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Year 4 - Della > 4A Obs & Gynae > Flashcards

4A Obs & Gynae Flashcards

1
Q

Mechanism of puberty onset

A

GnRH (gonadotropic releasing hormone) secreted in 2 hrly pulsatile fashion (positive feedback, from hypothalamus), menarche average 12 years.

To suppress cycle give GnRH continuously (negative feedback) OR GnRH agonists.

Pituitary released FSH and LH, act on ovaries, release oestrogen and progesterone.

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2
Q

Functions of FSH?

LH?

A

NB too much oestrogen - > fast growth, hyperplasia, more likelihood of atypical cells, cancer.

LH - more androgens. Theca cells (outer layer of follicle) produce androgens.
Granulosa cells convert androgens to oestrogens (middle layer of follicle)

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3
Q

Menstrual cycle

A

Menstruation eg. day 0-4)
Proliferative follicular phase (eg. day 5-13)
Ovulation - high oestrogen triggers LH surge, triggers enzymatic action to release egg → 36 hours after LH surge.
Secretory / luteal phase (eg. day 14-28)

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4
Q

Spermatogenesis

Leydig cells secrete _________
Sertoli cells act as _______cells

A

androgens

nursing

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5
Q

History for abnormal menstrual bleeding

A

Previous pregnancies
Plans for more children
Cervical screening/ smears - last smear, any abnormal, any treatment
Sexual history eg. PCB post coital bleeding
Contraception
Chance of pregnancy?

PMH

Surgical hx - for abnormal bleeding

Family hx - coagulation disorders, gynaecological cancer

Physical examination
- anaemia
- abdominal mass
- Bimanual palpation to feel for cervix
- Visualise and palpation cervix

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6
Q

Red flags in abnormal bleeding?

A
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7
Q

Causes of abnormal bleeding?

A

Most common - fibroids aka leiomyomata (firm growths from muscle layer. Removal called myomectomy), polyps (soft growths from endometrial layer), leiomyomas

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8
Q

Investigations in abnormal bleeding?

Management?

A

Bloods - FBC, co-ag screen.
Non-routine : FSH/LH, TFT, Ferritin.

Ultrasound Hysteroscopy +- endometrial biopsy
MRI

Management
- Mirena coil / IUCD
- Endometrial ablation / Transcervical resection of endometrium (TCRE) - for women to have completed their family
- Myomectomy
- Uterine artery embolisation (painful)
- Hysterectomy

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9
Q

What medical increases risk of endometrial cancer?

A

Tamoxifen.

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10
Q

Amenorrhoea - Causes?

A

weight loss, stress, eating disorder, depression, exercise, pituitary tumour, hydrocephalus, craniopharyngioma, Kallman syndrome, no eggs eg Turner’s syndrome, Premature ovarian failure. Imperforate hymen.
Androgen insensitivity syndrome (looks female but genetically male)

Secondary amenorrhoea - Sheehans syndrome, PCOS, radiation /chemo, Ashermans syndrome, cervical stenosis.

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11
Q

Vaginal prolapse
- Risk factors
- types

A

Risk factors
- Multiparous women
- Age
- Post penopause
- Smoking / chronic cough
- Heavy lifting

Types
- urethral, vaginal, rectal

Scoring system
- POPQ

Management
- Prevention, avoid constipation, chronic cough etc, pelvic floor exercises
- Physiotherapy
- Pessary / ring (nurse specialist input) shelf, Gellhorn. Change every 4-6 months.

  • Surgery (anterior repair on anterior wall of vagina, posterior repair on posterior wall) Vaginal hysterectomy - most common. Colpocliesis (removal of vagina completely - no sexual function).

1 in 10 women have surgery for prolapse in their lifetimes

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12
Q

Incontinence

A

Urge incontinence. Overactive bladder - involuntary bladder contractins (Detrusor overactivity)
Bladder diary = frequent small volumes. Avoid caffeine, tomatoes…
Oxybutynin (DRY MOUTH), tolterodine, solifenacin.
(all - constipation, blurred vision)
Mirabegron CI in servere uncontrolled HTN or acute open angle glaucoma.
Botox.

