this during labour and develop serious infections as a result
131
What is the ix, mx for UTI in pregnant women 3 Why do we treat asx bacteruria
1st line nitrofurantoin (not given in final trimester due to risk of neonatal RBC haemolysis) for 7 days
2nd line amoxicillin for 7 days
trimethoprim is CI for first trimester, but generally avoided throughout
1/2nd trimester: nitrofurantoin 7 days
3rd trimester: cefalexin 7 days
-> send intial urine culture
-> should send off culture after treatement to check if the abx have worked
always treat as it can become pyelonephritis which can have an impact on the fetus (early birth/ poor growth). A regular UTI cannot affect the fetus unless it caues kidney issues which is what abx tries to prevent
132
What is the mx for Puerperal pyrexia
-> if endometritis suspected, pt referred to hospital for IV clindamycin and gentamicin until afebrile for more than 24 hours
133
When should urine cultures be sent for UTIs 3
65+
haematuria
pregnancy
paediatrics
134
Why is varicella zoster dangerous in pregnant women?
-> congenital varicella syndrome/ severe neonatal varicella infection for baby
-> varicella pneumonitis/ hepatitis/ encephalitis for mum
135
What is congenital varicella syndrome/ fetal varicella syndrome? 5 When does it occur?
skin scarring,
eye defects (microphthalmia- one/both of babys eyes are small),
limb hypoplasia,
microcephaly
learning disabilities
Varicella
very small limbs
abnormal eye: microphthalmia- one/both of babys eyes are small
red lesions of scarred skin
intellectual- learning disabilities
cephaly is micro
when infection in first 28 weeks of gestation
136
What are the ix that can be done for varicella zoster in pregnancy 1 and what is the condition for this
1. check VZV IgG levels (if positive, mum is immune and has antibodies)
only if mother is unsure about having chickenpox as a child
137
What is the mx for varicella zoster in pregnancy 3
1. Give oral acyclovir as prophylaxis between day 7-14 after chickenpox exposure (apparently more effective compared to immediately)
2. once chickenpox rash appears, give oral aciclovir if it is within 24 hours and if they are more than 20 weeks gestation
3. once baby delivered, monitor and give IV acyclovir
138
What is uterine hypoactivity and why is this a problem
2 or fewer contractions in 10 minutes and each lasting less than 40 seconds
leads to suboptimal progress during labour
139
What is Oligohydramnios and causes 3
low volume of amniotic fluid surrounding fetus at pregnancy
1. rupture of membranes= fluid loss
2. fetal growth restriction (baby produces less urine= less fluid)
3. things that reduce baby's ability to wee: eg renal agenesis in potter sequence
140
What is the ix 1 and mx 1 of oligohydranmios
US: max vertical pocket <2cm and amniotic fluid infex <5
therapeutic amnioinfusion
141
How does the process of amniotic fluid work?
amniotic fluid is initially produced by mother until 33 weeks of gestation. This declines until there is only 500ml at term
Fetus breathes and swallows the amniotic fluid which gets processed and the fetus wees out, eventually replacing the amniotic fluid with fetal urine
142
What is Polyhydramnios and causes 3
abnormally large level of amniotic fluid during pregnancy
-> maternal diabetes
-> macrosomia
-> fetal infections (TORCH)
143
What is the mx for Polyhydramnios 1
only if so severe that it is causing mother SOB, then aminoreduction (needle to drain some fluid)
144
What is a breech mapresentation?
bottom is closest to uterus
145
What is uterine rupture
and complications 2 and symptoms 2
rupture of myometrium of uterus during a labour contraction whilst the baby is inside
complication: this is an issue because the fetus is deprived of oxygen and mum can get peritonitis- fatal for both
vaginal bleeding and ceasing of uterine contractions
rfx: previous c-section
146
What is Cephalopelvic disproportion
when baby's head doesn't fit through opening of pelvis
147
What is the mx for breech malpresentation? 2
if still breech at 36 weeks NICE recommend external cephalic version (ECV)- CI= ruptured membranes and multiple pregnancy
if baby still breech then discuss delivery options eg planned caesarean (which carries reduced reduced mortality for babies in breech)
148
How is uterine rupture managed? 2
emergency caesarean section to remove the baby ASAP
may need a hysterectomy to remove uterus or repair uterus in same surgery as c section
149
main risk factor for uterine rupture and investigations
previous caesarean section
CTG: will be abnormal- fetal bradycardia
150
What are the 3 stages of labour?
