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B TO REVISE - PHASE 3A > B WOMENS TO DO > Flashcards

B WOMENS TO DO Flashcards

1
Q

MISCARRIAGE
What are some other causes of miscarriage?

A
  • PCOS
  • TORCH infections
  • Iatrogenic (amniocentesis, CVS)
  • Smoking, substance abuse
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2
Q

MISCARRIAGE
What are some causes of recurrent miscarriage?

A
  • Antiphospholipid syndrome
  • Hereditary thrombophilias (Factor V leiden deficiency, factor II prothrombin gene mutation, protein C/S deficiency)
  • Uterine abnormalities (uterine septate, fibroids)
  • Poor controlled chronic conditions (DM, thyroid, SLE)
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3
Q

MISCARRIAGE
What are the investigations for recurrent miscarriage?

A

≥3 1st trimester, ≥1 in 2nd –
- Lupus anticoagulant, anti-cardiolipin + phospholipid antibodies
- Thrombophilia screen
- Pelvic USS for structural issues
- Cytogenic analysis of POC after 3rd miscarriage
- Parental blood for karyotyping

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4
Q

PLACENTAL ABRUPTION
What are the major risk factors for placental abruption?
What are some other risk factors?

A
  • IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption
  • Cocaine use, multiple pregnancy or high parity, trauma
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5
Q

VASA PRAEVIA
What are some risk factors for vasa praevia?

A
  • Placenta praevia
  • Multiple pregnancy
  • IVF pregnancy
  • Bilobed placentas
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6
Q

PRE-ECLAMPSIA
What is the result of placental ischaemia?

A
  • Pro-inflammatory protein + thromboplastin release leads to endothelial damage > vasoconstriction, clotting dysfunction + increased vascular permeability
  • Ultimately leads to poor renal perfusion > RAAS activation > HTN, proteinuria ± oedema > pre-eclampsia + eclampsia (if continues)
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7
Q

PRE-ECLAMPSIA

What are the…

i) high risk
ii) moderate risk

factors for pre-eclampsia?

A

i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM)
ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2

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8
Q

PRE-ECLAMPSIA
What are the 2 main causes of symptoms in pre-eclampsia?

A
  • Local areas of vasospasm leading to hypoperfusion
  • Oedema due to increased vascular permeability + hypoproteinaemia
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9
Q

PRE-ECLAMPSIA
What symptoms are caused by local areas of vasospasm and what area is affected?

A

Renal = glomerular damage (low GFR) –
- Oliguria + proteinuria
Retinal –
- Visual disturbances (blurred, flashing lights, scotoma)
Liver = injury + swelling stretches liver capsule –
- RUQ or epigastric pain

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10
Q

PRE-ECLAMPSIA
What blood investigations would you do in pre-eclampsia?

A
  • FBC with platelets (thrombocytopenia)
  • Serum uric acid levels (raised due to renal issues)
  • LFTs (elevated liver enzymes ALT + AST)
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11
Q

PRE-ECLAMPSIA
What other investigations could you perform in pre-eclampsia?

A
  • Proteinuria on dipstick (++ or +++ is severe)
  • Protein:Creatinine ratio (PCR) ≥30ng/nmol = significant proteinuria
  • Accurate dating + USS to assess foetal growth
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12
Q

IUGR
What are some maternal causes of IUGR?

A
  • Chronic disease (HTN, cardiac, CKD)
  • Substance abuse (cocaine, alcohol) smoking, previous SGA baby
  • Autoimmune
  • Low socioeconomic status
  • > 40
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13
Q

IUGR
What are the investigations for IUGR?

A
  • BP + urine dipstick (?pre-eclampsia)
  • Karyotyping (?foetal)
  • Infection screen, TORCH (?infection)
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14
Q

OLIGOHYDRAMNIOS
What are some causes of oligohydramnios?

A
  • PROM or SROM
  • Renal agenesis (Potter’s syndrome) or non-functional kidneys
  • Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output
  • Genetic anomalies
  • Obstructive uropathy
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15
Q

POLYHYDRAMNIOS
What are the causes of polyhydramnios?

A
  • Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops
  • Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)
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16
Q

GESTATIONAL DIABETES
What are some anti-insulin hormones produced by the placenta?

A
  • Main one is human placental lactogen (hPL)
  • Also glucagon + cortisol
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17
Q

OBSTETRIC CHOLESTASIS
Why can clotting be deranged in obstetric cholestasis?

A
  • Bile acids important for fat soluble vitamin absorption like vitamin K
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18
Q

OBSTETRIC CHOLESTASIS
What are the complications of obstetric cholestasis?

A
  • Maternal = vitamin K deficiency (may lead to PPH)
  • Foetal = stillbirth (#1), increased risk of prematurity (often iatrogenic)
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19
Q

ANAEMIA + PREGNANCY
What are the complications of iron deficiency anaemia?
How is it managed?

A
  • LBW + preterm delivery
  • Ferrous sulfate 200mg TDS
  • If not anaemic but low ferritin indicating iron stores then start them on it
  • Vitamin C can increase absorption of iron
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20
Q

PROM
What are some risk factors for (P)PROM?

A
  • Previous PROM/preterm
  • Smoking
  • Polyhydramnios
  • Amniocentesis
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21
Q

STAGES OF LABOUR
What are 7 important hormones in labour?

A
  • Prostaglandins
  • Oxytocin
  • Oestrogen
  • Beta-endorphins
  • Adrenaline
  • Prolactin
  • Relaxin
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22
Q

STAGES OF LABOUR
What are the 6 cardinal movements of labour?