Stress incontinence - sphincter weakness
Bladder diary = larger less frequent volumes
Physio

Fistula
Neurological
Mixed

History
Bladder cart (FVC = frequency volume chart)
Urinalysis (dipstick and MSU)
Uroflow
Bladder scan

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13
Q

Pelvic Pain
- Causes
- Investigations

A

Chronic pelvic pain - 6 months (not ax w/ pregnancy, menstruation, intercourse)

History
Abdominal exam - don’t miss tumours, ascites, anaemia

Investigations
- beta HCG (exclude pregnancy)
- Pelvic USS - TV (transvaginal) scan or abdominal
- MRI (to check bowel or bladder involvement)
- Diagnostic laparoscopy

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14
Q

Endometriosis

A

Presence of endometrial tissue outside normal location

Hormone driven - pain varies over menstrual cycle

Diagnostic laparoscopy

Medical management
- Pain relief
- COCP , POP
- GNRH agonists eg goserelin (chemical menopause - not tolerably well young women)

Surgical

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15
Q

Gravida
Parity

A

Gravida - Previous pregnancies
Parity - births over 24 weeks

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16
Q

Meds contraindicated in pregnancy?

A

Statins
ACE inhibitors - can cause oligohydramnios, skull defects.
Sodium valproate
Warfarin
Tetracycline
Diuretics
ARBs
NSAIDs - can cause premature closure of ductus arteriosus.
Lithium - avoid if possible, particularly first trimester.
Trimethoprim - 1st trimester
Nitrofurantoin - 3rd
Ondansetron - avoid 1st trimester

Discontinue all diabetic drugs except metformin and insulin - avoid gliclazide due to hypos.

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17
Q

Meds ok in pregnancy

A

SSRIS benefits generally outweigh risks: Sertraline, citalopram
Labetolol (change to this from ARBs, ACE inhibitors).
Levetiracetam (Keppra), lamotrigine
Aspirin - used as pre-eclampsia prophylaxis if previous pre-eclampsia.
Heparin
Insulin

Paracetamol, codeine, oromorph

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18
Q

Normal dose folic acid?
High dose folic acid?
Who needs high dose?

A

400mcg OD advised for 3 months prior to conception

High dose folic acid 5mg for groups at high risk of Neural Tube Defects - diabetics, epileptics, patients with history of NTD, obesity

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19
Q

Trisomy 13
Trisomy 18
Trisomy 21

A

Patau syndrome
Edward’s syndrome
Down’s syndrome

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20
Q

Twin pregnancies

A

‘Zygocity’
Monozygous = identical
Dizygous = non-identical

Chorionicity - whether they share a placenta or not.
Dizygotic / dichorionic / diamniotic - two placentas.

Identical twins can have separate placentas and sacs if egg splits early.
Egg splits later - share placenta but separate sacs (most common) MCDA = monochorionic diamniotic.

egg splits even later - twins share placenta ands.

Dichorionic = DC = 2 amniotic sacs. Lamda sign.

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21
Q
A

Delivery of DCDAs by 37 weeks
MCDAs by 36 weeks.

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22
Q

Twin to twin transfusion syndrome - what type of twins?
Monitoring?
Treatment?

A

Usually develops by 24 /26 weeks.
Untreated - mortality up to 80%.
Treatment by laser ablation of communicating vessels - refer to UCLH London.

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23
Q

HCG level. At what level should you see an intrauterine pregnancy on ultrasound?

A

1500

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24
Q

Hypertension in pregnancy
- Signs on examination
- Investigations
- Treatment

A

Examination:
- Signs of oedema, papilloedema, proteinuria, headaches
- Test reflexes (hyper reflexia)
- Listen to chest and heart
- Monitor baby hb

Investigations
- Urine dipstick
- Urine PCR/ACR. 30+ = significant risk of preeclampsia.
- Bloods: FBC - high or low hb, low platelets - haemolysis, U&E, LFT, clotting

Management:
IUGR → GROWTH SCANS
Stillbirth
Early delivery as placenta won’t last to term
ASPIRIN150mg OD from 12/40 until delivery for women with any high risk factor or ≥ 2 moderate risk factors
- Labetolol 100mg BD orally? (afro-caribbeans do not respond to labetolol)
OR. nifedipine up to 60mg per day start 10mg BD, methyldopa or hydralazine
IV Magnesium sulphate (infusion)
IV labetolol (not in severe asthma) ** give first before magnesium sulphate. or IV hydralazine

