Y4 Lectures Flashcards
1
Q
Risk factors for vulval carcinoma?
A
HPV
Lichen sclerosis / lichen planus
Multiple sexual partners
Early first age of intercourse
Smoking
2
Q
Vulval carcinomas are what type of cancers?
A
Squamous cell carcinoma
3
Q
Symptoms of vulval carcinoma:
A
Common symptoms include: Pruritis, burning, soreness, bleeding, pain or a lump.
It is uncommon to find genital warts in postmenopausal women, hence any findings should be examined to rule out cancer. Most squamous cell carcinomas are unifocal andoccur on the labia majora.
4
Q
Diagnosis of vulval carcinoma?
A
Keye’s punch biopsy
5
Q
Treatment of vulval cancer?
- skim details
A
Surgical resection is gold standard.
- Wide local excision is recommended for small cancers.
- Partial radical vulvectomy is recommended for cancers that are confined to either side of the vulva, or the front or back only. This may mean that a large part of the vulva is removed. Usually, nearby lymph nodes are also removed.
- Complete radical vulvectomy is recommended for cancers that cover a large area of the vulva. The surgeon removes the entire vulva and the deep tissues around the vulva. Invariably the nearby lymph nodes are also removed.
6
Q
Cell type of cervical cancer?
A
SCC
7
Q
What viruses cause genital warts?
A
HPV 6 HPV 11
8
Q
Cervical cancer risk factors:
A
HPV!!
- Smoking
- Other sexually transmitted infections
- Long-term(> 8 years) combined oral contraceptive pill use
- Immunodeficiency (e.g. HIV)
9
Q
Clinical features of cervical cancer:
A
Most common symptom is abnormal vaginal bleeding (e.g post-coital, intermenstrual or post-menopausal).
Other features:
- Vaginal discharge (blood-stained, foul-smelling)
Dyspareunia
Pelvic pain
Weight loss
However, it is often asymptomatic – particularly in the early stages of disease – and many cases are detected throughroutine screening.
10
Q
Clinical examinations for patients with suspected cervical cancer (for OSCE’s).
A
- Speculum examination– assess for evidence of bleeding, discharge and ulceration.
- Bimanual examination– assess for pelvic masses.
- GI examination– assess for hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.
11
Q
Cervical cancer differentials:
A
There are a large number of possible causes forabnormal vaginal bleeding. These include sexually transmitted infection, cervical ectropion, polyp, fibroids, and pregnancy related bleeding.
12
Q
Investigations for suspected cervical cancer:
A
In a woman presenting with symptoms suggestive of cervical cancer, the initial investigation depends on age:
- Pre-menopausal– test for chlamydia trachomatis infection
- If positive; treat for chlamydia infection. If symptoms persist after treatment, refer for colposcopy and biopsy.
- If negative; a colposcopy and biopsy is usually performed.
- Post-menopausal– urgent colposcopy and biopsy.
Acolposcopyis where a colposcope (modified microscope) is used to produce a magnified view of the cervix. Acetic acid is used to stain dysplastic areas, and a biopsy is taken.
If the diagnosis of cervical cancer is confirmed, further investigations are required:
- Basic blood tests–such as full blood count, liver function tests and urea & electrolytes
- CT Chest-Abdomen-Pelvis–looking for metastases.
- Further staging scans–e.g. MRI pelvis, PET.
- +/- examination under anaesthesiawith further biopsies.
Note: The cervical cancer screening programme aims to detect pre-invasive disease (i.e CIN). Cervical smears are not used to detect cervical cancer.
13
Q
Treatment of cervical cancer:
A
MDT - surgery, radiotherapy and chemotherapy are all options.
Chemoradiation therapy is thegold standard.
- 5-8 weeks of radiotherapy + chemotherapy
Stage 4 = resection of all pelvic adnexae
14
Q
Read the use of chemotherapy to treat cervical cancer:
A
Chemotherapy in cervical cancer is often cisplatin-based.
It can be given before treatment by surgery or radiotherapy (known asneoadjuvant chemotherapy), or after treatment (adjuvant chemotherapy).
It is also the mainstay of treatment in thepalliativesetting.
15
Q
Skim note on patient follow up for cervical cancer:
A
Patients should be reviewed by a gynaecologist every 4 months after treatment has been completed for the first 2 years, and every 6-12 months for the subsequent 3 years.
