GOSH Flashcards
Describe the UK cervical screening programme
Aged 25-49 –> every 3 years
Aged 50-64 –> every 5 years
Screening for gestational diabetes in women with risk factors?
OGTT at 24-28 weeks gestation
Screening for gestational diabetes in women who have previously had gestational diabetes?
OGTT immediately after booking and at 24-28 weeks if the first test is normal.
Give 6 reasons for taking high dose folic acid
1) Obesity (BMI ≥30)
2) Woman is taking antiepileptic drugs
3) Woman has coeliac disease
4) Woman has diabetes
5) Woman has thalassaemia trait
6) Either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
Why may uterine fibroids grow during pregnancy?
Due to increased oestrogen
Next steps if cervical smear results are HPV positive but normal cytology?
Repeat 12 months later.
If same again –> repeat 12 months later.
If same again –> refer for colposcopy
Next steps if cervical smear results are inadequate (i.e. inadequate sample)?
Repeat in 3 months
If still inadequate –> colposcopy
Mx if a woman with known placenta praevia goes into labour (with or without bleeding)?
Emergency c-section
Define blood loss in PPH
> 500ml after vaginal delivery
Mx of 1st degree perineal tears?
Usually no repair needed
Induction of labour if Bishop’s score is ≤6?
Vaginal prostaglandins or oral misoprostol
Mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
Induction of labour if Bishop’s score is >6?
Amniotomy and IV oxytocin
What is the main complication of induction of labour?
Uterine hyperstimulation
What is 1st line management of postpartum thyroiditis?
Propanolol –> The hyperthyroid phase should be treated with beta blockers and NOT antithyroid drugs.
What terminology is used to describe the head in relation to the ischial spine?
Station
Sex hormone binding globulin concentration in PCOS?
Low
Which hepatitis is routinely screened for during pregnancy?
Hep B
What is the Abx of choice for GBS prophylaxis?
Benzylpenicillin
What are the 3 main types of ovarian cancer?
1) Epithelial cell tumour
2) Germ cell tumour
3) Sex cord tumour
Typical presentation of a germ cell tumour?
1) Younger age (<30)
2) May have FH of ovarian cancer
3) Possible signs:
- precocious puberty
- symptoms of pregnancy
- abnormal vaginal bleeding
Give 2 examples of a germ cell tumour
1) Teratoma (called a dermoid cyst when occurs at birth)
2) Choriocarcinoma
What 3 tumour markers are produced by germ cell tumours?
1) AFP
2) B-HCG
3) LDH
What is a choriocarcinoma?
A rare germ cell tumor of trophoblastic cell.
The abnormal cells start in the tissue that would normally become the placenta.
Typical mx of a germ cell tumour?
Platinum based chemotherapy
Monitoring for recurrence (tumour markers + physical exam)
What condition are teratomas particularly associated with?
Ovarian torsion
Typical presentation of sex cord/stromal tumours of the ovary?
1) Reproductive age
2) May have symptoms of:
- abnormal vaginal discharge
- hirsutism
- virilisation
What may sex cord/stromal tumours of the ovaries produce?
Ovarian steroid hormone production (e.g., androgens, estrogens, and corticoids).
What tumour markers should be obtained in suspected sex cord/stromal ovarian tumour?
1) Inhibin A & B
2) AFP
3) Oestrogen
4) Testosterone
Give 2 types of sex cord tumour
1) Granulosa cell (most common)
2) Sertoli-Leydig cell
What is a krukenberg tumour?
Refers to a metastasis in the ovary, usually from a GI tract cancer, particularly the stomach.
what is the characteristic sign of a krukenberg tumour in histology?
‘signet ring’ sign
What are the 2 types of VIN (vulval intraepithelial neoplasia)?
1) High grade –> related to HPV, seen in younger patients
2) Differentiated –> related to lichen sclerosus, seen in older patients
Which type of VIN is related to HPV infection?
High grade
Which type of VIN is associated with lichen sclerosus?
Differentiated
What is required to diagnose VIN?
Biopsy
What contraceptive method should be avoided in Wilson’s?
Copper coil
What type of condoms can be used in latex allergy?
Polyurethane condoms
What can damage latex condoms?
Oil based lubricants (more likely t tear)
What must be used with a diaphragm or cervical cap?
Spermicide
How long must a cervical cap/diaphragm be left in place for after sex?
6 hours
What COCP is recommended first line? Why?