A
  • Engagement + descent
  • Flexion
  • Internal rotation
  • Extension (crowning)
  • Restitution/external rotation
  • Expulsion
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23
Q

FAILURE TO PROGRESS
What are the components of the Bishop score?

A
  • Cervical dilation – <1cm (0), 1-2 (1), 3-4 (2), >5cm (3)
  • Cervical consistency – firm (0), intermediate (1), soft (2)
  • Cervical effacement –<30% (0), 40-50 (1), 60-70 (2), 80% (3)
  • Cervical position – posterior (0), intermediate (1), anterior (2)
  • Foetal station – –3 (0), -2 (1), -1/0 (2), ≥1 (3)
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24
Q

BREECH
What are the 3 types of breech presentation?

A
  • Extended (Frank) = most common, hips flexed, both legs extended with feet by head, buttocks presenting
  • Flexed (Complete) = hips + knees flexed so buttocks + feet presenting (Cannonballing)
  • Footling = one leg flexed, one extended, foot hanging through cervix
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25
SHOULDER DYSTOCIA What are the 3 rotational manoeuvres?
- Rubin II = pressure on post. aspect of ant. shoulder to help deliver under symphysis pubis - Woods' screw = Rubin II + pressure on ant. aspect of post. shoulder - Reverse woods' screw = pressure on ant. aspect of ant. shoulder + post. aspect of post. shoulder in opposite way
26
PAIN RELIEF What are some complications of regional techniques?
- Potential for spinal cord damage - Hypotension + bradycardia - Haematoma/abscess at injection site - Anaphylaxis if allergic - Post-dural puncture headache
27
PPH What are the risk factors for PPH?
- Before birth = previous PPH, APH, twins/triplets, pre-eclampsia, obesity, polyhydramnios - Labour = prolonged, c-section, perineal tear or episiotomy, macrosomia
28
MENTAL HEALTH Why can mental health disorders be difficult to detect in the puerperium?
- Fear of treatment - Fear of children being removed - Cultural lack of recognition - Denial - Stigma
29
HYPEREMESIS What are some associations of hyperemesis gravidarum?
- nulliparity, - hyperthyroid, - obesity, - decreased in smokers
30
HYPEREMESIS How is severity assessed?
Pregnancy-Unique Quantification of Emesis (PUQE) – - <7 mild, - 7-12 mod, - >12 severe
31
ANAEMIA + PREGNANCY What are some causes?
Physiological, Fe deficiency (increased demand), B12 or folate deficiency
32
ANAEMIA + PREGNANCY What are some risk factors?
Menorrhagia, malaria, hookworm, twins, poor diet
33
HELLP what other condition is HELLP associated with?
- 10% have antiphospholipid syndrome
34
HELLP what are the risk factors for HELLP?
➢ White ethnicity ➢ Maternal age >35 yrs. ➢ Obesity ➢ Chronic hypertension ➢ DM ➢ Autoimmune disorders ➢ Abnormal placentation and multiple gestation ➢ Previous pregnancy with preeclampsia
35
SICKLE CELL DISEASE IN PREGNANCY what are the risks of sickle cell disease during pregnancy?
* Crises are more common during pregnancy * Increased risk of pre-eclampsia * Increased risk of delivery by CS due to fetal distress
36
SICKLE CELL DISEASE IN PREGNANCY what are the foetal risks in sickle cell disease?
- miscarriage - IUGR - prematurity - stillbirth
37
SICKLE CELL DISEASE IN PREGNANCY what is the management?
- Pre-Pregnancy counselling - Stop iron chelating agents before pregnancy - Give folic acid and penicillin prophylaxis for hypersplenism - Screen for UTI infections each visit - Crisis Treatment: Analgesics, oxygen, hydration, and antibiotics if infection is suspected - Regular foetal monitoring - Aim for vaginal delivery
38
FOETAL HYDROPS what is the pathophysiology?
an imbalance of interstitial fluid production and inadequate lymphatic return. This can result from congestive heart failure, obstructed lymphatic flow, or decreased plasma osmotic pressure.
39
FOETAL HYDROPS what are the causes of non-immune foetal hydrops
- severe anaemia (parvovirus B19, thalassaemia, G6PD) - cardiac abnormalities - chromosomal abnormalities (trisomies 13, 18 and 21) - genetic conditions - other infections (toxoplasmosis, rubella, CMV, varicella) - structural abnormalities (CCAM, diaphragmatic hernia) - twin-to-twin transfusion syndrome - chorioangioma
40
FOETAL HYDROPS what is the management?
depends on the cause - anaemia = in-utero blood transfusion - pleural effusions/CCAM = shunt - twin-to-twin transfusion syndrome = laser photocoagulation of placental anastomoses - cardiac arrhythmias = maternal digoxin + flecanide
41
LOW BIRTH WEIGHT what are the risk factors for low birth weight?
➢ Low socioeconomic ➢ History of abuse ➢ Age (<15 or >35) ➢ Race (black, ethnic minorities...)
42
LOW BIRTH WEIGHT what are the causes of low birth weight?
➢ Preterm birth (before 37 weeks gestation) ➢ Genetics (could be chromosomal abnormalities...) ➢ Uteroplacental insufficiency ➢ Multiple pregnancy ➢ Substance abuse (smoking, drinking alcohol, illicit drug) causing IUGR ➢ Chronic conditions and infections (hypertension, rubella, CMV, syphilis, toxoplasmosis, BV...) ➢ Medications (sodium valproate, ramipril, warfarin...)
43
UTEROPLACENTAL INSUFFICIENCY what are the investigations?
➢ USS ➢ Maternal alpha fetoprotein levels ➢ CTG
44
PUERPERAL INFECTION what is the management?
➢ Supportive (analgesics/NSAIDS, wound care, ice packs...) ➢ Antibiotics (for endometritis – IV clindamycin and gentamicin until >24hrs afebrile) ➢ Surgical (drain abscess, secondary repair of wound, drainage of hematomas...)
45
