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Obs and Gynae > Genito-urinary medicine > Flashcards

Genito-urinary medicine Flashcards

1
Q

Mechanism of action of contraception:

  • COCP
  • POP
  • Desogestrel
  • Implant
  • Depo provera
  • IUS
  • IUD
A

COCP: prevents ovulation, thickens cervical mucus and thins endometrium

POP: thickens cervical mucus, and alters endometrial lining

Desogestrel: inhibits ovulation and thickens cervical mucus

Implant: prevents ovulation, thickens cervical mucus

Depo provera: inhibits ovulations, thickens cervical mucus, thins endometrial lining

IUS: prevents endometrial proliferation and causes cervical mucus thickening

IUD: decreased sperm motility and survival

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2
Q

Advice on taking the COCP

A
  • If started on first 5 days of cycle, no additional contraception needed
  • If started at any other point, used additional contraception for 7 days
  • Take pill for 21 days and then stop for 7 (or use placebo for 7)
  • Reduced efficacy if vomited within 2 hours of taking pill, or if taking CYP450 inducers (PCBRAS)
  • Should be taken at the same time every day
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3
Q

Advised on missed COCP

A

1 missed pill at any point of cycle: take the missed pill even if it means taking two pills in one day. continue as normal, no additional contraception needed.

2+ pills missed:

  • take last missed pill even if it means taking 2 pills in one day, leave any earlier missed pills
  • Use condom until pill has been taken for 7 consecutive days
  • If pills are missed in days 1-7 of cycle: emergency contraception needed if unprotected sex occurred in pill-free week or in week 1
  • If pills are missed in days 8-14: take last missed pill even if it means taking 2 in one day, leave any earlier missed pills, use condom for 7 days, no emergency contraception needed
  • If pills are missed in days 15-21: finish current pack and start new pack, omitting the pill free week, no emergency contraception needed
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4
Q

COCP contraindications where disadvantages outweigh the advantages

A 
>35y and smoking <15/day
BMI>35
FHx VTE in first degree relative <45y
BRCA1/2 carrier
Controlled HTN
Immobility

DM diagnosed >20yrs ago depending on severity

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5
Q

COCP contraindications carrying an unacceptable health risk

A 
>35y smoking >15/day
Migraine with aura
Hx VTE
Current breast cancer
Uncontrolled HTN
Major surgery with prolonged immobilisation
Hx of IHD/stroke
Breast feeding <6wks post-partum

DM diagnosed >20yrs ago depending on severity

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6
Q

Pros vs cons of COCP

A

Pros:

  • failure rate 0.3% if used perfectly
  • doesnt interfere with sex
  • easily reversible
  • reduced risk of ovarian, endometrial and colorectal cancer
  • may protect from PID
  • makes periods lighter, regular and less painful
  • reduced incidence of acne, ovarian cysts and benign breast disease

Cons:

  • people may forget to take it
  • no STI protection
  • increased risk of VTE
  • increased risk of breast and cervical cancer
  • increased risk of stroke and IHD
  • headache, nausea, breast tenderness
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7
Q

Common adverse effect of POP

A

Irregular vaginal bleeding

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8
Q

Advice on taking POP

A
  • If started on days 1-5: no contraception needed
  • If started at any other time: contraception for 2 days
  • should be taken at the same time everyday without a pill free break
  • Most POPs have a 3 hour window every day where you have to take your pill
  • Desogestrel has a 12 hour window
  • If you have D+V then assume the pill has been missed and take action
  • CYP450 inducer reduce efficacy
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9
Q

Advice for missed POP

A

If missed but still within 3hours (<12hr if desogestrel) - continue as normal

If missed and >3hrs (>12hrs for desogestrel) - take missed pill ASAP, continue rest of pack as normal, use extra contraception for 48 hours

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10
Q

Advice on contraception following insertion of IUS

A

If inserted on days 1-7 of cycle: no additional contraception needed

If inserted at any other point of the cycle: extra protection for 7 days

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11
Q

Side effects and risks associated with IUS

A

Side effects: initial frequent uterine bleeding, but then usually people become amenorrhoeic or have intermittent light bleeding, with reduced dysmenorrhoea

Risks:

  • Uterine perforation
  • Small increased risk of PID in the first 20 days
  • Expulsion in the first 3 months
  • If you become pregnant, it is more likely to be ectopic (although absolute number of ectopics is reduced compared to population because there is a reduced number of pregnancies on IUS)
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12
Q

Indications and contraindications of IUS

A

Indications: first line for menorrhagia, contraception, HRT (with unopposed oestrogen HRT to prevent endometrial hyperplasia)

Contraindications:

  • current/recurrent PID or STI
  • current pregnancy
  • uterine abnormality distorting the uterine cavity
  • cervical/endometrial cancer
  • breast cancer in last 5 yrs
  • current DVT/ PE
  • IHD
  • liver disease
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13
Q

What is the IUS also called? What does it secrete?