All follow-ups should involve a physical examination of the vagina and cervix (if they haven’t been removed).
16
Q
Name the two most common benign epithelial cell tumours:
A
Mucinous cystadenoma
Serous cystadenoma
17
Q
What is pseudomyxoma peritonei?
A
If a mucinous cystadenoma ruptures, it may cause pseudomyxoma peritonei.
18
Q
What type of tumour causes meigs syndrome?
A
Sex-cord stromal tumours: (ovarian tumour)
Fibroma – the most common stromal tumour. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.
19
Q
Investigations for pre-menopausal women with ovarian cysts?
A
If a diagnosis of a simple ovarian cyst has been made ultrasonographically, CA125 does not need to be undertaken. Lactate dehydrogenase, alphafetoprotein, and hCG should be measured in all women under 40 due to the possibility of germ cell tumours. Cysts should be rescanned in 6 weeks, and if they are persistent or over 5cm, laparoscopic cystectomy or oophorectomy may be considered.
20
Q
Genetic links to ovarian cancer:
A
BRCA 1 & 2 genes - OC has a strong link to family history
HNPCC (lynch syndrome)
21
Q
Ovarian cancer risk factors:
A
- Nulliparity
- Early menarche
- Late menopause
- Hormone replacement therapy containing oestrogen only
- Smoking
- Obesity
22
Q
Ovarian cancer protective factors:
A
- Multiparity
- Combined contraceptive methods
- Breastfeeding
23
Q
Ovarian cancer symptoms:
A
- Bloating
- Change in bowel habit
- Change in urinary frequency
- Weight loss
- Irritable bowel syndrome
- Bleeding per vagina
When taking a history from patients it is important to bear in mind that the presentation of ovarian cancer is often vague causing a delay in diagnosis and presentation to specialists with advanced disease. Therefore, never ignore a postmenopausal patient with nonspecific gynaecological or gastrointestinal symptoms. Enquire specifically about:
24
Q
Presentation of ovarian cysts / tumours:
A
- Incidental and asymptomatic– found on scanning for other reasons e.g. pregnancy.
- Chronic pain–may develop secondary to pressure on the bladder or bowel also causing frequency or constipation.
- It may also manifest as dyspareunia or cyclical pain in those patients with endometriosis who have developed chocolate cysts.
- Acute pain– these patients may have bleeding into the cyst, rupture or torsion.
- Bleeding per vagina.
25
What is the most common form of endometrial cancer?
The most common form of endometrial cancer is adenocarcinoma, which is caused by stimulation of the endometrium by oestrogen, without the protective effects of progesterone.
26
What is the main clinical feature of Endometrial cancer, and what is its differential diagnosis?
The main clinical feature of endometrial cancer is postmenopausal bleeding, and its differential diagnoses include vulval causes, cervical causes, and endometrial causes.
27
Diagnosis of endometrial cancer?
The investigations used to diagnose endometrial cancer include transvaginal ultrasound scan and endometrial biopsy.
28
Explain the management of endometrial hyperplasia:
Non-malignant hyperplasia without atypia can be treated with progestogens, while atypical hyperplasia should be treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy.
29
Read summary of endometrial cancer:
Endometrial cancer predominantly affects post-menopausal women, and its incidence has risen, possibly because of the increasing incidence of obesity. Its predominant symptom is postmenopausal bleeding, and women with menstrual irregularities or postmenopausal bleeding require further investigation. Hyperplasia and atypia may precede malignancy and should be treated, and followed up with surveillance biopsies. Where identified, endometrial cancer is usually stage I, and at this stage has a good survival rate.
30
Management of endometrial carcinoma:
The management offered in endometrial carcinoma is dependent on the stage of the cancer, and may include total hysterectomy and bilateral salpingo-oophorectomy, radical hysterectomy, maximal de-bulking surgery, and adjuvant radiotherapy.
31
Link of endometrial cancer to obesity:
Approximately 40% of endometrial cancer cases are thought to be linked to obesity.
The greater the amount of subcutaneous fat, the faster the rate of peripheral aromatisation of androgens to oestrogen – which increases unopposed oestrogen levels in post-menopausal women.