OBSTRUCTED LABOUR What are the different types of causes of obstructed labour?
- Power (most common) - Passage - Passenger - Psyche (maternal exhaustion in second stage)
46
CHLAMYDIA IN PREGNANCY what are the risks of chlamydia infection during pregnancy?
- preterm labour - PROM - low birth weight - infection during delivery (conjunctivitis and pneumonia)
47
GONORRHOEA IN PREGNANCY what are the risks?
- miscarriage - premature birth - low birth weight - PROM - chorioamnionitis - eye infection in newborn
48
SYPHILIS IN PREGNANCY what are the risks?
congenital syphilis - premature births - still births - multi-organ problems to brain, eyes, heart, skin, teeth and bones
49
TRICH VAGINALIS IN PREGNANCY what are the risks?
- PROM - preterm births - low birth weight - female newborns can acquire infection during birth
50
UTIs IN PREGNANCY which antibiotics should be avoided in the third trimester and why?
- nitrofurantoin - risk of haemolytic anaemia in newborn with G6PD - sulfonamides - risk of kernicterus in newborn due to displacement of protein binding of bilirubin
51
UTIs IN PREGNANCY which antibiotics are contraindicated in pregnancy?
- tetracyclines - cause permanent staining of teeth and problems with skeletal development - ciprofloxacin - causes skeletal problems
52
CEPHALOPELVIC DISPROPORTION what can increase the risk?
- flat (platypelloid) pelvic opening - heart-shaped (android) pelvis
53
FIBROIDS What are the different types of fibroids?
- Intramural (most common) = within the myometrium - Subserosal = >50% fibroid mass extends outside uterine contours - Submucosal = >50% projection into the endometrial cavity - Subserosal + submucosal can be pedunculated (on stalk = risk of torsion)
54
ENDOMETRIOSIS What are 3 theories about the cause of endometriosis?
- Sampson's = retrograde menstruation (endometrial lining flows backwards through fallopian tubes + into pelvis/peritoneum where endometrial tissue seeds itself - Meyer's = metaplasia of mesothelial cells - Halban's = via blood or lymphatics
55
PCOS How does insulin resistance contribute to PCOS?
- Insulin resistance = pancreas produces more insulin - Insulin mimics action of insulin-like growth factor 1 which augments androgen production by theca cells in response to LH - Higher insulin = higher androgens (testosterone)
56
PCOS How does high insulin levels contribute to PCOS?
- Insulin suppresses sex hormone-binding globulin (SHBG) produced by liver which normally binds to androgens + suppresses their function further promoting hyperandrogenism - Also contribute to halting development of follicles in ovaries > anovulation + multiple partially developed follicles (polycystic ovaries)
57
PCOS What are the 3 main presenting features of PCOS?
- Hyperandrogenism - Insulin resistance - Oligo or amenorrhoea + sub/infertility
58
PCOS What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) – - Oligo- or anovulation (may present as oligo- or amenorrhoea) - Hyperandrogenism (biochemical or clinical) - Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
59
PCOS What hormone tests may be used in PCOS?
- Testosterone (raised) - SHBG (low) - LH (raised) + raised LH:FSH ratio (LH>FSH) - Prolactin (normal), TFTs (exclude causes)
60
PCOS What are some associations and complications of PCOS?
- DM, CVD + hypercholesterolaemia - Obstructive sleep apnoea, MH issues, sexual problems - Endometrial hyperplasia or cancer
61
PCOS What are the PCOS risk factors for endometrial cancer? How is the risk of endometrial cancer managed in PCOS?
- Obesity, DM, insulin resistance, amenorrhoea - Mirena coil for continuous endometrial protection - Induce withdrawal bleed AT LEAST every 3m with COCP or cyclical progesterones medroxyprogesterone 10mg 14d)
62
PCOS How is hirsutism + acne managed?
- Hair removal cream, topical eflornithine to treat facial hirsutism - Co-cyprindiol is COCP licensed for hirsutism + acne as anti-androgen effect but only used for 3m as increased VTE risk - Spironolactone by specialist (mineralocorticoid antagonist with anti-androgen effects)
63
CERVICAL CANCER What are some risk factors for cervical cancer?
- Increased risk of catching HPV = early (unsafe) sex, lots of sexual partners - Smoking (limits availability to clear HPV) - HIV - COCP - High parity - Previous CIN/abnormal smear or FHx
64
CERVICAL CANCER What is used to grade the level of dysplasia, or premalignant change, in the cells of the cervix after colposcopy?
- Cervical intra-epithelial neoplasia (CIN) - CIN I = mild, affects 1/3 thickness of epithelial layer, likely to return to normal without Tx - CIN II = mod, affects 2/3 thickness of epithelial layer, likely to progress to cancer without Tx - CIN III or cervical carcinoma in situ = severe, v likely to progress to cancer without Tx
65
OVARIAN CANCER What are some types of epithelial cell tumours?
- Serous carcinoma (#1) - Endometrioid, clear cell, mucinous + undifferentiated tumours too
66
OVARIAN CANCER What are sex-cord stromal tumours?
- Arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles) - Sertoli-Leydig + granulosa cell tumours
67
OVARIAN CANCER What are some risk factors of ovarian cancer?
Unopposed oestrogen + increased # of ovulations – - Early menarche - Late menopause - Increased age - Endometriosis - Obesity + smoking Genetics (BRCA1/2, HNPCC/lynch syndrome)
68
OVARIAN CANCER Hence, what are some protective factors of ovarian cancer?