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25
HELLP syndrome - 3 features?
Haemolysis Elevated liver enzymes Low platelets
26
Symptoms of preeclampsia?
27
What drugs don't cross the placenta?
Drugs that don't cross placenta - only insulin and heparin.
28
Placental abruption - signs and symptoms?
'woody, hard uterus' PAIN Firm abdomen Bleeding
29
Placenta previa - signs and symptoms? Advice for patient?
Soft uterus / abdomen PainLESS bleeding Advice - abstain from sex - avoid contact sports
30
What is asymmetrical foetal growth restriction? Causes?
Asymmetrical - normal head size but small body Cause - pathology of later onset eg. pre-eclampsia, smoking, essential hypertension
31
Causes of intrauterine growth restriction? IUGR Management?
Management - Increased monitoring , usually USS growth scans - Delivery of baby if compromised - if early onset, foetal karyotyping, blood gas, virology investigations, detailed USS looking for abnormalities
32
What happens to the following in pregnancy? 1. Blood volume 2. Blood pressure 3. Heart rate 4. Cardiac output 5. Haemoglobin
1. Up by 50% 2. Down 3. Up 4. Up 5. Down
33
What is vasa praevia?
In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death. https://zerotofinals.com/obgyn/antenatal/vasapraevia/
34
PPH Post partum haemorrhage - Treatment?
35
PPH Post partum haemorrhage Causes? 4 T's
Tone Trauma Tissue Thrombin
36
PPH post partum haemorrhage Risk factors?
37
Hyperemesis Gravidarum
1. Cyclizine, promethazine 2. Metoclopramide 3. Ondansetron (ax w/ cleft palate < 12 weeks) 4. Steroids (discuss with women first) Last resort - termination of pregnancy
38
What is the criteria for SGA (small for gestational age)?
39
What is foetal growth restriction?
40
Hypertension in pregnancy - what medication? (4)
Labetolol 100mg BD orally? (afro-caribbeans do not respond to labetolol) OR. nifedipine up to 60mg per day start 10mg BD, methyldopa or hydralazine
41
Criteria for miscarriage
- fetal pole 7mm or more no FH - empty gestation sac > 25mm - no change in USS findings after 7days TVS, 14 days TAS
42
Medical management - missed MC - Incomplete - TOP - ectopic - PID
Missed. - 800 mcg PV mioprostol Incomplete - 600mcg PV misoprostol TOP - mifepristone & misoprostol ectopic - mxt : unraptured, <35mm no HB, HCG <5000. Side effects, no pregnancy 3/12 after. PID - 14 days abx usually oral is enough. see slide
43
Assessing progress in labour - Abdominal methods? - Vaginal methods?
Abdominal exam - Contractions, timing (1 minute good) and frequency (3/4 in 10 mins) - Engagement (fifths, pubic symphysis) free is 5 fifths palpable. 5/5 → 0/5. Vaginal exam - Cervical position, effacement and consistency,dilation - presenting part - station/position presentation - cephalic/breech position - occiput of baby in relation to maternal pelvis eg. occiput anterior (OA - normal) /posterior. occiput transverse. Ant font - 4 sutures, post font - 3 sutures. station - 0 station level with ischial spines. start about at -2.born at 3?
44
What advice to give women on starting POP? - Side effects - When is it effective when started?
POP eg cerazette (desogestrel) Side effect: Irregular bleeding When is it effective? - Day 0-5 of cycle: Immediately - Any other point in cycle: 48 hours (use condoms) Info: Doesn't protect against STIs. Antibiotics have no effect D&V - treat as missed pills (use barrier method as well)
45
Contraceptives, time until effective? - IUD - POP - COCP - Injection - Implant - IUS
Contraceptives - time until effective (if not first day period): instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS
46
Chickenpox infection in pregnancy (Varicella zoster) 1. Treatment? 2. Meaning of IgM? 3. Meaning of IgG? 4. chickenpox exposure in pregnancy?
1. Oral acyclovir (IV if severe infection) Women who develop chickenpox during pregnancy should be treated with oral aciclovir 800mg 5 times a day for 7 days if >20 weeks pregnant. if the woman is < 20 weeks the aciclovir should be 'considered with caution' 2. IgM = New infection (M= Mum, young, new). IMMediate. 3. IgG = Old infection (G = Grandma, old) 4. - if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies - oral aciclovir (or valaciclovir) is now the first choice of PEP for pregnant women at any stage of pregnancy antivirals should be given at day 7 to day 14 after exposure, not immediately Exposure: If unsure about previous VZV infection - Check Varicella antibodies All pregnant women at any stage of pregnancy - Oral Aciclovir (given day 7-14 post-exposure) Chickenpox in pregnancy (rash develops): <20wks - Oral Aciclovir 'considered with caution' ≥20wks - Oral Aciclovir (within 24hrs of rash onset)
