Day 12 OBGYN Flashcards
A 28 year old female attends her GP with her husband, who is 29.
They have been trying to become pregnant for six months.
They are both fit and healthy, are not using any contraception, and are having intercourse three to four times per week.
She is concerned she is infertile and is wondering what investigations are available to her.
What is the most appropriate initial management for this couple?
No specific medical investigations are warranted at this time
As a healthy young couple, they have a high (80%) chance of conception within one year of regular unprotected intercourse.
It is sensible to provide this couple with lifestyle advice related to conception e.g. alcohol and caffeine intake, folic acid supplementation, drug use, smoking and body weight.
A woman of reproductive age that has not conceived after one year of regular unprotected intercourse should be offered further clinical assessment and investigation, along with her partner.
A 23 year old para 1 (previous vaginal delivery) woman is brought into maternity by ambulance at 28+3 weeks with heavy vaginal bleeding and intense abdominal pain.
She reports a sudden onset of abdominal pain this morning ‘like a contraction but continuous’, unrelieved by Paracetamol.
40 minutes later she noted heavy vaginal bleeding, soaking through three sanitary pads in the last hour.
Her observations are: pulse 110, blood pressure 132/96, respiratory rate 24, SpO2 99%, temperature 37.4
She is otherwise well and has had an uncomplicated pregnancy so far.
On examination her abdomen is hard and tender and you are unable to feel foetal movements.
Dark red vaginal bleeding is ongoing.
What is the most likely diagnosis?
Placental abruption occurs when the placental prematurely separates from the wall of the uterus. This can cause profuse bleeding as the uterine vessels are sheared.
Immediate investigations in this case would involve evaluation of the foetus via either dopplar or CTG and ultrasound scan to view the uterus and look for evidence of placental abruption. Ongoing management would depend on the status of the patient, viability of the foetus and the degree of placental abruption suspected. In this case, bleeding continues to be heavy, and therefore urgent caesarean section would be considered.
A 30 year old primiparous woman who is now 41 weeks pregnant is seen in the antenatal clinic by the midwife.
She has had an uncomplicated pregnancy so far and all bloods and scans have been normal.
There has been no rupture of membranes.
On examination the symphysis-fundal height is 40cm, the fetus is cephalic presentation and the head is 2/5 palpable.
The mother explains that she is “fed up” and hopes that she goes into labour soon.
Which is the next most appropriate step in her management?
She should be offered a cervical membrane sweep to try and stimulate spontaneous labour
A cervical membrane sweep increases the likelihood of spontaneous labour initiating as it causes release of prostaglandins.
A 31 year old woman attends her booking visit at 10 weeks gestation.
This is her first pregnancy and other than some morning sickness she has had no vaginal bleeding or other problems so far.
The results of her booking bloods come back which show no abnormalities, but her Rhesus status is found to be negative.
She is worried that she will need injections.
Which of the following is the most appropriate management?
Give anti-D immunoglobulin at 28 weeks.
National guidelines advise one 1500IU dose of anti-D immunoglobulin at 28 weeks gestation, with further doses if sensitising events occur (such as heavy vaginal bleeding, amniocentesis, delivery and external cephalic version).
Facts about placenta praevia
(4)
A digital vaginal examination should not be performed with known placenta praevia as it can cause massive haemorrhage.
Bleeding from placenta praevia is usually painless and rarely fatal. It presents after 20 weeks of gestation.
Multiparity is considered a risk factor for placenta praevia.
Increasing maternal age is a risk factor placenta praevia.
An ultrasonography of a 25 year old female at 24 weeks gestation reveals twin pregnancy.
Both foetuses are female and it appears to be a diamniotic, monochorionic twin pregnancy.
Twin A appears much smaller than Twin B.
Which of the following is a concern for Twin B?
What is the cause?
Hypervolaemia
The recipient twin would develop hypervolemia as a result of receiving transfusion from the donor twin (which would develop oligohydramnios and growth retardation).
You meet a 37-year-old woman on labour ward who is 40+5 weeks gestation and has elected to be induced.
You return shortly after induction to find the patient is barely responsive and visibly dyspnoeic.
Your colleage takes some observations which show the patient is hypoxic and hypotensive.
You suspect an amniotic fluid embolism.
Which of the following is the most appropriate next step in management?
Give the patient 15l oxygen via a non-rebreathe mask and call an anaesthetist
In amniotic fluid embolism, patients can quickly deteriorate and develop acute respiratory distress syndrome.