- COCP - Early menopause - Breast feeding - Childbearing
69
OVARIAN CANCER How is the risk of malignancy index calculated?
- Menopausal status = 1 (pre) or 3 (post) - Pelvic USS findings = 1 (1 feature) or 3 (>1 feature) - CA-125 levels IU/mL as marker for epithelial cell ovarian cancer
70
OVARIAN CANCER What can cause falsely elevated CA-125 levels?
- Endometriosis - Fibroids + adenomyosis - Pelvic infection - Pregnancy - Benign cysts
71
OVARIAN CYST What are the three types of functional cysts?
- Follicular (most common) - Corpus luteum - Theca lutein
72
OVARIAN CYST What are theca lutein cysts? Association?
- Stimulates growth of follicular theca cells so usually bilateral as resting follicles on both sides - Overstimulation of hCG (multiple + molar pregnancy as hCG v high)
73
OVARIAN CYST What are the 2 benign epithelial neoplasms?
- Serous cystadenoma (most common epithelial tumour) - Mucinous cystadenoma
74
OVARIAN CYST What are some risk factors of ovarian cysts?
- Obesity, tamoxifen, early menarche, infertility - Dermoid cysts = most common in young women, can run in families - Epithelial cysts = most common in post-menopausal (?malignant)
75
OVARIAN CYST What is Meig's syndrome? Who is it commonly seen in? What is the management?
- Triad of fibroma, pleural effusion + ascites - Older women - Removal of fibroma = complete solution
76
OVARIAN CYST What are the germ cell tumour markers?
- Lactate dehydrogenase - Alpha-fetoprotein - Human chorionic gonadotropin
77
ENDOMETRIAL CANCER What is the most common histological type of endometrial cancer? What are some others?
- Adenocarcinoma (80%) - Adenosquamous, squamous, papillary serous, clear cell + uterine sarcoma
78
ENDOMETRIAL CANCER What are some risk factors for endometrial cancer?
Unopposed oestrogen – - Obesity (adipose tissue contains aromatase) - Nulliparous - Early menarche - Late menopause - Oestrogen-only HRT - Tamoxifen - PCOS - Increased age - T2DM - HNPCC (Lynch syndrome)
79
ENDOMETRIAL CANCER What are some protective factors for endometrial cancer?
- COCP - Mirena coil - Multiparity - Cigarette smoking (Seem to have anti-oestrogenic effect)
80
ENDOMETRIAL POLYP What are some risk factors of endometrial polyps?
- Being peri or post-menopausal - HTN - Obesity - Tamoxifen
81
VULVAL CANCER What are some risk factors for vulval cancer?
- Vulval intraepithelial neoplasia (VIN) due to HPV in younger women - Lichen sclerosus in older women
82
VULVAL CANCER What is the management of VIN?
- Biopsy to Dx - Watch + wait with close follow up - Wide local excision to surgically remove lesion - Imiquimod cream or laser ablation
83
MENOPAUSE What contraception is suitable in older women? How do hormonal contraceptives affect the menopause?
- UKMEC1 = barrier, IUS/IUD, POP, long-acting progesterone (<45), sterilisation - UKMEC2 = COCP after 40 used until 50, try ones with levonorgestrel or norethisterone as lower VTE risk - They don't but may mask Sx
84
MENOPAUSE What is the mechanism of action of clonidine?
- Alpha-adrenergic receptor agonist
85
HRT What are the side effects associated with oestrogen?
- Nausea, - bloating, - headaches, - breast swelling or tenderness, - leg cramps
86
URINARY INCONTINENCE What is the physiology of micturition?
- Detrusor = smooth muscle, transitional epithelium normally only contracts during micturition = sacral parasympathetic innervation from S2-4 - M2+3 muscarinic receptors with ACh - Sympathetic nerve fibres from T11-L2 maintain relaxation of bladder for storage
87
URINARY INCONTINENCE What are the 6 main types of incontinence?
- Overactive bladder/urge incontinence - Stress incontinence - Mixed incontinence (of the 2 above) - Overflow incontinence - Fistula - Neurological
88
URINARY INCONTINENCE What causes urge incontinence/OAB?
- Overactivity + involuntary contractions of the detrusor muscle
89
URINARY INCONTINENCE What are last resort options for urge incontinence?
- Augmentation cystoplasty with bowel tissue - Bypass (urostomy) - Botox can paralyse detrusor + block ACh release
90
PELVIC ORGAN PROLAPSE What are some risk factors of pelvic organ prolapse?
- Age - BMI - Multiparity (vaginal) - Spina bifida - Pelvic surgery - Menopause
91
PREMENSTRUAL SYNDROME What specialist management can be given for PMS?
- Continuous transdermal oestrogen with progestogens - GnRH analogues if severe (add HRT to mitigate osteoporosis risk) - Hysterectomy + bilateral oophorectomy to induce menopause if severe - Danazol + tamoxifen for cyclical breast pain - Spironolactone for breast swelling + bloating
92
ASHERMAN'S SYNDROME What is the pathophysiology of Asherman's?
- Damage to basal layer of endometrium, damaged tissue may heal abnormally, creating scar tissue (adhesions) - Adhesions can bind uterine walls together or endocervix, sealing it shut causing obstruction > infertility, 2* amenorrhoea
93
ASHERMAN'S SYNDROME What causes Asherman's syndrome?
- Pregnancy-related dilatation + curettage procedures - After uterine surgery - Pelvic infection like endometritis
94
ASHERMAN'S SYNDROME What is the clinical presentation of Asherman's syndrome?
- Secondary amenorrhoea - Infertility - Significantly lighter periods - Dysmenorrhoea
95
ASHERMAN'S SYNDROME What is the management of Asherman's syndrome?
- Hysterosalpingography = contrast injected into uterus + XR - Sonohysterography = uterus filled with fluid + pelvic USS - Hysteroscopy gold standard + can dissect adhesions (recurrence after common)