A 
IUS = mirena coil
Releases levonorgestrol (progesterone)
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14
Q

IUD (copper) contraception advice following insertion

A

Effective immediately following contraception, no need for extra protection

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15
Q

Risk of copper IUD

A

Makes periods heavier, longer and more painful
Uterine perforation
Expulsion
Small risk of PID in first 20 days
Increased proportion of pregnancies are ectopic

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16
Q

Implant contraception advice following insertion

How long to wait to insert it after TOP

A

Additional protection needed for 7 days if not inserted on days 1-5

Can be inserted immediately following TOP

Best contraceptive option for young people

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17
Q

Side effects and contraindications of implant

A

Side effects: irregular/ heavy bleeding, headache, nausea, breast pain

CYP450 inducers may affect efficacy

Contraindications: IHD/stroke, suspicious vaginal bleeding, previous or current breast cancer, severe liver cirrhosis, liver cancer

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18
Q

Depo provera

  • what does it release
  • how/when is it administered
A

Releases medroxyprogesterone acetate

IM injection every 12 weeks in the upper outer quadrant of the glute

19
Q

Adverse effects and risks of depo provera

A

Irregular bleeding, weight gain, not easily reversible, delayed return to fertility (up to 12m)
Potential increased risk of osteoporosis (so not advised in adolescence)

20
Q

What time window post-partum is safe to have sex without needing contraception?

A

21 days

21
Q

3 types of emergency contraception

A

1.5mg levonorgestrol
30mg ulipristal (EllaOne)
IUD

22
Q

Levonorgestrol emergency contraception

  • dose
  • when to take
  • MoA
  • effect on menstrual cycle
A

1.5mg Levonorgestrol

Must be taken within 72 hours of unprotected sexual intercourse

Thought to stop ovulation and inhibit implantation

If vomiting occurs, repeat dose

Doesnt seem to disturb menstrual cycle

23
Q

Ulipristal (EllaOne)

  • dose
  • when to take
  • MoA
  • Effect on hormonal contraception
  • Effect on breastfeeding
A

30mg

Take within 120 hours

Progesterone receptor modulator -> inhibits ovulation

May reduce effectiveness of hormonal contraception. Restart hormonal contraception 5 days after ulipristal and use extra protection during this time

Delay breastfeeding for one week after ulipristal

24
Q

How long to wait after vasectomy until unprotected sex can happen safely?

What happens in a vasectomy?

How effective?

A

2 month wait because sperm can survive in the ends for a brief period

Prevents sperm entering the ejaculate by bilaterally dividing the vas deferens

Very effective (failure rate <1%)

25
Q

Tubal ligation

  • what happens
  • failure rate
  • associated with what?
A

Tying.blocking/partial exclusion of fallopian tubes

Failure rate 0.75-3.5%

Associated with ectopic pregnancies

26
Q

Failure rate of condoms

Advantage of condoms

A

Failure rate 3-6%

Prevents STIs

27
Q

Risk factors for STIs

A 
Under 25
New sexual partner
lack of barrier contraception
Women undergoing TOP
COCP
28
Q

Triple swabs for STIs in women

A

High vaginal (sweep the posterior fornix - candida, trichomonas, BV)

Endocervical (1cm into endocervix, rotate gently - gonorrhoea)

Endocervix (1cm into endocervix, rotate vigorously for 10s - chlamydia)

29
Q

Chlamydia trachomatis

  • what is it
  • symptoms
  • examination
  • diagnosis
  • management
  • complications
A

Intracellular bacterium, affects endocervix and urethra

Sx: discharge, lower abdo pain, irregular PV bleed, dyspareunia, urinary symptoms

Exam: normal, +/- discharge, cervicitis, contact bleeding, adnexal tenderness

Diagnosis: endocervical swab, NAAT

Mx: 1g oral azithromycin stat, or 100mg oral doxycycline BD 7 days (CI in pregnancy), or 500mg erythromycin QDS 7 days or BD 14 days

Complications: PID, ectopics, chronic pelvic pain, infertility

30
Q

Obstetric complications of chlamydia

A

Prem delivery, foetal growth restriction, low birth weight, increased neonatal morbidity/mortality, still birth, miscarriage, neonatal conjunctivitis, neonatal pneumonia

31
Q

Neisseria gonorrhoeae

  • what is it
  • symptoms
  • examination
  • diagnosis
  • management
  • complications
A

Gram neg diplococci, affects mucous membranes of endocervix, urethra, rectum, eye and throat

Sx: discharge, lower abdo pain, IMB/PCB, dysuria, dyspareunia

Exam: discharge, cervicitis, contact bleeding, pelvic tenderness

Diagnosis: NAAT, culture from endocervical/ urethral/ rectal/ throat swabs

Mx: IM ceftriaxone 1g stat

Complications: PID, chronic pain, infertility, ectopics, disseminated gonococcal infection, gonococcal septic arthritis

32
Q

Screening for chlamydia

A

Offered to all patients aged 15-24

33
Q

Trichomonas vaginalis

  • what is it
  • features
  • diagnosis
  • treatment
  • trichomonas in pregnancy
A

Protozoa infection the vagina, urethra and paraurethral glands

Features: vaginal discharge (offensive yellow/green frothy), vulvovaginitis, strawberry cervix, pH >4.5, dysuria, dyspareunia