47
Anatomy of fallopian tube 1. which part most common location of ectopic / most common site of fertilisation? 3. Which part most likely to rupture?
1. Ampulla 3. Isthmus (because its narrowest)
48
HIV - when does seroconversion illness occur?
Start treatment right away - don't wait for CD4 count to drop. 6 months into treatment viral load undetectable. 30-60% have seroconversion illness eg sore throat, rash, fever, lymphadenopathy. Abrupt onset 2-4 weeks post exposure, lasts 1-2 weeks.
49
AIDS defining illnesses?
+ Severe oral hairy leukoplakia = White patch on side of tongue Kaposi's sarcoma = cancer of epithelium, violet coloured. Commonly nose tip, can be disseminated all over. Severe oral thrush Atypical shingles (more than one dermatome)
50
What is this?
Severe PCP PCP 80% of untreated HIV +ve patients, may present with insidious onset of increasing shortness of breath, increasing dry cough, pyrexia, malaise, CXR normal in early disease
51
What is this?
TB - left upper lung Test sputum - acid fast bacilli Mycobacterium avian complex - atypical TB.
52
What is this?
Recurrent bacterial pneumonia, right middle lung
53
What is this?
Toxoplasma brain abscess (left) - presents with weakness right side of body. Start treatment - weakness will improve. If delay - permanent loss of movement.
54
What is this? Sx? Tx?
CMV retinitis - aids defining illness Sx: blurred vision Tx - gancyclovir . Blind if not started early.
55
Aids association infections?
56
HIV monitoring 1. Patient not on treatment 2. Patient on treatment
57
HIV Post Exposure Prophylaxis - name the three drugs
Same treatment as HIV but short term
58
DRUGS - what is it for? 1. Mifepristone 2. Misoprostol
1. Mifepristone (oral) = progesterone receptor antagonist → weakens attachment to the endometrial wall and dilates the cervix. Used for : Treatment for missed miscarriage (+ then misoprostol if needed) 2. Misoprostol (vaginal, oral or sublingual aka oral prostaglandin E1) = prostaglandin analogue → binds to myometrial cells → strong myometrial (uterine) contractions → expulsion of products of conception Used for : medical management for incomplete miscarriage Missed Miscarriage = double MM = Mifepristone + Misoprostol Incomplete Miscarriage = single M = Misoprostol
59
DRUGS FOR STIs 1. Gonorrhoea? 2. TV 3. Syphillis
1. Gonorrhea - Ceftriaxone 1g IM single dose, mixed with lidocaine. Or - Ciprofloxacin 500mg PO single dose (if culture shows sensitivity) 2. Trichomosas vaginalis (protozoa) / tricomoniasis. - Metronidazole 400-500mg BD 7 days. 3. Syphillis - Benzathine penicillin 2.4 MU, IM injection, mixed with lidocaine - 1st line for primary, secondary and early latent syphillis.
60
CONSULTATION SKILLS - sexual history eg. man with 4 day history of dysuria
Frame correctly - I need to ask you some personal questions to find the cause of this - when was the last time you had sex? Use word 'condoms' not protection.
61
HRT prescribing - name of a combined HRT pill?
Elleste eg. elleste duet conti.
62
Treatment for BV? - Pregnant - Non-pregnant
Clindamycin - pregnant Metronidazole
63
Changes in drug metabolism in pregnancy
ADME Absorption Distribution (increased body water, fall in plasma, increased fat). Metabolism (hepatic blood flow increases) Excretion (renal increases)
64
Anti-emetics in pregnancy 1. first line 2. second line 3. third line
65
Emergency contraception - name 3 types and how long can you use them after UPSI (unprotected sexual intercourse)?
Levonorgestrel (levonelle) - 3 days (72 hours) - stops ovulation and inhibits implantation Ulipristal (EllaOne) - 5 days (120 hours) - stops ovulation - Caution in severe asthma IUD (copper coil) - 5 days after UPSI or 5 days after ovulation - inhibits fertilisation / implantation
66
Induction of labour 1. Why might we induce labour? 2. When would we NOT induce labour? 3. Consultation skills - what to say?
1. Pre-eclampsia, PROM (to prevent sepsis), intrauterine fetal death (IUD), reduced fetal movements, macrosomia (big baby), post dates, diabetes. 2. Breech. FGR with compromise. History of precipitate labour. 3. Ask woman's preference MOD. Explain this is a medical intervention and will affect her options and experience of birth. Discuss why, where, when, how, pain relief, benefits, risks (failure). Has choice to start/stop change her mind. Give PIL (leaflet) and give time to discuss with others and decide.
67
Induction of labour 1. Benefits? 2. Risks?
68
Methods of Induction of labour