32
Risk factors for endometrial cancer:
Age
Obesity
Iatrogenic (oestrogen / tamoxifen)
Genetic - lynch syndrome / PCOS
33
Investigations for endometrial cancer:
1. US - assess endometrial thickness.
2. Biopsy for diagnosis.
3. MRI pelvis / CT abdo pelvis or chest for staging.
34
Management summary of endometrial cancer:
1. Hysterectomy for disease confined to the uterus
2. Chemotherapy for high grade disease outside uterus
3. Radiotherapy reduces risk of local recurrence
4. Hormones (high dose progestogens) if desire to preserve fertility or unfit for other treatment
35
Cervical cancer ix
1. Examination - colposcopy + biopsy.
2. MRI
3. PET CT
36
Indications for inducing labour:
1. Offered after 40 weeks, particularly after 42 weeks.
2. Premature rupture of membranes >37 weeks
3. Maternal health problems (pre-eclampsia, diabetes, cholestasis).
4. Fetal growth restriction.
5. Intrauterine fetal death.
37
What are the three main methods of induction?
1. Vaginal prostaglandins
2. Amniotomy
3. Membrane Sweep
38
How do prostaglandins induce labour?
Prostaglandins act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus. They come as either a tablet, gel or a controlled-release pessary.
39
Read summary on amniotomy:
An amniotomy is where the membranes are ruptured artificially using an instrument called an amnihook. As with a membrane sweep, this process releases prostaglandins in an attempt to expedite labour. It is only performed when the cervix has been deemed as ‘ripe’ (see Bishop Score below).
Often, an infusion of artificial oxytocin (**Syntocinon**) will be given alongside an amniotomy, acting to increase the strength and frequency of contractions. The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes.
NICE guidelines (2008) advise that amniotomy +/- oxytocin should NOT be used as the primary method of IOL, unless use of prostaglandins are contraindicated e.g. high risk of uterine hyperstimulation.
40
Read summary on the membrane sweep:
The membrane sweep is offered at 40 and 41 weeks’ gestation to nulliparous women, and 41 weeks to multiparous women.
It is classified as an adjunct of IOL. Performing it increases the likelihood of spontaneous delivery, reducing the need for a formal induction.
The procedure is performed by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua. The separation helps to release natural prostaglandins in an attempt to kick-start labour.
41
Summary of the Bishop's score:
The bishop score is an assessment of ‘cervical ripeness‘ based on measurements taken during vaginal examination. It is checked prior to induction, and during induction to assess progress (6 hours post-table/gel, 24 hours post-pessary):
- Score of >8 – suggests the cervix is ripe or ‘favourable’ – this means that there is a high chance of a response to interventions made to induce labour (i.e. induction of labour is possible).
- Score of <4 – suggests that labour is unlikely to progress naturally and prostaglandin tablet/gel/pessary will be required
Failure of a cervix to ripen despite use of prostaglandins may result in the need for a caesarean section.
42
When should cardiotocography be used?
Prior to induction of labour, a reassuring fetal heart rate must be confirmed by cardiotocography.
After initiation of IOL, when contractions begin assess fetal heart rate using continuous CTG until a normal rate is confirmed. Subsequently assess using intermittent auscultation.
If an oxytocin infusion is started, monitor using continuous CTG throughout labour.
43
What is uterine hyperstimulation?
Uterine hyperstimulation (1-5%) – contractions last too long or are too frequent, leading to fetal distress. Can be managed with tocolytic agents (anti-contraction) such as terbutaline.
- can be triggered by vaginal prostaglandins.
44
Treatment of uterine hyperstimulation?
Terbutaline
45
Read the complications of induction of labour:
- Failure of induction (15%) – offer a further cycle of prostaglandins, or a caesarean section.
- Uterine hyperstimulation (1-5%) – contractions last too long or are too frequent, leading to fetal distress. Can be managed with tocolytic agents (anti-contraction) such as terbutaline.
- Cord prolapse – can occur at time of amniotomy, particularly if the presentation of the fetal head is high.
- Infection – risk is reduced by using pessary vs tablet/gel, as fewer vaginal examinations are required to check progress.
- Pain – IOL is often more painful than spontaneous labour. Often epidural analgesia is required.
- Increased rate of further intervention vs spontaneous labour – 22% require emergency caesarean sections, and 15% require instrumental deliveries.
- Uterine rupture (rare).
46
What are the two main instruments used in operative deliveries?