As such, the first step in management should be treating the maternal hypoxia in an effort to prevent any neurological sequelae
What is a sign of placental separation during the third stage of labour? (3)
Signs of placental separation and imminent placental delivery:
- Gush of blood
- Lengthening of the umbilical cord
- Ascension of the uterus in the abdomen
A 34 year women G3P2 is undergoing labour at 41 weeks gestation.
She has a history of two previous uncomplicated vaginal deliveries.
After 20 minutes of pushing, the midwife notices a visible umbilical cord in the vagina.
The patient is prepared for an emergency caesarean section.
What should the patient be instructed to do in the mean time?
Ask the patient to go on all fours, on knees and elbows
This is cord prolapse, which is an emergency as if left untreated because cord compression or spasm can lead to foetal hypoxia, irreversible damage, or death. As the patient is being prepared for an emergency caesarean section, they should be asked to on all fours on knees and elbows, while someone else pushes the presenting part of the foetus up to prevent cord compression.
You see a 25-year-old nulliparous patient in clinic who has recently had a singleton pregnancy confirmed.
She was diagnosed with epilepsy 6 years ago and has been seizure free for 18 months on her current dose of lamotrogine.
She is concerned about how her to manage both her epilepsy and pregnancy and is seeking advice.
She has no other medical history of note.
Which of the following is best advice to give this patient after delivering the baby?
It is recommended that she try to breastfeed after delivery
Anticonvulsant medication is present in breast milk in smaller quantities and allows the baby to withdraw slowly
A 35 year old primiparous woman attends antenatal clinic at 35 weeks gestation.
The baby has breech throughout the pregnancy and has failed to turn spontaneously.
She is thus offered an elective Caesarean section.
She is worried about the risks of having a Caesarean section, in particular the implications on any future pregnancies.
Regarding future placenta, which of the following statements is true after caesarean?
Increased risk of placenta accreta
Following Caesarean section there is increased risk of placental abnormalities for future pregnancies. Placenta accreta is the abnormal implantation of the placenta into the uterine wall, a common site being the old Caesarean scar.
A 22 year old woman presents to her GP at 34 weeks gestation with a new thick, white, odourless vaginal discharge.
She also complains her vulva is itchy and becoming red and sore.
She is otherwise well.
She has had no new sexual partners since becoming pregnant.
On examination, her blood pressure is 122/76, pulse 68, her abdomen is soft and non-tender with a fundal height appropriate for 34 weeks.
On external genital examination, the vulval area is red and excoriated.
There are no discrete ulcers or lesions. On speculum, there is copious thick lumpy discharge seen.
The cervix is long and closed. There is no bleeding seen.
What is the most likely diagnosis?
Vulvovaginal candidiasis
Vulvovaginal candidiasis (thrush) is common in pregnancy and typically presents with a thick white discharge (often described as ‘like cottage cheese’) which is usually odourless. It is a fungal infection that can cause itching and irritation around the vulva and vagina.
Candidiasis should be treated in pregnancy with an intravaginal antifungal agent such as a Clotrimazole pessary +/- a topical antifungal cream e.g. Clotrimazole. Oral antifungal medication is not recommended for pregnant women
A 24 year old woman presents to her GP at 30 weeks gestation suffering with ‘heartburn’.
She describes a retrosternal burning sensation, which commonly occurs following eating, or when lying in bed at night.
Which hormone is responsible for the promotion of smooth muscle relaxation, which contributes to reduced oesophageal tone and reflux oesophagitis?
Progesterone
Progesterone is increased throughout pregnancy.
It is produced by the corpus luteum in the first four weeks of pregnancy and by the placenta thereafter.
It promotes smooth muscle relaxation in the digestive system, urinary system and uterus.
A 25 year old primiparous woman presents to the day assessment unit at 37 weeks gestation with rupture of membranes.
This occurred 24 hours ago but still no contractions have occurred yet.
She feels generally well with no vaginal bleeding or pain.
A cardiotocograph is normal and the mother reports that the baby has been moving normally.
On examination her temperature is 36.8ºC, symphysis-fundal height is 34cm and the fetus is cephalic presentation with 3/5 palpable.
Which of the following is the next most appropriate step in her management?
She should be offered an induction of labour as it has now been 24 hours since the rupture of membranes with no commencement of labour.