1. onset of true contractions to 10cm cervical dilation
2. from 10cm until baby is delivered
3. from baby delivered to placenta delivered
151
What are braxton hicks contractions? How to tell the difference between this and true contractions
irregular contractions of uterus in 2/3 trimester which are NOT true contractions and do not indicate onset of labour
-> comparatively, true contractions progress and become regular
152
What are the 4 signs of labour
Show (mucus plug from the cervix falls out)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
153
What is classed as prematurity and what is classed as unviable
premature: before 37 weeks
non viable: below 23 weeks
154
What is prophylaxis for preterm labour 2
1. vaginal progesterone (prevents cervix contracting)- short term eg enough time to give steroids and then do c-section
2. cervical cerclage (stitch in cervix to keep it closed which is then removed in labour) can be inserted at week 14
155
What are the instruments that can be used to help in labour? 2 complications of these?
1. ventouse (suction cup)- Cephalohematoma or caput succedaneum
2. forceps- CN 7 palsy
156
What are the forms of pain relief in labour? 3
1. conservative: perianal and fundal massage, TENS (transcutaneous elective nerve stimulation)
2. meds: paracetomol in early labour, entonox (NO + O2 gas), IM pethidine (2 boluses max)
3. epidural anaesthesia= CI in fetal distress and doac/ low platelets (risk of bleeding) (SE: urine retention, hypotension, headache)
157
What is shoulder dystocia, comp, mx2
failure of the anterior shoulder to pass under the symphysis pubis after the head has been delivered
need to deliver within 4 minutes to prevent fetal hypoxia and brain damage
-> McRoberts position
-> superpubic pressure to rotate and adduct baby's shoulders to make the shoulders closer together for shoulders to pass through
158
What is an umbilical cord prolapse and sx 2
cord descends before the baby which is an emergency (as it can lead to compression of the cord AND cord exposed to outside temp= vasocontriction= fetal hypoxia)
sx: visible cord, fetal bradycardia
159
What is the tx for cord prolapse 4
A-E assessment
1. go on all 4s to reduce pressure on cord or trendelenburg position to have feet higher than head to releive pressure
2. can give tocolytics to buy time for c-section as it reduces uterine contractions -terbutaline
3. can catheterise + retrofill the bladder with saline (elevates the presenting part= feels better)
4. c-section needed (cat 1 if fetal distress and cat 2 otherwise)
160
What is PPROM and causes 4
Preterm premature rupture of the membranes (before 37 weeks)= gush of fluid
trauma, TORCH, CVS, amniocentesis
161
How is PPROM diagnosed 2
1. speculum exam= pooling of amniotic fluid in posterior fornix of vagina
2. if doubt, IGFBP-1 test (should be +)
162
What is the mx for PPROM? 5
1. 10 days oral erythromycin QDS 250mg to prevent chorioamnionitis
2. antenatal steroids if before 36 weeks (develop fetal lungs and reduce resp distress)- 2 doses IM betamethasone 24 hours apart if beteeen 24 and 34 weeks
3. IV magnesium sulfate to protect fetal brain from cerebral palsy if before 34 weeks (given within 24 hours of delivery of preterm less than 24) only IF labour started
4. delivery plan for 34 weeks with expectant mx if no other contraindicaitions to this-planned preterm dilvery due to increase risk of chorioamnionitis
5. admit for 72 hours to monitor for any infections
163
What is a note about giving magnesium sulfate to preterm labour mothers?
magnesium toxicity
signs: reduced tendon reflexes (esp patella), reduced resp rate, reduced BP
164
What is tocolysis, example and its purpose
using meds to stop uterine contractions eg nifedipine
-> used to delay delivery (SHORT TERM) and buy time for further fetal development/ to give steroids
-> given between 24 to 33+6 weeks
165
How does fetal monitoring occur?
CTG
166
How does CTG work??
-> uses doppler sound waves to check when the baby's heart moves
-> this tracks the baby's heart rate
167
What are the components of CTG 7
DR C BRAVADO
define risk
contractions 3-5 times in 10 mins
baseline (heart) rate
variability: how much fluctuation from baseline
acceleration
deceleration
overall/ other
168
How to define risk of pregnancy via CTG and action for high risk
LOW risk: regular contractions, HR 110-160, variability 6-25, accelerations present, early decelerations
HIGH risk: brady/tachycardia, variability <5 (for less than 40 mins= sleeping fetus), no accelerations, late/ variable decelerations
-> consider fetal scalp sample and if low pH, it indicates hypoxia= needs immediate c-section
169
What is a normal variability, acceleration and deceleration in CTG
variability= fetal heart rate fluctuation from one beat to the next, normal is between 6-25 bpm
accelerations= when fetal heart rate is 15 or more bpm ABOVE its baseline for 15+ seconds
decelerations= when fetal heart rate is 15 or more bpm BELOW baseline for 15+ seconds
170
What is antepartum haemorrhage and causes 5
haemorrhage after 24 weeks but before labour
placenta praevia
vasa praevia
placental abruption
infection
no cause
171
What is Placenta Accreta Spectrum, ix and mx
what is the main rfx for this
when placenta invades into muscle of uterus= placenta will not separate from uterus during labour properly, increasing risk of postpartum haemorrhage
ix: sometimes seen on US, better mx can be done if identified before labour
mx: elective c-section + caesarian hysterectomy to completely remove placenta
main rfx: previous c-section
172
What is placenta praevia and ix, mx, acute presentation
when placenta is low-lying in cervix and blocks birth canal
ix: dx with the 20 week transvaginal US, if low lying then repeat at 32 weeks and 36 if still low
mx: c-section
can present as PAINLESS vaginal bleeding with fetal distress, if after ROM then it is vasa praevia
173
What is placental abruption? 2 comp? Sx? 3
separated of a normal sited placenta from the uterine wall= maternal haemorrhage in the intervening space and fetal hypoxia
sx: shock which doesn't align with visible loss, constant pain, tender and tense and woody uterus
abr-
Uterus is tender and tense
Pain
T(sh sound)- shock that doesnt align with visible loss
-ion
174
What is the mx for placental abruption? 3
if fetal distress then immediate c-section
if fetus dead= induce vaginal delivery
if no fetal distress, deliver vaginally (if less than 36 weeks then give steroids and observe closely)
175
What is vasa praevia
When fetal vessels travel across the internal cervical os (this exposes them and they do not have the protection of the umbilical cord or the placenta)
176
Vasa praevia sx, diagnosis and managed?