Ventouse / Forceps
47
Maternal complications of an instrumental delivery:
Vaginal tears
3rd/4th degree tears:
1:100 in normal vaginal delivery
4:100 in ventouse
10:100 in forceps
VTE
Incontinence
PPH
Shoulder dystocia
Infection
48
Fetal complications of a vaginal delivery:
Neonatal jaundice
Scalp lacerations
Cephalhaematoma
Subgaleal haematoma
Facial bruising
Facial nerve damage
Skull fractures
Retinal haemorrhage
49
How is prelabour rupture of membranes managed?
1. High vaginal swab - swabbing for GBS.
2. Management depends on gestation:
- <34 weeks gestation – The balance would normally be in favour of aiming for increased gestation.
- >36 weeks gestation – If labour does not start, induction of labour ought to be considered at 24–48 hours. This is because the risk of infection outweighs any benefit of the fetus remaining in utero.
- 34 – 36 weeks - Induction of labour once there has been a course of steroids.
50
Read PROM and P-PROM summary:
- PROM is defined as rupture of membranes > 1 hour prior to the onset of labour occurring ≥ 37 weeks gestation.
- P-PROM is rupture of the amniotic sac < 37 weeks gestation.
- Diagnosis of membrane rupture is usually from maternal history and sterile speculum examination.
- IOL and delivery should be considered where gestational age > 34 weeks and expectant management < 34 weeks gestation.
- P-PROM is associated with much higher rates of complications than PROM. The main causes of neonatal mortality include complications associated with prematurity, sepsis and pulmonary hypoplasia.
51
Indications for a caesarean section:
Breech presentation
Twin pregnancy – when the first twin is not a cephalic presentation.
Maternal medical conditions (e.g. cardiomyopathy) – where labour would be dangerous for the mother.
Shoulder dystocia
Placenta praevia
Maternal request - needs specialist counselling.
52
What are the two types of caesarean section?
- Lower segment caesarean section: now comprises 99% of cases
- Classic caesarean section: longitudinal incision in the upper segment of the uterus
53
Contraindications to a vaginal birth after a caesarean section:
- Contraindications include previous uterine rupture or classical caesarean scar
54
Management of uterine rupture:
Uterine rupture is an obstetric emergency. Therefore, it is vital to first undertake an A-E approach, and call the appropriate staff – including senior obstetricians, midwives and anaesthetists, and, where appropriate, invoke the Massive Obstetric Haemorrhage protocol.
55
Presentation of a uterine rupture?
The initial clinical features of uterine rupture are non-specific, which makes diagnosis and prompt management difficult.
The most common presenting symptom is sudden severe abdominal pain, which persists between contractions. The patient may also experience shoulder-tip pain (from diaphragmatic irritation) and/or vaginal bleeding.
On examination, there may be regression of the presenting part, with abdominal palpation revealing scar tenderness and palpable fetal parts. Significant haemorrhage can produce signs of hypovolaemic shock; such as tachycardia and hypotension.
Fetal monitoring may reveal fetal distress or absent heart sounds.
56
What is shoulder dystocia?
Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory.
- OBSTETRIC EMERGENCY!
57
What is the major risk of shoulder dystocia?
Permanent brachial plexus
If managed appropriately the risk of permanent brachial plexus injury can be almost eliminated.
58
Management of shoulder dystocia
- Call for help – shoulder dystocia is an obstetric emergency (will need senior obstetrician, senior midwife and paediatrician in attendance).
- Advise the mother to stop pushing – this can worsen the impaction.
- Avoid downwards traction on the fetal head (increases risk of brachial plexus injury) – only use “routine” axial traction (i.e. keep the head in line with the baby’s spine), and do not apply fundal pressure (increases the risk of uterine rupture).
- Consider episiotomy – this will not relieve obstruction but can make access for manoeuvres easier.
1st and 2nd line manouveres
59
What are the first line manoeuvres to manage shoulder dystocia?
McRobert's manoeuvre
Suprapubic pressure
60
McRobert's manoeuvre
Hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher when combined with ‘suprapubic pressure’.
61
What are the second line manoeuvres to manage shoulder dystocia?
Posterior arm
Internal rotation (corkscrew manoeuvre)
62
What is eclampsia?
Eclampsia is defined as the occurrence of one or more convulsions in a pre-eclamptic woman in the absence of any other neurological or metabolic causes.
