extra Flashcards
A 42-year-old Caucasian lady is referred to the gynaecology clinic as she has not had any periods in 8 months. She also complains of joint pains for the last 2 years as well as lethargy. Her past medical history is significant for diabetes diagnosed 4 months ago and early-stage liver fibrosis diagnosed 6 months ago. She has no other past medical history and has never consumed alcohol.
A hormone profile requested by the gynaecologist reveals low levels of FSH and LH.
Which of the following investigations should be performed next?
Iron studies
This patient has secondary amenorrhoea which is the cessation of menstruation for at least 6 months in a patient who had periods before. The symptoms of lethargy and history of recent diabetes together with liver fibrosis point towards a diagnosis of hereditary haemochromatosis. This is a primary disorder of iron overload and can cause amenorrhoea due to deposition of iron in the hypothalamus and ovaries. Iron studies would reveal elevated levels of serum iron, raised ferritin and raised transferrin saturation. Transferrin levels and total iron-binding capacity (TIBC) would be reduced
AMH is hormone that serves as a marker of ovarian reserve.
decreased in what women
POI
what is ashermans syndrome
Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea.
in this case, the cyclical abdominal pain may be a sign that menstruation is occurring.
what is sheehan syndrome
Sheehan syndrome is hypopituitarism caused by ischaemic necrosis of the pituitary gland following excessive peri-partum blood loss. However, it is very rare in the developed world and the history is not consistent with this diagnosis
most common type of vulvar cancer
squamous cell carcinomas.
sx of vulvar cancer
Lump with or without lymphadenopathy
Itching
Non-healing ulcer
Vulval pain
Skin changes
Bleeding
how long do you not need contraception for in postnatal period
first 3 weeks
if you had a classic vertical. section can you have NVD after
no only if had LSCS
A 76 year old man comes into the GP clinic with a complaint of erectile dysfunction. He is prescribed Viagra (sildenafil). Which of the following medications is contraindicated with concurrent use?
Sildenafil is a PDE5 inhibitor and leads to vasodilation of the peripheral vasculature leading to a drop in the blood pressure in a similar way to how nitrates work - cannot be taken together
on examination of cervix in preg
a halo of red tissue around external os
blue ish tinge - increased blood flow
slit like apparance - pinpoint
is all nromal what is abnromal
odourless clear white watery fluid in posteriro vaginal vault - PPROm
recognised complication of epidural
Maternal and foetal distress secondary to hypotension are a recognised complication
This is correct. Maternal hypotension can be a distressing complication from epidural anaesthesia. It can be treated with 1L Hartmann’s solution over 20 minutes
how can maternal hypotension be treated in a distressing complication from epidural anaethesia
1L Hartmann’s solution over 20 minutes
A 32 year old patient with a history of depression presents with four episodes of severe shooting pain on her right cheek. Cranial nerve examination is normal, but the patient complains of worsening pain on light touch in the same area.
trigmeninal neuralgia
treated with carbamazepine
symptoms of local anaesthetic toxicity
Symptoms include the tinnitus, tremor, dizziness and paraesthesia seen in this patient
diabetic neuropathy first line
duloxetine
suxamethonium apnoea occurs in individuals who have a defect in
the enzymes (plasma cholinesterase) to metabolise suxamethonium leading to sustained action of the drug on the post-synaptic membrane of the neuromuscular junction
prolonged paralysis
uterine rupture common is sudden onset abdo pain and loss of contractions especially in context of previous c section
emergence lapratomy
cardiac disease - maternal, hypertension, pre-eclampsia or pre-existing renal disease can cause what in the baby
Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. This is most commonly caused by maternal conditions such as hypertension, pre-eclampsia or pre-existing renal or cardiac disease. This can also be caused by maternal substance abuse.