dx: US ideally but likely to be found through vaginal exam
sx: during labour or when there is fetal distress +
painless dark-red bleeding in 3rd trimester/ after ROM
mx: emergency c-section
if asymptomatic then steroids to mature fetal lungs and elective c-section planned for 34-36 weeks
177
What is postpartum haemorrhage? Two categories?
blood loss of > 500 ml after a vaginal delivery= EMERGENCY
primary (within 24 hours), secondary (24hours to 6 weeks)
178
What are the causes of postpartum haemorrhage 4 and mx for each
4 Ts:
Tone (uterine atony= decreased uterus tone after birth): MC- = decreased pressure on spiral arterioles= more dilation and blood filling= bleed
-> first uterine massage then uterotonics (cause uterine contraction- opposite of tocolytics) eg oxytocin
Trauma (e.g. perineal tear/ uterine rupture)
-> repair
Tissue (retained tissue eg placenta)
->MROP
Thrombin (e.g. clotting/bleeding disorder)
-> transfusion/ fresh frozen plasma
179
What is the mx for postpartum haemorrhage? 7
1. call for senior help
2. ABCDE
3. cross match blood group and have blood transfusion ready- do group and save first then 2 x 14G large bore cannulae for IV fluid + transfusion
4. fundal massage to stimulate contractions
5. catheterise to empty bladder
6. IV oxytocin then IV ergometrine (uteronics)
7. if all fails, then surgery: intrauterine balloon tamponade
8. SACFEIS (sacface pronounced)
180
What is rhesus disease of the newborn?
prior sensitisation in Rh- mum from Rh+ child and causes t2 hypersensitivty in the 2nd child, which results in IgG transplacental RhD IgG causing fetal distress in utero
181
What are the sx of Rhesus disease 6
1. Hydrops foetalis appearing as foetal oedema in at least two compartments, seen on antenatal ultrasound
2. Erythroblastosis fetalis: yellow coloured amniotic fluid due to excess bilirubin
3. Neonatal jaundice and kernicterus
4. Foetal Anaemia causing skin pallor
5. Hepatomegaly or splenomegaly
6. Severe oedema if hydrops foetalis was present in utero= congestive HF and resp distress
SHANE diagnosed HYDROPS FETALIS on US
182
How is rhesus disease of the newborn diagnosed? 4
1. + direct and indirect coombs test
2. + kleihauer test (fetomaternal
4. increased reticucloblasts
5. amniocentesis/ CVS= yellow amniotic fluid aspirate
183
How is rhesus disease of the newborn treated? 3
1. prevent= IM anti D immunoglobulin (28w + 34w to Rh- mums)
2. give anti D immunoglobulin intrapartum and in miscarriage/ termination of pregnancy
3. ABCDE + transfusion + treat any jaundice
184
What is the antenatal advice for all pregnant women? 5
1. folic acid 400mcg daily from a month before conception to 12 weeks gestation to reduce risk of neural tube defect
2. daily vitamin D 10mcg daily
3. avoid vitamin A (cod liver oil/ eating liver)
4. no smoking or alcohol
5. avoid air travel 37+ weeks due to increased VTE risk, if multiple pregnancy then 32+
185
What is premenstrual syndrome (PMS) and sx 5
emotional and physical symptoms that women may experience in the luteal phase
emotional: anxiety, fatigue, mood swings
physical: bloating, breast pain
186
What is the mx for premenstrual syndrome?