This is the most appropriate answer. Following rupture of membranes if spontaneous labour does not occur within 24 hours induction of labour should be offered.
A 24-year-old lady attends a pre-conception clinic for advice.
She has a past medical history of epilepsy well controlled with Valproate.
Her doctor advises her that it is important to switch to a safer antiepileptic drug (AED) in pregnancy.
Which of the following is the most common fetal anomaly associated with Valproate?
Neural tube defects
This is the correct answer. Valproate exposure in the first trimester is associated with the highest risk of major congenital malformations. These include neural tube defects, cardiovascular anomalies, genital abnormalities, skeletal abnormalities and developmental delay. AEDs such as Valproate, Phenytoin and Carbamazapine are known to be associated with the risk of development of neural tube defects.
A 30 year old primiparous woman is inactive labour at 37 weeks gestation.
She is having a vaginal delivery and is currently in the second stage of labour.
She has been pushing regularly with contractions and the fetal head has now extended fully out of the vaginal introitus.
The fetal head is in an occipito-anterior position.
What is the next step in this labour?
Restitution
Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position. This facilitates delivery of the anterior shoulder and expulsion of the fetus.
What is restitution?
Restitution
Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position. This facilitates delivery of the anterior shoulder and expulsion of the fetus.
A 17-year-old woman presents to her GP.
She states that her menstrual period has been several weeks later than expected, which is unusual as her menstrual cycle is normally very regular.
She also explains that her period was accompanied by some “grey bits” and a few blood clots.
She had unprotected sexual intercourse with someone at a party 5 weeks ago.
Which of the following is the most likely diagnosis?
Miscarriage
If the woman had become pregnant because of her unprotected sexual intercourse this would explain why her period did not occur when she was expecting it.
Passage of fetal and placental tissue during a miscarriage can appear as greyish tissue and be accompanied by blood clots.
Indications for Category 1 Caesarean sections?
(2)
Category 1 (immediate) Caesarean section should be performed where there is evidence or clinical suspicion of acute foetal compromise:
- cord prolapse
- Scalp pH <7.2 is an indication for category 1 Caesarean section
A 14 year old female presents to her GP with a positive pregnancy test, nausea and slight vaginal bleeding.
She does not know when her last menstrual period was.
She is referred to the antenatal clinic where a a transvaginal ultrasound is performed.
The transvaginal ultrasound shows a ‘cloud like’ appearance and she is diagnosed with a molar pregnancy.
Which of the following is true regarding management of a molar pregnancy? (2)
The molar pregnancy requires removal as it is not viable. This is usually achieved surgically using a dilatation and curettage
Correct. A molar pregnancy (or hydatidform mole) occurs when there is an abnormality in the usual fusion of sperm and egg, resulting in a rapidly dividing tissue mass which is not compatible with a normal pregnancy.
Molar pregnancies can be subdivided into:
- Complete mole = Occurs when one or two sperm fertilise an egg that contains no chromosomal material. Therefore there is no maternal chromosomal material. A placenta is formed but there is no embryo.
- Partial mole = Occurs when two sperm fertilise a normal egg and instead of forming twins, there is an abnormal proliferation of tissue. There is embryonic tissue, but this is not a viable pregnancy.
A molar pregnancy is not a viable pregnancy and requires removal as there is a risk it may progress to invasive or malignant disease.
A 28 year old G2P2 is nearing term and has planned to breastfeed her baby after delivery.
She is wondering which of her medications is safe to continue during breastfeeding.
Which asthmatic drug is permitted during breastfeeding?
Which drugs are absolutely contra-indicated?
Salbutamol
The absolute contraindications to breastfeeding are:
- Infants of mothers with TB infection
- Infants of mothers with uncontrolled/unmonitored HIV
- Infants of mothers who are taking medications which may be harmful e.g. amiodarone
A 30-year-old, 41 week pregnant woman with gestational diabetes has failed to progress in the second stage of labour and is becoming distressed.
You suspect shoulder dystocia and call for additional help.
An episiotomy has been performed.
What of the following is the most appropriate next step in management?
McRoberts’ manoeuvre
After an episiotiomy has been performed, the patient should be placed in McRoberts’ position.
This involves hyperflexion at the hips with the thighs abducted and externally rotated
Gaskin manoeuvre
Gaskin manoeuvre
The Gaskin manoeuvre involves the patient rolling over to an ‘all fours’ position. The change in pelvic dimensions may assist with delivery
Rubin II manoeuvre
Rubin II manoeuvre
This is an internal manoeuvre used in shoulder dystocia involving applying external pressure to the posterior aspect of the anterior shoulder.