A pill with levonorgestrel or norethisterone first line (e.g. Microgynon or Leostrin).
These choices have a lower risk of venous thromboembolism.
COCPs containing what are considered first-line for premenstrual syndrome?
Why?
Drospirenone
Drospirenone has anti-mineralocorticoid and anti-androgen activity, and may help with symptoms of bloating, water retention and mood changes.
COCPs containing what are considered in the treatment of acne and hirsutism?
Why?
Cyproterone acetate (i.e. co-cyprindiol)
Cyproterone acetate has anti-androgen effects.
What is potential risk in COCPs with co-cyprindiol?
Increased risk of VTE (usually only used for 3 months).
What UKMEC is a BMI > 35 for the COCP?
UKMEC 3
When switching between COCPs, what should you do?
finish one pack, then immediately start the new pill pack without the pill-free period.
When switching from a traditional progesterone-only pill (POP) to COCP, do you require extra protection?
They can switch at any time but 7 days of extra contraception (i.e. condoms) is required.
Exception –> if POP contains desogestrel (can switch with no additional contraception).
This differs from a traditional POP because desogestrel inhibits ovulation.
When is a ‘missed pill’ for desogestrel POPs?
12 hours
When is a ‘missed pill’ for norethisterone and levonorgestrel POPs?
3 hours
What is the missed pill window for drospirenone POPs?
24 hours
How do drospirenone POPs work? How are they different?
Inhibits ovulation and is taken daily (similar to other POPs), however 4 pills out of a 28-day pack are hormone-free placebos to allow for a break
When switching from a COCP to POP, when can a woman start the POP immediately without additional contraception? (2)
1) Have taken the COCP consistently for >7 days
2) Are on days 1-2 of hormone-free period following a full pack of the COCP
Where in the body is the contraceptive injection typically given?
IM into buttocks
What is the main action of progesterone only injection?
Inhibits ovulation
Also:
1) Thickening cervical mucus
2) Thins endometrium
What 2 side effects are unique to the progesterone only injection?
1) Osteoporosis
2) Weight gain
What can be taking alongside the progesterone only injection for three months when problematic bleeding occurs to help settle the bleeding
COCP
Or a short course (5 days) of mefenamic acid to halt the bleeding.
Between what ages is Nexpanon (implant) licensed for use?
18-40 y/o
What is added to Nexplanon so that it can be seen on xrays?
Barium sulphate
What test is typically performed before insertion of a coil?
Screening for chlamydia and gonorrhoea in women at increased risk of STIs (e.g. under 25 years old)
When the coil threads cannot be seen or palpated, what is the 1st line investigation?
US
In what condition is the copper coil contraindicated?
Wilson’s disease
What are the 2 methods of female sterilisation
1) Tubal occlusion (using ‘Filshie clips’)
2) Salpingectomy
After female sterilisation, how long is alternative contraception required?
Required until the next menstrual period, as an ovum may have already reached the uterus during that cycle, ready for fertilisation.
After male sterilisation, how long is alternative contraception required?
Alternative contraception is required for two months after the procedure.
Testing of the semen to confirm the absence of sperm is necessary before it can be relied upon for contraception.
Semen testing is usually carried out around 12 weeks after the procedure, as it takes time for sperm that are still in the tubes to be cleared. A second semen analysis may be required for confirmation.
How does levonorgestrel work?
Prevents/delays ovulation
Is levonorgestrel hamrful to the pregnancy if pregnancy does occur?
No
Can the COCP or POP be started immediately after taking levonorgestrel?
Yes
Single dose of levonorgestrel given as emergency contraception?
1.5mg as a single dose
3mg as a single dose in women above 70kg or BMI above 26
How does ulipristal acetate work as an emergency contraception?
Ulipristal acetate is a selective progesterone receptor modulator (SERM) that works by delaying ovulation
Can the COCP or POP be started immediately after taking ulipristal acetate?
No
Must wait 5 days
What are 2 major contraindications with urlipristal acetate?
1) Severe asthma
2) Breastfeeding (milk should be expressed and discarded for 1 week)
How soon after unprotected sex should the copper coil be inserted?
Can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
Next steps if patient has missed 1 vs 2 COCPs in last week of packet?
1 –> take missed pill, no further action
2 –> take missed pill, omit pill free period
What BMI is a risk factor for pre-eclampsia?