mild sx: sleep well, exercise, have regular frequent small meals rich in complex carbohydrates
moderate: COCP eg microgynon (ethinylestradiol)
severe: SSRI
187
What are breast cyst sx and mx? Does this increase risk of breast cancer? What are the fluids in the cyst aspiration? 3
smooth, discrete lump (benign breast lump condition)
mx: aspirate cysts, those that are blood stained or persistently refill should be biopsied or excised
only small risk of breast cancer (but is benign)
white (galac), green (simple), blood (bad)
188
What is fibroadenoma sx? mx? Does this increase risk of breast cancer?
mobile, firm, painless breast lump which can grow bigger, stay same or shrink (benign breast lump condition)
mx: routine, triple assessment, if >3cm wide local excision
doesn't increase risk
189
What is intraductal papilloma sx? mx? Does this increase risk of breast cancer?
breast lump with nipple discharge: clear or bloody (benign breast lump condition)
mx: triple assessment, Microdochectomy (removes ducts)
no increased risk of breast cancer
190
What are the sx of breast mastitis +/- abscess
sx: wedge shaped distribution +/- pus/ bloody discharge and fever, typically in lactating female
191
What is the mx for breast mastitis +/- abscess
lactating: make sure they are regularly expressing (as stagnant milk can cause this) for 12 hours and sx continue or if culture of breast milk comes back postive then start on flucloxacillin
non-lac: flucloxacillin/ erythromycin + metronidazole and triple assessment
192
What is pagets disease of the nipple
unrelenting nipple eczema persisting after 2+ weeks of steroids/ antifungals
starts with nipple then spreads to areola (opposite in eczema) then moves on to rest of breast
193
Ix for pagets disease of the nipple? 2
1. triple assessment (the mammography can evaluate breast tissue for underlying malignancies as pagets increases risk of malignancy)
2. punch biopsy and histology shows pagets cells (round large pale cells with lots of cytoplasm and large nuclei)
194
What protein is associated with pagets disease of the nipple
HER 2
195
What is the mx for pagets disease of the nipple? 2
mastectomy or wide local excision
196
What are the complications of silicone implants complications 3
1. rupture
2. capsular contractures (hard scar tissue formed around breast implant which is painful)
3. BIA-ALCL (remove ASAP)- breast implant associated Anaplastic Large Cell Lymphoma, sx appear years after getting a breast implant
197
What are the methods of breast reconstruction after mastectomy? 4
1. external prosthesis (shaped mould in bra so appears normal in clothes)
2. partial reduction: lat dorsi/ fat used to fill the gap
3. reduction and reshaping (removing tissues and reshaping both breasts to match)
4. breast implants
198
What is mammary ductal ectasia? Mx? 3
sticky brown-green nipple discharge, suggesting clogged ducts (benign breast lump condition)
3x assessment, watch and wait
if severe pain or repeated infections, microchodectomy
199
Mammary dysplasia sx? Mx? 2
lumpy grains of rice on breast (benign breast lump condition) in middle aged women, can be painful
mx: supportive bra, NSAIDs for pain
200
What is fat necrosis of the breast?
benign breast lump after trauma
201
What are the rfx for breast cancer? 6
1. nulliparous
2. early menarche/ late menopause
3. progesterone or HRT for more than 5 years
4. alcohol
5. 1st degree relative with breast cancer
6. BRCA 1 & 2
202
What are the types of breast cancer?
1. MC adenocarcinoma
-> of which most are ductal (unilateral, easily detectable on scan) and fewer are lobular (bilateral, harder to detect on imaging)
203
Compare in situ and invasive breast cancer
in situ: asymptomatic, not invaded basement membrane
invasive: invaded basement membrane
204
What is the most common type of breast cancer?
invasive ductal carcinoma
205
How is breast cancer graded?
how well differentiated cancer is
grade 1= well differentiated
grade 3= poorly differentiated
206
What are the features of breast cancer? 3
1. unrelenting nipple eczema
2. breast lump: tethering + fixed hard lump
3. nipple changes: inverted/ bloody discharge
207
What indicates 2 week wait referral for breast cancer?
30+ unexplained breast lump
50+ unilateral suspicious nipple changes (inversion/ discharge)
or high risk
208
What is the medical management for breast cancer?