96
HRT What are the side effects associated with progesterone?
Mood swings, fluid retention, weight gain, acne greasy skin
97
PELVIC ORGAN PROLAPSE What surgical intervention is provided for uterine prolapse?
Hysterectomy or sacrohysteropexy
98
HYDATIDIFORM MOLE What is a complete mole?
- Diploid trophoblast cells - Empty egg + sperm that duplicates DNA (all genetic material comes from father) - No foetal tissue
99
HYDATIDIFORM MOLE What is a partial mole?
- Triploid (69XXX, 69XXY) trophoblast cells - 2 sperm fertilise 1 egg - Some recognisable foetal tissue
100
HYDATIDIFORM MOLE What are some risk factors for hydatidiform mole?
- Extremes of reproductive age - Previous molar pregnancy - Multiple pregnancies - Asian women - OCP
101
HYDATIDIFORM MOLE What is the management of hydatidiform mole after evacuation?
- Check urinary pregnancy test in 3w – if high or mets may need chemo (cisplatin) - Effective contraception as advised to avoid pregnancy for 12m
102
PELVIC INFLAMMATORY DISEASE What are some risk factors for PID?
- Not using barrier contraception - Multiple sexual partners - Intrauterine device - Younger age - Existing STIs - Previous PID
103
PID What might you look for on microscopy in PID? What is the relevance?
- Pus cells on swabs from vagina or endocervix - Absence is useful to exclude PID
104
PELVIC INFLAMMATORY DISEASE What are the non-infective causes of PID?
- Post-partum (retained tissue), - uterine instrumentation (hysteroscopy, IUCD), - descended from other organs (appendicitis)
105
PELVIC INFLAMMATORY DISEASE What are the non-STI infective causes of PID?
Gardnerella vaginalis, H. influenzae, E. coli.
106
GENITAL TRACT FISTULA what are the causes of genital tract fistulas?
injury (primarily in childbirth), surgery, infection radiation.
107
GENITAL TRACT FISTULA what are the different types?
➢ Vesicovaginal fistula ➢ Ureterovaginal fistula ➢ Urethrovaginal fistula ➢ Rectovaginal fistula ➢ Enterovaginal fistula ➢ Colovaginal fistula
108
GENITAL TRACT FISTULA what are the risk factors for genital tract fistulas?
➢ Childbirth ➢ Surgery ➢ Infection ➢ IBD ➢ Radiation
109
GENITAL TRACT FISTULAS what are the investigations for genital tract fistulas?
➢ Vaginal/anal examination (could use proctoscope or speculum) ➢ Contrast tests (barium enema) ➢ Blue dye test ➔ put a tampon in the vagina then blue dye in rectum. If tampon is stained = test positive ➢ CT, MRI, Ultrasound, Manometry
110
OVERACTIVE BLADDER what are the risk factors for overactive bladder?
➢ Old age ➢ Pregnancy/childbirth ➢ Hysterectomy ➢ Obesity ➢ Family history
111
URINARY INCONTINENCE What are some side effects of anti-muscarinics?
- "Can't see, spit, pee or shit" > caution in elderly as falls esp oxybutynin immediate release in frail
112
URINARY INCONTINENCE What is a caution of beta-3-adrenergic agonists?
- C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
113
SYPHILIS What is a potential adverse effect of treating syphilis?
- Jarisch-Herxheimer reaction within a few hours of treatment - Fever, rash + tachycardia thought to be due to release of endotoxins following bacterial death
114
GENITAL WARTS How is genital warts managed?
- Prophylaxis with HPV vaccine for 12–13y (may be given to MSM, trans men/women + sex workers) - Topical podophyllotoxin cream/lotion or cryotherapy. - GUM contact tracing, contraceptive advice
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HIV What is HIV? What is the pathophysiology of HIV?
- RNA retrovirus that encodes reverse transcriptase - Binds to GP120 envelope glycoprotein to CD4 receptors which migrate to lymphoid tissue where virus replicates + produces billions of new virions - Reverse transcriptase makes single strand RNA > double stranded DNA + viral DNA is integrated to host cell's DNA with enzyme integrase + core viral proteins synthesised + cleaved by viral protease - These then released + in turn infect new CD4 cells
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HIV What tests can be used to investigation HIV?
- Serum/salivary HIV enzyme-linked immunosorbent assay (ELISA) - Rapid point of care screening blood test for HIV antibodies - PCR testing
117
HIV Explain the process of HIV ELISA
Can take 3m for HIV Ab detection so confirmatory assay after 3m.
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HIV What is the generic management for HIV? What is the standard therapy? What is the aim of therapy?
- Specialist HIV, infectious diseases + GUM clinics - Highly active anti-retrovirus therapy (HAART) with 2 NRTIs + third agent - Goal to achieve normal CD4 count + undetectable viral load
119
HIV What are the 4 main groups of HIV treatment?
- Nucleoside reverse transcriptase inhibitors (NRTIs) - Protease inhibitors (PIs) - Integrase inhibitors (IIs) - Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
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HIV What are some examples of and the mechanism of action of... i) NRTIs? ii) PIs? iii) IIs? iv) NNRTIs?
i) Zidovudine, tenofovir, emtricitabine – inhibits synthesis of DNA by reverse transcriptase ii) Indinavir (end –navir) – acts competitively on HIV enzyme involved in production of functional viral proteins iii) Raltegravir (end –gravir) – inhibits insertion of HIV DNA to genome iv) Nevirapine – binds directly to + inhibits reverse transcriptase
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SYPHILIS What is the causative organism?