If successful, it allows the shoulders to be adducted and rotated to the larger oblique diameter
Woods’ screw manoeuvre
Reverse Woods’ screw manoeuvre
Woods’ screw manoeuvre
This is another internal manoeuvre that follows a failed Rubin II manoeuvre. It combines the Rubin II manoeuvre with pressure on the anterior aspect of the posterior shoulder
Reverse Woods’ screw manoeuvre
This is another internal manoeuvre that can be conducted if the abovementioned manoeuvres fail. It involves applying pressure on the anterior aspect of the anterior shoulder and posterior aspect of the posterior shoulder
A 22 year old male has attended the GUM clinic with itching and tingling in his genital region.
On questioning, he states that he had a genital herpes infection 4 months ago.
He has also been successfully treated for Chlamydia in the past.
At present he is not using any form of contraception
What is the most appropriate advice for this patient?
Abstain from all sexual activity until asymptomatic
The patient is experiencing the prodromal phase that precedes a recurrent herpes infection.
This occurs in 50% of patients who experience a recurrence of herpes infection.
The current guidance states that the patient should abstain from all sexual activity until symptoms from the prodromal phase and the clinical recurrence have passed.
A 22 year old woman visits the GUM clinic.
She is asking about types of contraception.
On questioning it is determined that she suffers from migraines that are associated with a preceding change in smell.
She also comments that she is against having an intra uterine device fitted and is currently using no contraception.
Given the clinical picture and patient preferences, what is the most appropriate contraceptive method to use?
POP
The current guidance stipulates that patients who suffer from migraines with aura should be offered the progesterone only pill is a suitable alternative.
A 42 year old female visits A&E with exertional shortness of breath.
A chest X-ray is requested and demonstrates bilateral bihilar interstitial infiltrates.
She has a past history of using intravenous drugs.
Give the most likely diagnosis. (2)
What is the most appropriate initial treatment? (1)
What is the second line treatment? (1)
She has (Pneumocystis pneumonia) infection, common in patients with HIV.
First line = Co-Trimoxazole
This is the appropriate first line treatment for PCP. The presentation confers adequate evidence of PCP infection, thus treatment can be prescribed in this case
Second line = Clindamycin-primaquine
Clindamycin-primaquine are used as second line agents in severe PCP refractory to Co-trimoxazole treatment.
What is cART?
(3)
The introduction of combined antiretroviral therapy (cART) in 1996 ushered in a new era for HIV-infected individuals in countries where this therapy was available.
- cART increases CD4 count
- decreases HIV RNA level
- extends AIDS-free survival
What is Liposomal Amphotericin?
(3)
This would be the appropriate treatment for Histoplasmosis infection.
Histoplasmosis is an infection caused by a fungus called Histoplasma.
This would present:
- disseminated infection
- weight loss
- fever
- dyspnoea
A 24 year old pregnant patient visits the antenatal clinic for her booking appointment.
She has had a cough for the last two days and is experiencing general coryzal symptoms.
When is the booking appointment?
Which of the following is the next most appropriate investigation?
between 8-12 weeks
HIV antigen and HIV antibody
The point of this question is to remind you that every patient who presents for a booking appointment should be tested for HIV. Given the absence of other features, this is most likely to be a common cold.
A 47 year old HIV positive man presents to A & E with a non-productive cough and shortness of breath.
He notes that he has become more breathless recently as he walks.
Which is the most likely causative organism? (3)
Pneumocystis Jiroveci
- The classic sign of PCP is a lowering of oxygen saturations on exercise.
- This would manifest as newfound breathlessness in patients recently infected.
- commonly found in patients with HIV
A 70 year old male presents to his GP with a red, hot and painful scrotal swelling that has worsened over the past 2 days.
He also reports pain on urination.
Examination reveals a red, hot swollen left testicle that is tender on palpation.
There is no regional lymphadenopathy.
What is the diagnosis?
Which is the most likely cause of his presentation?
E. coli
This is the most common cause of epididymoorchitis in older males, which is often associated with urinary tract infections.
An 18 year old woman visits the GP clinic asking about different types of contraception.
Previously she has been using barrier protection, but would like hormonal contraception.
She has a past medical history of epilepsy.
Of the following, what is the most appropriate contraceptive method to prescribe?