can a HIV positive patient have a normal vaginal delivery
If a patient has a viral load of <50 copies/ml and is taking multiple antiretroviral medications, they can be offered a vaginal delivery
can a HIV positive patient have a normal vaginal delivery
If a patient has a viral load of <50 copies/ml and is taking multiple antiretroviral medications, they can be offered a vaginal delivery
Intrahepatic cholestasis generally seen in third trimester. There is accumulation of bile salts in the serum. As a result it often involves pruritus in the palms and soles. Liver enzymes rarely rise above 250 u/l along with elevated bilirubin
Acute fatty liver of pregnancy is a rare complication of pregnancy but important to be aware of. It commonly occurs in the third trimester or immediately following delivery and is thought to be more common in nulliparous women as in the case of this patient. A typical patient will present with a few days history of general malaise, anorexia, vomiting, and jaundice. Pain in the right upper quadrant may sometimes be present. Blood results would show marked elevation of liver enzymes, prolonged PT, raised and bilirubin. Low platelets will be seen due to consumptive coagulopathy
nulliparous
follows delivery
RUQ
and raised LFTs
iron deficiency anaemia no symtpoms what shoudl you be given
oral ferrosu sulpahte fumarate 200mg TDS
and checked HB in 2 weeks
remain on for at least 3 months
B12 deficiency
IM cyanocobalamin 12mg
what if fitz hugh curtis syndrome
Fitz–Hugh–Curtis syndrome is a complication of pelvic inflammatory disease where the liver capsule becomes inflamed, leading to the development of adhesions between the capsule and the surrounding peritoneum. This causes right upper quadrant pain, which can radiate up to the shoulder, alongside symptoms of pelvic inflammatory disease such as vaginal discharge and fever.
The risk of malignancy (RMI) index is used to determine the risk category in a woman with suspected ovarian malignancy.
The RMI is a product of
ultrasound scan score, menopausal status and the serum CA125 level (IU/ml)
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).
kallmann syndrome main feature
no smell
lack of all secondary sex - so no breasts
what is androgen-insensitivity syndrome
Androgen-insensitivity syndrome occurs when an individual has XY chromosomes (male sex), but their body does not respond to the androgen hormones that drive the development of the male body.
Hence, they have externally female characteristics but no female reproductive organs.
features - primary amenorrhoea, lack of secondary sexual characteristics (except for breast development), absence of female reproductive organs and a short vagina (sometimes described as ‘blind ending’).
Breast development still occurs because testosterone can be converted to oestrogen in the periphery to drive breast development, but it is not present in the reproductive system.
bhcg readings
molar massive over 10000
When a pregnancy is not seen on an early scan, a β-hCG should be performed. If it is more than 1500 mIU/ml, the pregnancy should be treated as ectopic. If it is lower than this, the test will be repeated in 48 h and the two numbers compared. If the second reading is less than half of the first reading, it is most likely a miscarriage. If the second reading is more than double the first reading, it is most likely a viable pregnancy. If the second reading is between half and double the first reading, it should be treated as an ectopic pregnancy - which is the case for this woman.
what contraceptive measure reduces pelvic pain in endometriosis
POP
normally women do not have to take a withdrawl bleed whilst on the COCP what about with PCOS
Advice about the COCP has changed in recent years. While all women were initially advised not to take it continuously for more than 3 months, advice now states that it is safe to take it continuously without withdrawal bleeds. However, for patients with PCOS, they should still induce a withdrawal bleed at least once every 3 months to reduce the risk of endometrial cancer.
what is chandlier sign
Chandelier sign
Chandelier sign is the informal name for cervical excitation, also known as cervical motion tenderness. Cervical excitation is a sign of inflammation of pelvic organs and/or peritoneum.
It is tested during a bimanual examination by pressing anteriorly on the cervix with one hand and on the fundus of the uterus with the other hand. This results in severe pain. It is commonly present in pelvic inflammatory disease (the most likely diagnosis here), and occasionally in ectopic pregnancy.
what is chadwick sign
Chadwick’s sign refers to a blueish tinge to the cervix, which is seen in early pregnancy due to cyanosis and softening of the cervix
A 50 year old woman presents to her GP with a 4 month history of irregular menstrual bleeding. She has not bled for 8 months prior. She is not sexually active and takes no regular medications.
What is the most appropriate first step in the management of this patient?
Arrange for transvaginal ultrasound
Whilst irregular menstruation is common in the perimenopausal period, women over the age of 45 with irregular bleeding should be investigated with a transvaginal ultrasound scan to assess the endometrial thickness. This may be followed up by an endometrial biopsy
best way preg
urianry BHCG
when is topical oestrogen cream used over HRT
for when there are only sypmoms nt systemuc such as vaginal dryness
no diagnossi needed for menopause
only under 45 is FHS
A 29-year-old woman attends for her cervical screen. She reports feeling well and denies any gynaecological symptoms. She has no significant past medical history and currently has four children. On insertion of the speculum, the GP notes four lumps around the cervical os, which contain amber mucous. They are approximately 4 mm in size each. What is the most likely diagnosis?