Treponema pallidum – spirochete (spiral-shaped) bacteria
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CANDIDIASIS What are some risk factors?
Increased oestrogen (pregnancy, during menstrual years) poorly controlled DM, immunosuppression, broad spectrum Abx
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LYMPHOGRANULOMA VENEREUM what is it?
STI caused by serovars L1, L2 or L3 or chlamydia trachomatis
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LYMPHOGRANULOMA VENEREUM what are the clinical features?
Painless genital ulcer Appears 3-12 days after infection May not be noticeable e.g. if occurs inside the vagina Inguinal lymphadenopathy Proctitis, rectal pain, rectal discharge (in rectal infections) Systemic symptoms such as fever and malaise
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LYMPHOGRANULOMA VENEREUM what is the management?
Treatment is with antibiotics. Common regimes include: Oral doxycycline 100 mg twice daily for 21 days Oral tetracycline 2 g daily for 21 days Oral erythromycin 500 mg four times daily for 21 days
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CHANCROID what are the causes?
Haemophilus ducreyi Given its relatively high incidence in topical areas and Greenland, it is important to inquire in the history about recent travel.
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CHANCROID what are the clinical features?
A painful genital lesion which may bleed on contact Associated symptoms include painful lymphadenopathy
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CHANCROID what is the management?
The infection is treated using antibiotics (typically Ceftriaxone, Azithromycin or Ciprofloxacin)
129
COCP What pill is recommended... i) as first line? ii) in PMS? iii) in acne + hirsutism?
i) Pills with levonorgestrel or noresthisterone (microgynon or Leostrin) as lower VTE risk. ii) Pills containing drospirenone as anti-mineralocorticoid + anti-androgen activity can help Sx (esp. w/ continuous use). ii) Pills containing cyproterone acetate (co-cyprindiol) as anti-androgen effects but the oestrogenic effects give it higher VTE risk so usually stopped after 3m when Sx reduced.
130
COCP What are the benefits of the COCP?
- Effective contraception, rapid return of fertility after stopping. - Improvement in PMS, menorrhagia + dysmenorrhoea (acne in some). - Reduced risk of endometrial, ovarian, colon cancer + benign ovarian cysts.
131
COCP What are some side effects + risks with the COCP?
- Unscheduled bleeding common in first 3m. - Breast pain + tenderness. - Mood changes + depression. - Headaches, HTN, VTE. - Small raise in risk of breast + cervical cancer (risk normalises after 10y taking pill). - Small raise in risk of MI + stroke.
132
COCP What are the UKMEC4 criteria for the COCP?
- Uncontrolled HTN. - Migraine with aura. - >35 smoking >15/day. - Major surgery with prolonged immobility (stop 4w before major surgery) - Hx of stroke, IHD, AF, VTE. - Active breast cancer. - Liver cirrhosis or tumours. - SLE + antiphospholipid syndrome. - Breastfeeding before 6w postpartum (UKMEC2 after).
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COCP What are the UKMEC3 criteria for the COCP?
- >35 smoking <15/day. - BMI >35kg/m^2. - Controlled HTN. - VTE FHx in 1st degree relatives. - Immobility. - Known carrier of BRCA1/2.
134
POP What different types of POP are there and what are their mechanisms?
Traditional POP (norgeston) – - Thickens cervical mucus. - Alters endometrium so less accepting of implantation. - Reduced ciliary action in fallopian tube. Desogestrel POP (Cerazette) – - Inhibits ovulation (main mechanism) + above.
135
POP What is the main complaint/side effect of the POP? What are some other side effects of the POP?
- Unscheduled bleeding common in first 3m (if persists exclude other causes like STIs, pregnancy, cancer). - Changes to bleeding schedule one of primary adverse effects (40% regular bleeding, 40% irregular, prolonged or troublesome + 20% amenorrhoeic). - Breast tenderness, headaches + acne.
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POP What are some risks of the POP?
- Increased risk of ovarian cysts, small risk of ectopic pregnancy with traditional POP due to reduced ciliary action, minimal increased risk of breast cancer (returns to normal 10y after stopping).
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PROGESTERONE INJECTION What is the mechanism of action of the progesterone injection?
- Inhibits ovulation by inhibiting FSH secretion by the pituitary gland + prevents development of follicles in the ovary. - Thickens cervical mucus + alters endometrium to make it less favourable for implantation.
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PROGESTERONE INJECTION What are 3 unique side effects to the progesterone injection?
- Weight gain - Reduced BMD (oestrogen maintains BMD + mostly produced by follicles in ovaries) – Makes depot unsuitable for those >45 - Takes 12m for fertility to return after stopping
139
PROGESTERONE INJECTION What are some general side effects of the progesterone injection?
- Acne. - Reduced libido. - Mood issues (depression). - Headaches. - Alopecia. - Skin reactions at injection sites. - Small rise in breast/cervical cancer risk.
140
PROGESTERONE INJECTION What are the UKMEC3 + 4 criteria for progesterone injection?