It is an obstetric emergency affecting approximately 5/10,000 pregnancies, with a maternal mortality rate of 1.8% and a fetal mortality rate of up to 30%.
63
How is eclampsia managed?
1. ABCDE + CTG
2. Lie patient in the left lateral position, secure airway + high flow oxygen.
3. Magnesium sulphate
4. BP control - labetalol/hydralazine aim for MAP <120mmHg
The patient should be assessed for signs of hypermagnesaemia, and the fetus monitored via continuous CTG.
Note: Definitive treatment is delivery of the baby.
64
Differentials for eclampsia:
Hypoglycaemia.
Medication-induced.
Pre-existing epilepsy.
Brain tumour.
Head trauma.
Cerebral aneurysm.
Haemorrhagic stroke.
Septic shock.
Meningitis.
Ischaemic stroke.
65
Read investigations for a patient with pre-eclampsia:
Investigations in suspected eclampsia are used to exclude other reversible causes (such as hypoglycaemia), and assess for any complications (such as DIC or HELLP syndrome).
Investigations to be considered:
- FBC:↓ Hb, ↓ platelets.
- U&Es: ↑ urea, ↑ creatinine, ↑ urate, ↓ urine output.
- LFTs: ↑ ALT, ↑ AST, ↑ bilirubin.
- Clotting studies
- Blood glucose
Abdominal ultrasound may be performed to estimate the gestational age and to rule out placental abruption which can complicate eclampsia. CTG monitoring is likely to indicate evidence of fetal distress and bradycardia.
It may be necessary to rule out other causes of seizures if there is any doubt regarding the diagnosis of eclampsia. For instance, if there is a history of head trauma or seizure onset in the 1st trimester, this is more likely to be associated with CNS pathology and requires a full neurological work-up including CT/ MRI head.
66
Signs of hypermagnesia:
Hypo-reflexia
Respiratory depression
67
Summary of amniotic fluid embolism:
- Amniotic fluid embolism is a rare yet often fatal complication of pregnancy and the puerperium.
- Little is known of the pathophysiology yet it resembles anaphylaxis/severe sepsis in presentation.
- Risk factors relate to abnormalities of the placenta, uterus and amniotic fluid.
- The focus of management is resuscitation of the mother by any means necessary and it is important to involve all members of the multidisciplinary team.
- Diagnosis can only be made definitively at post mortem examination.
68
What are the four categories of causes post-partum haemorrhage?
4 T's
Tone, tissue, trauma, and thrombin.
69
What is meant by tone in relation to P-PPH?
Tone refers to uterine atony, which is the most common cause of primary post-partum hemorrhage. This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle.
70
What is meant by tissue in the context of primary post-partum hemorrhage?
Tissue refers to retention of placental tissue, which prevents the uterus from contracting. It is the second most common cause of primary post-partum haemorrhage.
71
Management of PPPH due to uterine atony:
- Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina, then form a fist insider the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).
- Pharmacological measures – act to increase uterine myometrial contraction (oxytocin, ergometrine, carboprost)
- Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).
72
What drugs may be used in PPPH?
Syntocinon
Ergometrine
Carboprost
Misoprostol
73
Summary of Secondary Post-Partum Haemorrhage:
(Just read)
- Secondary PPH may occur between 24hrs up to twelve weeks postpartum.
- It may be associated with infection, retained placental tissue or abnormal involution of the placental site.
- A pelvic USS should be arranged in order to rule out the possibility of retained placental tissue. However, it is often difficult to differentiate between blood clots and retained tissue.
- The mainstay of management is antibiotics and uterotonics.
- Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings.
74
What is postpartum psychosis, and how does it differ from postnatal depression?
Postpartum psychosis is a severe mental illness that can occur in women with no previous psychiatric history, and it can develop rapidly after delivery. It is characterized by symptoms such as confusion, agitation, delusions, hallucinations, and mania. In contrast, postnatal depression is a depressive episode that occurs within the first year after giving birth, and it is similar to depression outside of pregnancy.
75
What is post natal depression?
Postnatal depression is defined as a depressive episode within the *first twelve months postpartum*. The peak incidence appears to be during the first two months after childbirth. It should be distinguished from, the ‘Baby Blues’ (a period of low mood and irritability) which normally starts three to four days after birth, lasts for about seven days and doesn’t require treatment.
76
What is placenta praevia?
Placenta praevia is where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery.