1. if tumour oestrogen positive, give tamoxifen if premenopause (SE= increased risk VTW, endometrial cancer) if postmenopause give anastrazole (SE osteoporosis so give vit D, calcium and bisphosphonates)
2. if tumour is HER2 positive, give trastuzumab (need baseline echo, CI in heart disease)
209
What is the surgical management of breast cancer? 3
1. wide local excision with adjacent radiotherapy to prevent reoccurance
-> if palpable lymph nodes (if neg- US if positive for lymph nodes, if neg US then biopsy for lymph nodes) and these positive= axillary clearance with their surgery
2. mastectomy (total breast removal) if more than 20% of breast volume affected
-> if palpable lymph nodes (if neg- US if positive for lymph nodes, if neg US then biopsy for lymph nodes) and these positive= axillary clearance with their surgery3. chemo: for aggressive metastases
wide local excision + radio= ductal carcinoma in situ less than 4cm, peripheral lump, single, small
mastectomy= opposite of above, central lump etc
**ALWAYS** radio after wide local excision
radio in mastectomy only if T3/4 (size >5cm, or tethering) OR N2+ (>4 axillary nodes)
209
What is the drug class of
1. tamoxifen
2. anastrazole
3. trastuzumab
1. selective oestrogen receptor modulator (SERM)
2. non steroidal aromatase inhibitor
3. monoclonal antibody
210
Explain the Breast Screening Programme
women 50-71
offered mammogram every 3 years
if BRCA 1 mutation, yearly mammograms from age of 30
211
iBRCA 1 prophylaxis for women
BRCA 1 only, women can get an elective mastectomy and prophylactic tamoxifen BEFORE they get cancer
212
What is the staging for breast cancer?
T0-T4, N0-3, M0-1
(T0 less than 1cm, 1= < 2cm, 2= 2-5cm, 3= >5cm, 4= tethering)
**
**(N0= no lymph node nets, 1-3 axillary lymph node mets, 2= 4-9 axillary lymph node mets, 3= lymph nodes in 10+ axillary lymph nodes)
****
(M0= no cancer mets, M1 cancer mets elsewhere in body)
213
What are the measures of prognosis for breast cancer 4
1. Nottingham Prognostic index (prognosis of 10 year life expectancy after surgery)
2. NHS predict (10 year survival after chemo)
3. Ki67 growth factor (greater than 14= poor prognosis and needs chemo)
4. B15-3 monitors response to tx
Predicting (NHS predict)
Prognosis (Nottingham prognosis index)
for
Breast (B15-3)
Kancer (Ki67>14)
214
What is the breast cancer tx for pregnant women
surgery and chemo (chemo can be given in 2nd + 3rd trimester)
215
What genes increase breast/ ovarian cancer risk and where are they located
BRCA1 chromosome 17: increased risk breast, ovarian, bowel, prostate cancer
BRCA2 chromosome 13: increase risk breast + ovarian cancer
216
Explain Ductal Carcinoma In Situ
-> pre/ cancerous epithelial cells of breast ducts localised to a single area
-> potential to spread locally or to develop into an invasive breast cancer
-> good prognosis if fully excised and caught early enough
217
What is triple assessment for breast conditions
3 methods of ix for breast cancer, all done in a single hospital visit
1. physical exam
2. imaging: mammogram
3. biopsy
218
Where does breast cancer metastasise to? 4
2 Ls and 2 Bs
L – Lungs
L – Liver
B – Bones
B – Brain
219
What is a SE of axilla clearance?
lymphoedema in entire arm
220
What is the follow up for all pts treated for breast cancer?
**yearly** mammograms yearly for 5 years
221
What is Lymphogranuloma Venereum and what are the rfx? 3
STI caused by Chlamydia trachomatis serovars L 1,2+3 (normal chlamydia caused by serovars d to k)
-> men who have sex with men
-> the majority of patients who present are from developed countries and have HIV
222
What are the features of Lymphogranuloma venereum?
Typically infection comprises of three stages:
stage 1: small painless pustule which later forms an ulcer
stage 2: a few weeks later, painful inguinal lymphadenopathy
may occasionally form fistulating buboes
stage 3: proctocolitis
223
What is the difference between Lymphogranuloma venereum and normal chlamydia
normal chlamydia= urethritis and pelvic inflammatory disease, unlike Lymphogranuloma venereum
224
How is Lymphogranuloma venereum treated?
doxycycline
225
What are the causes and features of genital warts?
HPV 6 and 11
-> small (2 - 5 mm) fleshy protuberances which are slightly pigmented (look like skin tags
-> can itch/ bleed
226
What is the mx of genital warts 2
1. topical podophyllum (especially for multiple warts)
2. cryotherapy
227
What is pubic lice caused by, sx 3 and mx
bloodsucking parasite
sx: itching, red spots (bites), yellow dots attached to hair (eggs)
mx: insecticide eg permethrin
228
What are ix for erectile dysfunction 3
1. calculate QRISK (using lipids and fasting glucose) as erectile dysfunction can be the first presentation of a cardio disease)
2. general bloods: FBC, UE, TFT, testosterone, prolactin
3. free testosterone blood test needs to be between 9-11am
229
What can indicate the cause of erectile dysfuntion?