- UKMEC4 = active breast cancer. - UKMEC3 = IHD + stroke, unexplained vaginal bleeding, severe liver cirrhosis + liver cancer.
141
PROGESTERONE IMPLANT What is the mechanism of action for the progesterone implant?
- Inhibits ovulation. - Thickens cervical mucus. - Alters endometrium to make it less accepting to implantation.
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PROGESTERONE IMPLANT What are the pros of progesterone implant?
- Effective + reliable. - Can improve dysmenorrhoea + can make periods lighter or stop altogether. - No weight gain, effect on BMD, no VTE risk, no restrictions for obese patients.
143
PROGESTERONE IMPLANT What are the side effects of the progesterone implant?
- Problematic bleeding (20% amenorrhoeic, 25% frequent/prolonged bleeding, 33% infrequent, rest normal, can use COCP for 3m if problematic bleeding + no C/Is). - Can worsen acne, no STI protection.
144
COILS What are the risks of coil insertion?
- Insertion risks (bleeding, pain on insertion [use NSAIDs], - vasovagal reactions, - uterine perforation, - PID + expulsion rate highest in first 3m.
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COILS What are the contraindications to the coils?
- PID or infection, - immunosuppression, - pregnancy, - unexplained bleeding, - pelvic cancer, - uterine cavity distortion (fibroids).
146
COILS What are the drawbacks of the IUD?
- Procedure with risks for insertion/removal. - Can cause HMB/IMB which often settles. - Some women have pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out.
147
COILS What is the mechanism of action for the IUS?
- Progesterone component thickens cervical mucus. - Alters endometrium making less hospitable + inhibits ovulation in small # of women.
148
COILS What are the benefits of the IUS?
- Can make periods lighter or stop. - May improve dysmenorrhoea or pelvic pain related to endometriosis. - No effect on BMD, VTE, no restrictions in obese pts.
149
COILS What are the drawbacks of the IUS?
- Procedure with risks for insertion/removal. - Can cause spotting or irregular bleeding. - Some women experience pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out. - Increased incidence of ovarian cysts. - Systemic absorption can lead to progesterone Sx (acne, headaches, breast tenderness).
150
EMERGENCY CONTRACEPTION For the copper IUD, what are the pros and cons?
Pros - Choice not affected by BMI, enzyme-inducing drugs or malabsorption. - Can leave in as long-term contraceptive Cons - PID (especially if STIs) - Normal risks with coil insertion
151
EMERGENCY CONTRACEPTION For Ulipristal acetate, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) extra notes? vi) side effects?
i) Single 30mg dose ii) Second most effective but decreases with time iii) <120h iv) Selective progesterone receptor modulator that inhibits ovulation v) Vomiting within 3h then repeat dose vi) Spotting + changes to next menstrual period, abdo/pelvic/back pain, mood changes, headaches, dizziness, breast tenderness
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EMERGENCY CONTRACEPTION For Ulipristal acetate, what are the pros and cons?
Pros - More effective than levonorgestrel - Can be used >1 in one cycle Cons - Avoid breastfeeding for 1w (express but discard) - Avoid in severe asthma - Wait 5d before starting COCP or POP with 7 or 2d extra contraception needed
153
EMERGENCY CONTRACEPTION For levonorgestrel, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) side effects?
i) Single 1.5mg dose (3mg if BMI >26kg/m^2) ii) Least effective of group 84% iii) <72h iv) Stops ovulation + inhibits implantation v) Spotting + changes to next menstrual period, diarrhoea, breast tenderness, dizziness, depressed mood
154
EMERGENCY CONTRACEPTION For Levonorgestrel, what are the pros and cons?
Pros - Safe during breastfeeding (Avoid for 8h to avoid infant exposure though). - COCP/POP can start instantly but with extra contraception for 7/2d - Use more than once in a menstrual cycle Cons - Less effective
155
FEMALE INFERTILITY In terms of causes of female infertility, what are disorders of ovulation?
PCOS POI, pituitary tumours, hyperprolactinaemia, Turner syndrome, Sheehan's, previous radio/chemo
156
FEMALE INFERTILITY What are some risk factors of infertility?
- Extremes of weight - Increasing age - Smoking - Alcohol/drug use
157
FEMALE INFERTILITY What are the ovarian reserve tests?
- Serum FSH + LH on days 2–5 (high = poor ovarian reserve) - Anti-mullerian hormone (released by granulosa cells in growing follicles so falls as eggs depleted) - Antral follicle count on USS (Few suggest poor ovarian reserve)
158
FEMALE INFERTILITY How would you manage anovulation?
- Weight loss - Clomiphene (selective oestrogen receptor modulator on days 2–6 to inhibit oestrogen + cause more GnRH + so FSH + LH release) or letrozole (aromatase inhibitor) to stimulate ovulation. - Gonadotrophins to stimulate ovulation if resistant to clomiphene - Ovarian drilling may be used in PCOS
159
MALE INFERTILITY In terms of male infertility, what are the pre-testicular causes?
Pituitary/hypothalamus pathology, suppression due to stress, chronic conditions, hyperprolactinaemia, Kallmann's
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MALE INFERTILITY In terms of male infertility, what are the genetic/congenital causes?
Klinefelter's, Y chromosome deletions
161
MALE INFERTILITY When managing male infertility, what are some management options?