Nabothian cysts
Nabothian cysts are cysts on the cervix that occur when the squamous-cell epithelium of the cervix slightly covers the columnar epithelium. As the columnar epithelium secretes mucous, the mucous becomes trapped, and cysts form. The cysts contain yellow/amber mucous and are usually located around the os where the epitheliums transition. They are a normal finding, particularly in women who have had children. The cervical smear should still be taken.
hiv positve cevical smear
very year
how long shuld you wait after preg or termiantion for cervical smear
3 months
first lien for fibrioid IX - heavy blledding and pain in premenopausal
TVUS
combine HRT reduces the risk of
osteoporosis and fractures
moa of clomiphene citrate
Clomiphene Citrate
Clomiphene Citrate is an antioestrogen which increases endogenous follicle stimulating hormone (FSH) and acts to induce ovulation. It is usually given at a dose of 50mg on days 2-6 of the menstrual cycle, with a progesterone level taken on day 21 to confirm ovulation
What is the most appropriate management for this patient to reduce her risk of ovarian cancer?
Bilateral salpingooophorectomy
Hysterectomy and bilateral salpingoophorectomy
Hysterectomy is only recommended if required for other reasons e.g. fibroids or menorrhagia
lichen sclerosis tx
potent topical corticosteroids such as dermovate.
Treatment helps prevent complications such as scarring and narrowing of the vaginal opening and reduces the risk of vulval cancer.
small bartholin cysts warm compress largeer ones
Incision and drainage: under local anaesthetic, the swollen gland is incised and allowed to drain. A Word catheter may also be inserted to promote continued drainage
Antibiotics in cases of abscess
Salt water baths may relieve pain
Surgery may be required in recurrent cases
Marsupialisation
This is the recommended treatment for symptomatic Bartholin’s cysts. The Bartholin’s glands are two glands situated on either side of the vaginal opening. They function to secrete lubricating fluid during sexual arousal. Bartholin’s gland cysts occur when the duct of the gland becomes blocked. This leads to swelling and tenderness of the area. Marsupialisation involves cutting into the cyst and placing stitches to make a permanent opening so that the gland can drain freely. Insertion of a balloon catheter is a non-surgical alternative to marsupialisation.
most common cause of postmenopausal bleeding
Vaginal atrophy
Vaginal atrophy (also known as atrophic vaginitis) is the most common cause of postmenopausal bleeding. Any postmenopausal bleeding will require thorough investigation for endometrial cancer, but only 10% of all postmenopausal bleeding is caused by malignancy.
endometrial cancer referral pathway
According to NICE guidance, any woman over 55 with postmenopausal bleeding (defined as unexplained vaginal bleeding 12 months after the last menstrual period) should be referred under a 2-week wait pathway for endometrial cancer. The first-line investigation for endometrial cancer is a TVS to assess endometrial thickness.
A 70-year-old woman attends her GP with the feeling that something is ‘coming down’ in her vagina. On examination, a uterine prolapse is noted. What is the most appropriate first-line management of this case?
vaginal pessary 1st line
A 12-year-old girl is brought to her GP with a 4-day history of gradual-onset worsening abdominal pain and bloating. The pain is constant and is not associated with eating, urinating or passing stool. She has not started her periods yet and has never had sexual intercourse. Her vital signs are within normal ranges. On palpation, there is generalised abdominal pain but no masses are felt. On genital examination, breast development and pubic hair are seen. A blue and bulging membrane is overlying the vagina, with a mass protruding from behind. What is the most likely diagnosis?
imperforate hymen
A 22 year old patient presents complaining of anxiety and irritability prior to her period each month, which is starting to affect her interpersonal relationships, especially at work. She also finds it difficult to concentrate and sleeps more in the week prior to her period.
She has a regular menstrual cycle, not using contraception, is not sexually active, and is not planning any pregnancies.
What is the most appropriate first line management for premenstrual syndrome?