if gradual onset then likely psychogenic but if sudden then likely organic cause eg atherosclerosis
230
What is the mx for erectile dysfunction? 4
1. sildenafil (PDE 5 inhibitor)
2. vacuum erection devices (if sildenafil not appropriate)
3. young man always had difficulty achieving erection= referral to urology
4. people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
231
What is postpartum thyroiditis and stages 3
-> changes to thyroid function for a year after birth
1. Thyrotoxicosis (usually in the first three months)
2. Hypothyroid (usually from 3 – 6 months)
3. Thyroid function gradually returns to normal (usually within one year)
232
What are the ix for postpartum thyroiditis? 3 Mx? 2
1. TFTs 6/8 weeks after delivery
2. abnormal TFTs= endocrinologist referral
3. annual monitoring TFTs even after conditions resolved
Thyrotoxicosis: symptomatic control= propranolol
Hypothyroidism: levothyroxine
233
Explain what HIV is and pathophys
HIV is an RNA retrovirus, enclosed by a capsid of viral protein p24, with envelop proteins gp120 +41
HIV-1= MC (HIV2 in W Africa)
HIV attacks CD4 T-helper cells in host
234
What are the sx of HIV 2
-> initial seroconversion flu-like illness occurs first few weeks of infection (sore throat, arthralgia, rash)
-> asymptomatic until progression to immunodeficiency
235
How is HIV transmitted?
1. sexual contacat
2. vertical transmission (mum to child)
3. bodily fluid spread
236
How is HIV screened?
screening for all sexual health/ antenatal/ substance misuse service users
opt out system in emergency (tested for unless pt refuses) but in community, verbal consent required
1. fourth gen lab test: self-sample test to HIV antibodies AND p24 antigen (window period of 45 days after exposure to virus)
2. point of care test (ELISA) for HIV antibodies only (90 day window and immediate results)
237
How is HIV monitored
1. CD4 cell count
500-1200 cells/mm3= normal range
Under 200= high risk of opportunistic infections
2. HIV RNA viral load (undetectable= under 20)
238
How is HIV managed? 6
1. ART (antirectroviral therapy)
-> as soon as diagnosed, start patients on HAART which is two NRTIs (nucleoside reverse transcriptase inhibitors plus third agent (NNRTI or PI (non nucleoside... or protease inh)
-> aim is to return to a normal CD4 count and undetectable viral load
2. Prophylactic co-trimoxazole for HIV pt with CD4 under 200 to protect against pneumocystis jiroveci (which can cause pneumonia + pneumothorax)
3. yearly cervical smears (HIV increases risk of cervical cancer/ HPV infection)
4. regular monitoring of CV (HIV develops this)- eg blood lipids and prophylacis like statin
5. annual flu, penumococcal, HPV, hep A/B vaccinations
6. use condoms to prevent spread of HIV
239
How is HIV managed in pregnant women to prevent transmission? 4
1. measure mothers viral load: under 50= vaginal delivery otherwise pre-labour c-section recommended
2. IV zidovudine during labour
3. baby given zidovudine for 1 month if mothers viral load is <50, otherwise, combination therapy for 1 month: zidovudine, lamivudine and nevirapine
4. advise against breastfeeding
240
What is the pre AND post exposure prophylaxis (PEP) for HIV?
-> pre= ART combination therapy (emtricitabine/tenofovir)
-> post= ART combination therapy
take everyday for 1 month
for post exposure- ensure this is started within 72 hours/ 3 days of exposure
(emtricitabine/tenofovir and raltegravir for 28 days)
241
What is the connection between HIV and pneumocystis jiroveci
pneumocystis jiroveci is the most common opportunistic infection in AIDS
242
What is the cause of kaposi's sarcoma and who is at increased risk of getting this?
human herpes virus 8 (HHV 8)
HIV
243
What are the features of kaposi's sarcoma and what is the mx? 3 2
-> purple papules/ plaques on the skin or GI + resp mucosa
-> these can eventually ulcerate
-> resp involvement can lead to haemoptysis + PE
radiotherapy and resection
244
What are the MC causes 2 of nappy rashes and sx?
1. irritant dermatitis (due to irritation from urinary ammonia and faeces): creases are spared
2. candida dermatitis: red rash, involves creases and characteristic satellite lesions
245
What is the mx for nappy rashes? 5
1. leave baby without nappy when possible
2. use warm water rather than wipes
3. topical steroid cream eg hydrocortison if severe
4. clotrimazole (for suspected candida)
5. use sudocream/ castol oil as barrier for prevention for next time (NOT AS TX)
246
What is Precocious puberty
development of secondary sexual characteristics before 8 years in females and 9 years in males (basically premature sexual development)
247
What are the classes of Precocious puberty and explain the causes for each
1. Gonadotrophin dependent
-> due to premature activation of HPG axis
-> FSH and LH raised
2. Gonadotrophin independent
-> due to excess hormones
-> FSH and LH low
248
Compare male and female Precocious puberty
male: uncommon, usually organic cause eg McCune Albright syndrome
female: usually idiopathic or familial, often not concerning
if breast and menarche before 8 years, refer girls to a paediatric endocrinologist
249
What are the clinical features in a male that tells us about Precocious puberty 3
bilateral enlargement testes= gonadotrophin release from intracranial lesion
unilateral enlargement testes= gonadal tumour
small testes = adrenal cause (tumour or adrenal hyperplasia)
250
What are the screening tests that a pregnant woman goes through
12 weeks: scan which calculates gestational age from crown rump length and screening for downs, pataus and edwards if women choose to get screening
20 weeks: US scan to identify any abnormalities eg heart conditions
-> in between will have antenatal appointments:
1. BP
2. urine for protein and microscopy for asymptomatic bacteria
3. measure Symphysis–fundal height from 24 weeks
4. from 24 weeks oral glucose tolerance test if women at risk of gestational diabetes
5. check fetal presentation from 36 weeks
251
What are the injections offered for pregnant women and at what point in their pregnancy is it viable to take these?