Contraceptive injection
The injection is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes.
A 32 year old pregnant lady presents to the GP with vaginal discharge and an associated fishy odour.
She reports this is the first time this has happened and she has been successfully treated for a chlamydia infection in the past.
What is the appropriate next stage in management?
What is the diagnosis?
Oral Metronidazole
This is the correct treatment option for women who are pregnant and displaying classic symptoms of Bacterial Vaginosis, notably an uncomfortable vaginal discharge associated with a fishy odour.
A 55 year old male presents to the Emergency Department with a 2 month history of a persistent dry cough and breathlessness that worsens when going up the stairs. This has progressed to shortness of breath at rest over the past few days. Past medical history is relevant for a road traffic accident in rural Kenya, for which he had a splenectomy and blood transfusion. He has no recent history of illness apart from an episode of flu-like symptoms and a widespread rash 6 months ago, which has since spontaneously resolved.
Observations show a temperature of 37.9 degrees Celsius, respiratory rate of 30, oxygen saturations of 86% on room air, heart rate of 77 beats per minute and blood pressure of 125/80. Arterial blood gas (ABG) showed pH 7.37, PaO2 7.1 kPa, PCO2 5.5 kPa, HCO3 25 mmol/L.
What is the diagnosis?
What is the most appropriate initial treatment?
This man likely has PCP secondary to HIV
Co-trimoxazole and steroids
This is the best treatment for Pneumocystis pneumonia (PCP). This is the most likely diagnosis given the progressive shortness of breath, exertional dyspnoea, and desaturation on ABG. He is likely to have contracted HIV from a contaminated blood transfusion in rural Kenya, which explains the seroconversion illness he experienced 6 months ago. Adjunctive steroids should be administered to patients with PaO2 ≤8 kPa and/or evidence of hypoxaemia e.g. oxygen saturations <92%. This is to reduce mortality and risk of respiratory failure.
An 18 year old woman presents to the GUM clinic after having a coryzal illness for three days.
She then describes having some vulval tingling and is now complaining of three painful lesions that have appeared on her vulva.
What is the best advice to give the patient regarding ongoing sexual activity?
Sexual activity should be avoided until lesions are gone.
This is a classical description of a herpes simplex virus infection which manifests as genital ulcers. Typically, there is a viral prodrome which is followed by the appearance of painful ulcers on the genitals. The key piece of advice that needs to be given is that sex should be avoided when there is a prodrome and or genital lesions are present. Condoms and daily antivirals reduce transmission but cannot guarantee it. The only way to prevent transmission is to avoid all sexual contact until the lesions have disappeared.
A 27 year old female presents to her GP complaining of a one week history of unusual vaginal discharge. She describes this as grey-white, thin and watery. This is especially bad after sex and she is conscious of a fishy smell. There is no soreness or itching. She is in a stable relationship with her husband, both of whom have only had sex with each other. She is not pregnant. What is the treatment of choice?
Metronidazole
Bacterial vaginosis is a common cause of excessive vaginal discharge that can increase the chances of getting chlamydia. A key sign for BV is an odour, which resembles that of fish. It can or cannot present with soreness and itching. Oral or vaginal Metronidazole is the treatment of choice.
A 33 year old female presents to A+E with a 2-week history of worsening shortness of breath on exertion and a dry cough.
Her past medical history is notable for HIV infection, for which she has not been compliant with medication.
On examination, she is hemodynamically stable, alert and orientated. Chest and cardiovascular examinations are unremarkable, but the patient’s saturations while walking are 85%. Chest X-ray is clear.
Given the most likely cause for her symptoms, what treatment should be offered?
Co-trimoxazole
This is the first line treatment for Pneumocystis pneumonia. Side effects include Stevens-Johnson syndrome/TEN, drug-induced lupus and agranulocytosis
A 16 year old girl visits the GUM clinic asking about suitable types of contraception. She comments that she is often forgetful.
She has no other relevant medical history.
Which is the most appropriate contraceptive method to consider?
Contraceptive Implant
This is the contraceptive of choice in a 16 year old girl. It affords the patient the ability to not worry about their contraceptive, as the implant remains active without intervention for 3 years. This also aligns with the patient’s personal preferences.
A 24 year old gentleman visits the GUM clinic.
Upon genital examination, he has a painless lesion on his penis.
There is also evidence of a swollen inguinal ligament.