Diagnosis: high vaginal swab culture, direct observation of flagellates on a wet smear microscopy

Mx: metronidazole 2g oral stat, or metronidazole 400mg BD 5 days

Trichomonas in pregnancy: metronidazole not recommended in early pregnancy, and high dose metronidazole not recommended at all. If necessary, give a 5 day course in tri 1
Complications: PROM, low birth weight, maternal postpartum sepsis

34
Q

Gonorrhoea complications in pregnancy

A

Perinatal mortality, spontaneous abortion, prem labour, early foetal membrane rupture
Neonatal conjunctivitis

35
Q

Genital herpes

  • what is it
  • symptoms
  • diagnosis
  • management
  • complications
  • herpes in pregnancy
A

HSV type 1 or type 2. virus stays latent after primary infection and then may reactivate, causing infectious viral shedding

Symptoms: multiple painful small blisters around labia, dysuria, and vaginal discharge
Primary attack most severe: malaise, fever, anorexia, lymphadenopathy
Secondary attack: may occur during stress, less severe, may go unnoticed

Diagnosis: viral swab from base of lesion (rub to deroof lesion - painful)

Management: aciclovir 200mg 5 times a day for 5 days

Complications: urinary retention, aseptic meningitis, encephalitis

C-section at term if primary attack occurs during pregnancy after 28 weeks

36
Q

Genital warts

  • what is it
  • symptoms
  • examination
  • diagnosis
  • management
A

HPV 6 and 11.

Painless unsightly lesions on vagina, cervix, urethral meatus and anus

Examination: single or multiple irregular lesions (+/- bleeding, itching)

Diagnosis usually clinical (biopsy if pigmented)

Management:
First line is topical podophyllum or cryotherapy
Excision under LA/GA
Electrocautery or laser treatment

37
Q

Syphilis

  • what is it
  • classification
A

Treponema pallidum (spirochaete bacterium)

Primary: single painless indurated exudative genital ulcer (chancre) with regional lymphadenopathy

Secondary: 6-10wks later, malaise, fever, arthralgia, polymorphic rash, condylomata lata (wart plaques in moist areas), generalised lymphadenopathy

Tertiary: chronic granulomatous lesions of skin/bones, tabes dorsalis (charcot joint), argyll-robertson pupil, ascending aortic aneurysms, general paralysis

38
Q

Syphilis in pregnancy

Features of congenital syphilis

A

70-100% of babies form infected mothers will have congenital syphilis, with 30% resulting in still births, so treatment should be started ASAP

Congenital syphilis: <2yrs. Condylomata lata, saddle nose, deafness, keratitis

39
Q

Hep B in pregnancy

A

All women offered hep B screening
Babies born to infected women get hep B vaccines and hep B immunoglobulin

Not transmitted via breast feeding

40
Q

How to reduce transmission of HIV in pregnancy

A

Reduces vertical transmission fro 30% to 2%:

  • Maternal antiretroviral therapy during pregnancy
  • Caesarean section if notable viral load
  • Neonatal antiretroviral therapy
  • Bottle feeding (avoid breast feeding)

HIV screening in all pregnancy women

41
Q

Bacterial vaginosis

  • what is it
  • risk factors
  • features
  • diagnosis
  • management
A

Overgrowth of anaerobic Gardnerella vaginalis causes eradication of normal lactobacilli and increase in vaginal pH to up to 7 (normally <4.5)

Risk factors: smoking, IUD, black women, lots of sex

Features: asymptomatic, or offensive fishy smell, profuse thin white/creamy discharge

Diagnosis: Amsell’s criteria (3 of the 4 must be found): thin creamy discharge, clue cells at microscopy, sniff test (fishy when adding KOH), vaginal fluid pH>4.5

Management: oral metronidazole 400mg BD for 5 days, or 2g metronidazole stat
avoid vaginal douching, bath additives and soap

42
Q

Criteria for bacterial vaginosis

A 
Amsells criteria
3 out of 4 must be present for diagnosis
1. thin creamy discharge
2. clue cells at microscopy
3. sniff test (fishy odour when adding KOH)
4. vaginal fluid pH >4.5
43
Q

BV in pregnancy

A

Associated with increased mid-trimester loss, preterm prelabour ROM, preterm delivery and postnatal endometriosis

44
Q 
Vaginal thrush
-what is it
-risk factors
0features
-diagnosis
-management
A

Candida albicans fungus

Risk factors: DM, drugs (abx, steroids), pregnancy, immunosuppression (HIV, iatrogenic)

Features: asymptomatic, or itching, vulvitis, white lumpy cottage cheese discharge which doesnt smell, dysuria, superficial dyspareunia, vulval excoriation and inflammation, vaginal erythema

Diagnosis: microscopy showing spore and pseudohyphae

Mx: only indicated in symptomatic cases
Cotrimazole pessary, or oral itraconazole/fluconazole

Avoid tight fitted clothes, wear cotton, avoid irritants, live yoghurt

Obs and Gynae (3 decks)

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