1. Whooping cough (pertussis) from 16 weeks gestation
2. Influenza (flu) when available in autumn or winter
3. Anti-D injections in rhesus negative women (at 28 and 34 weeks)
252
What are cutaneous warts? Where are they located? Cause? What is a verruca? Transmission?
small, rough growths that are caused by infection of keratinocytes with human papilloma virus (HPV)
-> can be anywhere but tend to be on hands and feet
-> a wart on the sole of the foot
-> skin to skin contact/ indirectly eg contaminated floors like swimming pools
253
What is the mx for cutaneous warts? 2
1. typically resolves without treatment
2. if painful/ unslightly/ persistant then topical salicylic acid and cryotherapy
254
What is the features and mx for athletes foot 2 (tinea pedis)
-> typically scaling, flaking, and itching between the toes
mx: when feet are wet then towel dry between toes and terbafine
255
What are the features and mx for ringworm (tinea corporis)
well-defined annular, erythematous lesions with pustules and papules
mx: oral fluconazole
256
What is tinea capitis, cause 1, ix 1 and mx 2
-> scalp ringworm
-> Trichophyton tonsurans
-> scalp scrapings
-> terbinafine and topical ketoconazole shampoo for 2 weeks to reduce transmission
257
What are the functions of the 4 hormones for females
oestrogen: proliferates endometrial cells for ovulation and builds endometrial lining after menstrual cycle
progesterone: increases uterine mucus secretion and maintains endometrium and causes smooth muscle relaxation (why it drops for menstruation to start)
LH: acts on theca cells which stimulates oestrogen production and stimulates release of egg during ovulatoin
FSH: acts on granulosa cells for folliculogenesis
258
Explain 3 types of natural contraception
-> condom use
-> breastfeeding (for up to 6 months if period hasn't come back to delay ovulation)
-> tracking periods and when in the cycle you are most fertile
259
What are the shorter acting contraceptives 3
-> COCP (CI in CV disease, HTN, VTE hx, heavy smoker, breastfeeding, <6 weeks postpartum, migraines, breast cancer)
-> POP
-> HRT contraceptive patch (releases osteogen and progesterone- same 21/7 day cycle, better for people who want COCP but forget to taken pills)
260
What are the longer acting contraceptives 4
-> depo provera (medroxyprogesterone injection)
-> IUS (hormonal)
-> IUD (copper)
do not give IUS/D if 48h-4 weeks postpartum
-> nexplanon implant (implant in arm and releases progesterone, lasting for 3 years)
261
What are the sterilisation options 2
-> vasectomy (males)- reversible
-> tubal ligation (females)
262
What is the UK MEC guidance for contraceptions and how is it calculated?
UKMEC 1: no restriction
UKMEC 2: benefit generally outweighs the risk
UKMEC 3: theoretical or proven risk generally outweighs the benefit
UKMEC 4: contra-indicated
-> based on patient and their co-morbidities
263
How are COCPs taken? Example
21/7 cycle
-> 21 days of taking the pill at the same time each day
-> 7-day break where they will have a period-like withdrawal bleed
-> 3 monthly if irregular periods and monthly if regular
Microgynon 30
continous COCP taken for post menopausal women
264
What are the screening tests for infections/ genetic conditions for a fetus and when are they done
12 weeks: chorionic villus sampling
15+ weeks: amniocentesis to identify any chromosomal conditions eg downs/ pataus/ edwards or genetic cond eg cystic fibrosis/ sickle cell
15+ weeks: NIPT (alongside amniocentesis)- sample mums blood for cffDNA (very sensitive for Downs)
265
What are the two phases of stage 1 labour
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
266
What are the two phases of stage 2 labour
'passive second stage' absence of pushing
active second stage' refers to the active process of maternal pushing- can give oxytocin as part of hte active labour maangement
267
What are the indications of inducing labour? 3 what are the risks? 2
1. prolonged labour
2. maternal risks eg obesity/ preeclampsia/ gestational/ PPROM
* 1. uterine hyperstimulation (more than 6 contractions in 10 mins)
* 2. fetal ischaemia
268
Explain the two ways of labour induction
if bishops score < 6= vaginal prostaglandin or oral misoprostol
bishops >6= amniotomy with an amnihook and IV oxytocin
269
What does the bishops score measure and explain the scoring
cervical ripeness
1-5= unripe, unlikely to spontaneously induce= induce labour
5-7= intermediate
7+= ripe, likely to spontaneously induce, expectant mx
270
What can be done for a breech baby to turn them head first?