What is the most likely causative organism for this condition?
Chlamydia Trachomatis
The presentation in this instance is Lymphogranuloma Venereum (LGV).
This is a tropical disease, rare in the UK.
It classically presents with a non indurated lesion on his penis, and due to lymphatic destruction, it can cause a swollen inguinal ligament.
This is known as the Groove sign, with a groove visible above and below the inguinal ligament.
LGV is caused by Chlamydia, specifically serovars L1/L2/L3.
A 24 year old woman presents to the GUM clinic with vaginal discharge.
A sample of discharge is taken for microscopy.
Upon microscopy, the causative organism is noted to be flagellated and unicellular.
What is the most appropriate management?
What is the causative organism?
Prescribe Metronidazole
This is the appropriate treatment for Trichomoniasis. On microscopy,
Trichomonas bacteria are classically flagellated unicellular organisms. This is sufficient diagnostic evidence to begin treatment.
A 27-year old female presents with right upper quadrant (RUQ) pain and fever.
Her last menstrual period was 2 weeks ago, and she was last sexually active 10 weeks ago.
They did not use a condom, but she is on the oral contraceptive pill.
Her past medical history includes an appendectomy only.
She is febrile but other observations are stable.
On abdominal examination she is tender in the right upper quadrant.
Bimanual vaginal exam reveals cervical excitation.
Urine dip shows leucocytes but is negative on a pregnancy test.
Bloods show a leucocytosis but are otherwise entirely normal.
What is the most likely diagnosis?
What is the treatment?
(3)
Fitz-Hugh Curtis syndrome
- Fitz-Hugh Curtis syndrome is when pelvic inflammatory disease (PID) causes perihepatic inflammation, leading to RUQ pain and/or referred shoulder tip pain.
Chlamydia is the most common culprit.
This lady had sexual intercourse with contraceptive cover but no condom, and so may have contracted a sexually transmitted infection which has gone unchecked.
PID is indicated here by the presence of cervical excitation.
High vaginal swabs can confirm the diagnosis.
Perihepatic fine adhesions may develop as a later complication.
Treatment is with antibiotics, commonly doxycycline or azithromycin.
A 19 year old woman attends her GP 22 weeks into her first pregnancy.
She complains she has developed painful lesions on her vulva. She is otherwise well.
She has no history of previous sexually transmitted infections and is currently sexually active.
On examination, her observations are normal.
There are multiple wet ulcer-like vesicles on her vulva and perineum which are painful to touch, with surrounding erythema.
There is palpable inguinal lymphadenopathy.
What is the causative agent?
What is the most appropriate treatment?
Oral Aciclovir 400mg three times a day
This woman has a primary herpes simplex virus (HSV) genital infection.
A higher dose of 400mg three times a day is required due to the higher circulating blood volume found in pregnancy.
Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term.
If this woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn.
A 61-year-old woman is referred to gynaecology as she is suspected of having ovarian cancer.
She has a high Ca-125.
The pelvic ultrasound is abnormal and so a chest-abdomen-pelvis CT is requested.
The CT shows that the cancer has seeded in the peritoneum and the liver.
What of the following is the most appropriate next step? (4)
Surgery
- If early disease surgery can include removal of the uterus, ovaries, Fallopian tubes and infracolic omentectomy.
- In advanced disease debulking surgery can be performed.
Chemotherapy
- Adjuvant chemotherapy should be given to the patient in an ideal world.
- Intraperitoneal chemotherapy may be performed at the time of operation
A 32-year-old lady presents to her General Practitioner (GP) complaining that she has not had a period in the last 6 months.
She also reports reduced libido and white colour, milky discharge from both of her breasts.
Notably, she denies any headache or visual disturbance.
She says she takes an antipsychotic.
Which medication is most likely to be responsible for the set of symptoms described by the patient?
Risperidone
The symptoms of reduced libido, galactorrhoea (bilateral milky discharge from the breasts that is not associated with pregnancy or lactation) and amenorrhoea are highly suggestive of hyperprolactinaemia.
The release of prolactin from the anterior lobe of the pituitary gland is under dominant-negative control through the release of dopamine from the hypothalamus.
Hence, a reduction in the activity of dopamine in the pituitary will lead to excess release of prolactin.
Risperidone is a second-generation (atypical) antipsychotic and it is a dopamine antagonist.
Out of the second-generation agents, the highest prevalence of hyperprolactinaemia is associated with risperidone.