77
Placenta accreta
This is a condition where the chorionic villi insert into the myometrium, rather than superficially within the decidua basalis. As with placenta percreta, it can lead to severe haemorrhage, so if picked up prenatally, a hysterectomy during elective caesarian section should be discussed as an option following delivery.
78
Placenta increta
This is a condition where the chorionic villi insert through the myometrium. As with placenta percreta, it can lead to severe haemorrhage, so if picked up prenatally, a hysterectomy during elective caesarian section should be discussed as an option following delivery.
79
Placenta praevia
This is a condition where the placenta develops to cover the internal cervical os. Vaginal delivery is impossible in this case. Even if it is a good differential for a complicated caesarian section, placenta praevia does not invade through the perimetrium, but it can be described as a malpositioned normal placenta.
80
Sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.
- Diagnosis?
Ruptured ovarian cyst
81
Effect of COCP on cancer risks:
Combined oral contraceptive pill
Increased risk of breast and cervical cancer
Protective against ovarian and endometrial cancer
82
Management of hyperemesis gravidum:
1. Rest, avoid triggers, simple bland food in the morning.
2. First line meds:
- Antihistamines: oral cyclizine or promethazine.
- Phenothiazines: oral prochlorperazine or chlorpromazine
3. Consider admission for IV hydration and more complex antiemetics
83
When is an amniotomy offer for induction of labour?
Amniotomy is offered when the cervix is considered 'ripe' (bishop score ≥7) and may be used in combination with an oxytocin infusion.
84
Management of type 2 diabetes in pregnancy:
- what is the pharmacological management.
In the management of type 2 diabetes in pregnancy 'women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin'.
85
What is placental abruption?
Placental abruption is where a part or all of the placenta separates from the wall of the uterus prematurely. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery.
86
Presentation of placental abruption:
Placental abruption typically presents with painful vaginal bleeding (bleeding may not be visible if it is concealed). If the woman is in labour, inquire about pain between contractions.
On examination, the uterus may be woody (tense all of the time) and painful on palpation.
87
Degrees of perineal tears:
- 1st degree = tear within vaginal mucosa only
- 2nd degree = tear into subcutaneous tissue
- 3rd degree = laceration extends into external anal sphincter
- 4th degree = laceration extends through external anal sphincter into rectal mucosa
88
What triad is seen in pre-eclampsia?
- New-onset hypertension
- Proteinuria
- peripheral oedema
89
Read the definition of pre-eclampsia:
- New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction.
90
Management of pre-eclampsia:
- NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected.
- Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed.
- Oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used.
- Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario.
91
Management of stage 1 endometrial cancer:
Total hysterectomy and bilateral salpingo-oophorectomy. Peritoneal washings should also be taken. Traditionally, this has been performed as an open procedure, but laparoscopic surgery is increasingly performed.
92
How does a threatened miscarriage present?
A threatened miscarriage is where there is bleeding but a close cervical os.
93
PCOS is a risk factor for which cancer?
Endometrial
94
Menorrhagia, anaemia, bulk-related symptoms e.g. bloating/urinary frequency →?
Uterine fibroids
95
Type of miscarriage?
- Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
- The bleeding is often less than menstruation
- Cervical os is closed
- Complicates up to 25% of all pregnancies
Threatened misscarriage
96
Type of miscarriage?
- A gestational sac which contains a **dead fetus before 20 weeks** without the symptoms of expulsion
- Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature.
- Cervical os is closed.
- When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'.
Missed (delayed) miscarriage
97
Type of miscarriage:
- Heavy bleeding with clots and pain
- Cervical os is open
Inevitable miscarriage
98
Which of the following is the best way to detect ovulation?
Day 21 progesterone test is the most reliable test to confirm ovulation.
(7 days before cycle)
99
What causes endometrial hyperplasia?
Endometrial hyperplasia is caused by oestrogen which is unopposed by progesterone.
100
Management of chickenpox in pregnancy:
Chickenpox exposure in pregnancy > 20 weeks (if not immune): antivirals or VZIG should be given at days 7-14 post-exposure, not immediately
101
When can expectant management of an ectopic be performed?
Expectant management of an ectopic pregnancy can only be performed for
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
102
raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG is normal to low
Stereotypical pcos bloods
103
Non-tender bulky uterus on examination in a patient presenting with menorrhagia:
Fibroids