36 weeks, external cephalic version
-> try to turn the baby into a head-down position by applying pressure on your abdomen
271
What are the risks of breech baby vaginal delivery? 2
-> cord prolapse
-> dislocated hips
272
How to know what to prescribe for HRT
HRT (for perimenopausal sx management)
needs to be combined if they have a uterus
topical if sx are only vaginal, oral if sx are systemic
transdermal for systemic sx but risk of VTE (still needs to have a source of progesteron eg mirena coil)
CI in hormonal cancers and unexplained PMB
273
What is the implication of chlamydia contraction during pregnancy 2
neonatal conjunctivitis/ pneumonia
274
What are the neonatal complications of rubella infection in pregnancy and when can it be contracted
congenital deafness, cataracts and heart disease (PDA + pulmonary stenosis)
in the first 20 weeks of pregnancy
275
What are the complications of CMV infection during pregnancy
hearing/ vision loss
microcephaly
learning disabilities
seizures
fetal growth restriction
276
What are the symptoms of toxoplasmosis infection in pregnancy on the neonate and how does this spread
triad:
intracranial calcificaiton
hydrocephalus
chorioretinitis
faeces of cat more likely than a human
277
What are the neonatal complications of parovirus b19 infection during pregnancy
miscarriage/ fetal death
severe fetal anaemia
hydrops fetalis
278
Mx for reduced/ no fetal movements
If not felt movement by 24 weeks= urgent referral to fetal med unit
if reduced movement:
after 28 weeks, use handheld dopper to confirm fetal heartbeat and if this is NOT detected then immediate US. IF detected then cardiotocography for 20 mins to monitor heart rate
279
Mx for pregnancy related nausea 4
1. In mild-moderate N+V, lifestyle advice + diet modificaton should be offered first (including ginger)
2. first line meds is cyclizine/ promethazine
3. second line meds is metoclopramide/ ondansetron
4. if severe sx of dehydration then admission to hospital
280
infertility
infertility= failure to achieve a pregnancy after 12 months or more of regular UPSI (primary= couples that have never conceive, secondary= conceived already but struggling to again)
281
ovarian hyperstimulation syndrome cause, sx,
normally going through IVF and having injections
sx: n/v, bloating, SOB
282
What is the pathological basis behind the shortness of breath in this conditon?
1. Hyperstmulated ovaries release vasoactve mediators
2. Increased capillary permeability causes fluid shift
3. SOB due to pleural effusion
(can have ascites/ pericardial efusions due to efusion in respectve cavites)
283
COCP and POP missed pill rules
If 2-7 pills have been missed (72 hours or more since the
last pill in the current pack was taken) in week 1/2/3 after HFI
- Emergency contracepton is not required if there was
consistent, correct use in the previous 7 days
- Avoid sexual intercourse or use a barrier method of
contracepton untl 7 consecutve pills have been taken:
(this is overcautious, but is a back-up in case of
subsequent incorrect use.)
If 2+ pills missed in week 4, barrier for 7 days and omit next HFI period
if 7+ pills missed, start like its new, take a pregnancy test before this and barrier for 7 days
If 1 pill missed regardless of week, take missed pill ASAP and no emergency contraception required as long as had 7 days of correct use of pill
emergency contraception only required if 2+ pills missed and UPSI occured during HFI or week 1
if 1 pill missed on POP, no emergency contraception needed, take pill ASAP and use barrier contraception for 48 hours
284
investigations for hyperemesis gravidarum
immediate ix:
1. urine dipstick: to check for ketones 2. bloods: FBC, TFT (hypo= nausea), UE
285
mx for nausea in pregnancy
1. In mild-moderate N+V, lifestyle advice + diet modificaton should be offered first (including ginger)
2. first line meds is cyclizine/ promethazine
3. second line meds is metoclopramide/ ondansetron
4. if severe sx of dehydration then admission to hospital: give IV saline **with** potassium , thiamine, b6
286
What are the risk factors for hyperemesis gravidarum
1. first pregnancy
2. multiple pregnancy
3. prev phx of HG
4. molar pregnancy
287
contraceptives time until effective
POP- 2 days
COCP/IUS/implant/depot- 7 days
IUD- immediately
288
Tell me about emergency contraception
levonogesterol 1.5mg to be taken within 72 hours of UPSI
IUD= up to 5 days
ullipristol= 30 mg up to 120 hours/ 5 days after UPSI