Combined oral contraceptive pill with no pill-free interval
The COCP is useful for women with PMS however some suffer progestogenic side effects during the pill-free period. Therefore choosing a regime that has a shorter break, or no pill-free period may be more effective
An 81-year-old woman attends her GP complaining of a 2-month history of itching in the vulval region. On examination, the GP notes bleeding and ulceration suspicious of vulval cancer. Which part of the vulva is most commonly affected in vulval cancer?
labia majora
Transmural fibroid means what
Transmural fibroids are those located within the wall of the myometrium of the uterus.
difference between tranexamic acid and mefenamic acid
Tranexamic acid is an antifibrinolytic that has been shown to reduce menstrual blood loss.
Mefenamic acid is a non-steroidal anti-inflammatory drug (NSAID) that has been shown to reduce menstrual pain and menstrual blood loss.
This patient does not complain of pain, and tranexamic acid is more effective than mefenamic acid at reducing menstrual blood loss.
1st line for vaginal prolapse
A vaginal pessary is usually the first-line management of uterine prolapse (although sometimes, pelvic floor exercises known as Kegel exercises may be tried first in some mild cases).
POI
how many FSH readings under 25
tx
This is diagnosed in women under the age of 40 who have symptoms of menopause (eg. period cessation) alongside two FSH measurements of >25 IU/l. The most appropriate management is hormone-replacement therapy.
criteria for lactational amenorrhea
The woman has complete amenorrhoea.
The woman is fully, or nearly fully (>85% of feeds are breast milk) breastfeeding.
It has been six months or less since the birth of the baby
A 40-year-old primipara with an uneventful pregnancy is in established labour and 10cm dilated, experiencing powerful regular contractions. She is about to start pushing when she suddenly becomes tachypnoeic and hypotensive, and shortly after loses consciousness.
What is the most likely cause of her symptoms?
Amniotic fluid embolism
Amniotic fluid embolism is an extremely rare, often fatal, obstetric emergency. A bolus of amniotic fluid escapes the uterus and becomes lodged in the pulmonary circulation causing hypoxia, respiratory and often cardiac arrest, as well as disseminated intravascular coagulation. The treatment comprises resuscitation, steroids and immediate delivery, but it often results in the mother’s demise.
palecntal abruption likely to see other sx such as vag bleed
when does carcinoid syndroem coccur
when there are liver mets
diangostic for haitus hernia
barium swallow
lung cancer can cause
horners
best mx for FAP
Total proctocolectomy
cyclophosphoamide se
bladder problems - cystitis
cisplatin neohrotoxic and cx peripheral neuropathy
cyclophosphoamide se
bladder problems - cystitis
cisplatin neohrotoxic and cx peripheral neuropathy
common electrolyte imbalance seen in people with cancer mets
Hypercalcaemia
This is a common electrolyte imbalance in patients with cancer, especially those with bony metastases. The patient’s symptoms are acute and fit more with hypercalcaemia rather than more chronic conditions.
headahces triggered by coughing
raised ICP -need CT head
POP missed pill what should you do
Take the missed pill now. No further action required.
Correct. This patient takes Micronor (Norethisterone), a traditional POP. With a traditional POP, the rules are:
LESS than 3 hours late: Take the missed pill. No further action required.
MORE than 3 hours late: Take the missed pill as soon as possible. If more than one pill is missed - just take one pill. Take the next pill at its usual time even if it means taking two pills in the same day. Continue with the rest of the pack as normal but make sure to take extra precautions such as using condoms until the pill taking has re-established for 48 hours.
She is within the 3 hour window of taking her POP. Newer Desogestrel POPs are considered missed after 12 hours of being late to take them.
1 off seixure nroaml antomoty how much off driving
6 months
This patient has had an isolated unprovoked seizure with a normal CT head and EEG - DVLA guidance is for 6 months off driving.
if abnmrla ct 1 month
topical acetic acid
tx for ottitis externa
another name for bacterial vaginoss
gardenella vaginosis
what is lymphogranuoma venerum
Lymphogranuloma venereum (LGV)
Lymphogranuloma venereum (LGV) is an sexually transmitted infection (STI) caused by certain strains of Chlamydia trachomatis. LGV usually causes a painless genital ulcer at the site of inoculation and a subsequent inflammatory reaction of the inguinal nodes (buboes). LGV can also cause systemic symptoms of fever, fatigue and malaise. Given the patient’s history of unprotected sexual activity and the presence of these specific symptoms, LGV is the most likely diagnosis.
genital herpes normally resolves without treatment
correct
cervical motion tenderness
intense pain which examining the vagina
PID tx
Intramuscular ceftriaxone, oral doxycycline and oral metronidazole.