Sweep (cervix must be 1cm dilated to allow finger). Encourages release of prostaglandins. 'Propess' dinoprostone PGE2 controlled vaginal delivery system - kept in posterior fornix of cervix for 24 hours Other pharmacological but not/rarely used: - Dinoprostone 'prostin E2' vaginal tablet 3mg - Dinoprostone vaginal gel 0.5mg - Misoprostal PGE1 vaginal tablet 25mcg posterior fornix Oxytocin infusion Cervical dilation balloon - used in people at risk of scar rupture eg previous c-section or open fibroid surgery, grand multips. aka MIOL (mechanical induction of labour). ARM - artificial rupture of membranes with hook. Augmentation of existing labour - ARM or oxytocin
69
Bishops score - what are the criteria?
Cervical dilatation Cervical length Cervical consistency Cervical position Head station Score 6 or less → pharmacological eg propess or MIOL Score >6 → ARM, +- oxytocin
70
Partograms - assess progress of labour and maternal wellbeing 1. What should you do if patient hits the ALERT line? 2. What should you do if patient hits the ACTION line?
1. ASSESS and AUGMENT. The alert line should prompt a re- assessment and plan with the patient to increase progress (augment) 2. ASSESS and DELIVER. The Action line should prompt an assessment to expedite delivery.
71
CTG analysis 1. CTG stands for? 2. Acronym used to analyse CTGs? Explain.
1. Cardio tocography (measure's metal heartbeat and uterine contractions). 2. DR C BRAVADO DR = define risk. low risk pregnancy / risk factors present? C = contraction frequency eg. 4 in 10 BRA = Baseline rate eg. 140 bpm V = variability eg >5 bpm good variablity A = accelerations - good D = decelerations - bad. O = overall impression. Normal / suspicious / pathological?
72
CTG analysis What are the causes of 1. Early decelerations 2. Variable decelerations 3. Late decelerations
Early decelerations = when the trough of the deceleration co-incides with the peak of the contraction. Cause = head compression. Can be normal. Variable decelerations = No relationship with uterine contrsaction. Cause = cord compression, worrying → may need intervention Lare deceleration = occurs after the peak of contraction. Cause = uteroplacental insufficiency → intervention. Causes of reduced uteroplacental blood flow include:1 - Maternal hypotension - Pre-eclampsia - Uterine hyperstimulation
73
Pre-eclampsia prescribing 1. Labetalol - emergency dose? - non-emergency dose? - contraindications? 2. Magnesium sulphate - what dose? What does it do?
1. Labetalol Emergency - 50mg IV over at least 1 minute, then 50 mg every 5 minutes if required until a satisfactory response occurs; maximum 200 mg per course. Non-emergency dose - 20mg/hour IV infusion. Increased if necessary to 40 mg/hour after 30 minutes, then increased if necessary to 80 mg/hour after 30 minutes, then increased if necessary to 160 mg/hour after 30 minutes, adjusted according to response; Usual maximum 160 mg/hour. Contraindications - asthma, heart block, hypotension, bradycardia Side effects - abdominal discomfort, bradycardia, diarrhoea, dizziness. 2. MgSO - 4g IV Indication - to prevent seizures in preeclampsia / recurrent seizures in eclampsia OR neuroprotection of pre-term neonate Dose - Initially 4 g for 1 dose, to be given over 5–15 minutes, followed by (by continuous intravenous infusion) 1 gram/hour for 24 hours, if seizure occurs, give an additional dose of 2–4 g by intravenous injection over 5–15 minutes. Side effects - electrolyte imbalance, diarrhoea in mum, osteopenia in neonates.
74
O & G prescribing 1. Nifedipine - indications? Dose?
1. Nifedipine: 20mg oral. - For pre-eclampsia - For delay of premature labour Dose - Initially 20 mg, followed by 10–20 mg 3–4 times a day, adjusted according to uterine activity. Hypertension - 30mg-90mg daily?? Contraindications - Angina, recent MI, cardiogenic shock. Side effects: Abdo pain, dizziness, drowsiness, flushing, headache, palpitations, nausea/vomiting, oedema.
75
HELLP syndrome - Stands for? - Treatment?
HELLP is a microangiopathic haemolytic anaemia (MAHA), like DIC. → schistocytes. Treatment: Steroids, antihypertensives, MgSO (for seizure prevention), blood /platelet transfusion, IV fluids, delivery of baby. https://www.osmosis.org/answers/hellp-syndrome
76
Definition of fetal tachycardia? Causes?
Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm. It can be caused by: Fetal hypoxia Chorioamnionitis – if maternal fever also present Hyperthyroidism Fetal or maternal anaemia Fetal tachyarrhythmia

Year 4 - Della (4 decks)

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