- Intrauterine insemination, IUI (collect + separate high-quality sperm + inject into uterus) - Intracytoplasmic sperm injection, ICSI (inject sperm directly into cytoplasm of egg + inject into uterus) - Surgical correction of an obstruction in the vas
162
ASSISTED CONCEPTION What are the risks and complication with IVF?
- Multiple pregnancy - Miscarriage + ectopics - Ovarian hyperstimulation syndrome - Bleeding + infection at egg collection - Failure
163
ASSISTED CONCEPTION What is the clinical presentation of ovarian hyperstimulation syndrome?
- Mild = abdo pain + vomiting - Mod = N+V + ascites on USS - Severe = ascites, oliguria - Critical = anuria, VTE, ARDS
164
ASSISTED CONCEPTION What are the risk factors for ovarian hyperstimulation syndrome?
- Younger age. - Lower BMI. - PCOS. - Higher antral follicle count.
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ASSISTED CONCEPTION What investigations would you do in ovarian hyperstimulation syndrome and what would they show? How could you identify someone at risk?
- Activation of RAAS > high renin - Haematocrit raised as less fluid in intravascular space - USS + serum oestrogen (high = risk) – monitor these to identify those at risk.
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ASSISTED CONCEPTION How do you manage ovarian hyperstimulation syndrome?
- PO fluids - Monitor urine output - LMWH - Paracentesis for ascites - IV colloids
167
POP What are the rules about UPSI in for the POP?
Sex since missing pill or within 48h of restarting = emergency contraception.
168
FEMALE INFERTILITY In terms of causes of female infertility, what are the tubal/uterine/cervical factors?
PID, sterilisation, Asherman's, fibroids, polyps, endometriosis, uterine deformity
169
MALE INFERTILITY In terms of male infertility, what are the testicular causes?
Damage from mumps, undescended testes, trauma, cancer, radio/chemo
170
MALE INFERTILITY In terms of male infertility, what are the post-testicular causes?
Retrograde ejaculation, scarring from epididymitis (chlamydia), absence of vas deferens (may be associated with cystic fibrosis, even carriers), damage to testicle or vas (trauma, surgery, cancer).
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MALE INFERTILITY In terms of male infertility, what are the azoospermia causes?
Steroid abuse, vasectomy
172
MALE INFERTILITY In terms of male infertility, what are the teratozoospermia causes?
Testicular cancer
173
MALE INFERTILITY How would you manage hormonal causes of infertility?
- Gonadotrophins if hypogonadotrophic hypogonadism, bromocriptine if hyperprolactinaemia + sexual dysfunction
174
BREAST CANCER What tumour marker can be used to monitor response to breast cancer treatment and disease recurrence?
- CA 15-3
175
BREAST CANCER What are some complications of breast cancer?
- Locally advanced (rare), try shrink with radio, chemo, or hormone therapy to try operate, salvage surgery + stage for mets - Metastatic breast cancer (2Ls 2Bs) = Lungs, Liver, Bones, Brain
176
BREAST CANCER What adjuvant endocrine therapy may be given to women?
- All ER+ve women need endocrine therapy as increases survival - Bisphosphonates to reduce rate of bone mets in ER+ve - Trastuzumab (Herceptin) used in HER2+ve + chemo
177
BREAST INFECTION What is the management of non-lactational mastitis?
- Same as lactational mastitis (flucloxacillin or erythromycin) but + metronidazole
178
GYNAECOMASTIA What are some pathological causes of gynaecomastia?
- Drugs (spironolactone, oestrogen, anabolic steroids) - Marijuana - Liver failure - Testicular failure or tumour (Can produce beta-hCG)
179
METASTATIC BREAST CANCER What is the management?
- Bisphosphonates + denosumab, radio/chemo + Sx control
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BREAST CANCER what is tamoxifen?
tamoxifen inhibits the oestrogen receptor on breast cancer cells It increases survival by 15-25% in woman with ER+ cancer give for 10 years in higher risk women
181
BREAST CANCER what are the complications of tamoxifen?
hot flushes nausea vaginal bleeding rarely thrombosis and endometrial cancer
182
BREAST CANCER what are aromatase inhibitors?
letrozole Inhibit aromatase enzyme responsible for the conversion of androgens to oestogen in post-menopausal woman slightly better anticancer efficacy than tamoxifen
183
BREAST CANCER what are the side effects of aromatase inhibitors?
hot flushes reduced bone density joint pains
184
BREAST CANCER how is HER-2 breast cancer managed?
Currently 1 year of 3 weekly adjuvant Trastuzumab given alongside chemotherapy (usually FEC-T).
185
PAGET'S DISEASE OF THE NIPPLE what are the risk factors?
- old age - FHx of breast cancer - Previous breast cancer - overweight - excess alcohol - smoking - risk factors for breast cancer
186
PAPILLOMA what is the clinical presentation?
- bloody or clear discharge from a single duct
187
PAPILLOMA what is the management?
- removal via vacuum assisted excision (VAE)
188
PAPILLOMA what are they associated with?
atypical hyperplasia - this increases the risk of developing breast cancer
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ANAEMIA IN PREGNANCY What is the cut off for Hb in first trimester? What is the cut off for Hb in second/third trimester? What is the cut off for Hb postpartum?
first trimester - <110g/l second/third trimester - <105g/l postpartum - <100g/l

B TO REVISE - PHASE 3A (9 decks)

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