> 30
What age is a risk factor for pre-eclampsia?
> 40 y/o
What pregnancy interval is a risk factor for pre-eclampsia?
> 10 years
What are women with PCOS at particular risk of when undergoing IVF?
Ovarian hyperstimulation syndrome
How long is aspirin indicated for in the prevention of pre-eclampsia?
From 12 weeks gestation until birth
When should you consider referral regarding weight loss in babies in first week of life?
Weight loss >10%
If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
Cone biopsy vs LLETZ for management of CIN II and III?
LLETZ is preferred
What is the preferred method of smoking cessation in pregnant women?
Nicotine replacement therapy
What is required following a medical termination of pregnancy?
Multi-level pregnancy test in 2 weeks
Quadruple test results in Edward’s syndrome?
Oestriol –> low
Inhibin A –> normal
AFP –> low
hCG –> low
What is the gold standard investigation in placenta praevia?
TV US
Is further investigation needed in a suspected galactocele?
No
Typical Mx of localised disease in endometrial cancer?
Hysterectomy and bilateral salpingo-oophorectomy with consideration of radiotherapy if high-risk
Typical mx of endometrial cancer for frail patients that are not fit for surgery?
progestogen therapy
What may an abdo exam reveal in uterine fibroids?
An enlarged, irregularly shaped uterus may be palpable. The uterus may feel firm and nodular.
What may a speculum exam reveal in uterine fibroids?
May show an enlarged cervix or visible fibroids protruding into the vagina.
There may also be signs of heavy menstrual bleeding.
What may a bimanual exam reveal in uterine fibroids?
Can confirm the presence of an enlarged, irregular uterus.
Individual fibroids may be palpable as firm, irregular masses separate from the ovary and distinct from the smooth contour of the uterus.
There may also be tenderness on palpation if the fibroids are degenerating or causing torsion of a pedunculated fibroid.
When may a test of cure be indicated in chlamydia? (3)
1) pregnancy
2) rectal cases
3) where symptoms persist
What are some potential pregnancy related complications of chlamydia?
1) Preterm birth
2) PROM
3) Low birth weight
4) Postpartum endometritis
5) Neonatal infection (conjunctivitis and pneumonia)
What are 2 key presentations of neonatal infection with chlamydia?
1) conjunctivitis
2) pneumonia
What is Lymphogranuloma venereum (LGV)?
A condition affecting the lymphoid tissue around the site of infection with chlamydia.
Most commonly presents in MSM (anal discharge and pain, or anyone presenting with rectal chlamydia).
What does N. gonorrhoeae infect?
Mucous membranes w/ columnar epithelium e.g. pharynx, rectum, vagina.
What class of Abx is ceftriaxone?
Cephalosporin
What class of Abx is ciprofloxacin?
Fluoroquinolone
What is disseminated gonococcal infection?
A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.
Features of disseminated gonococcal infection?
1) Various non-specific skin lesions
2) Polyarthralgia (joint aches and pains)
3) Migratory polyarthritis (arthritis that moves between joints)
4) Tenosynovitis
5) Systemic symptoms e.g. fever and fatigue
What is the incubation period of syphilis (i.e. time from inital infection to symptom presentation)?
Approx 21 days
What type of bacteria is Treponema pallidum?
A spirochete, a type of spiral-shaped bacteria.
Congenital syphilis (i.e., present from birth) can be broken down into two stages.
What are these?
1) early –> presents <2 years old
2) late –> presents >2 years old
Most will develop symptoms by five weeks.
What rash is almost pathognomonic for 2ary syphilis?
Widespread, non-pruritic maculopapular, involving palms and soles of feet.
When does 3ary syphilis occur?
> 2 years after initial infection
What are 3 key features of 3ary syphilis?
1) Neurosyphilis e.g. dementia, altered behaviour, headache, Argyll-Robertson pupil
2) Aortic aneurysms
3) Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
What is an Argyll-Robertson pupil?
It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
They are often irregularly shaped.
A specific finding in neurosyphilis.
What is an Argyll-Robertson pupil a specific finding in?
Neurosyphilis
What is the mainstay of diagnosis of syphilis?
serology (i.e. antibody testing)
N.B. following successful treatment, parts of the syphilis serology will remain positive (can be lifelong).
What 2 conditions can affect the interpretation of syphilis serology?
1) Pregnancy
2) Immunological medical conditions (e.g. SLE and HIV)
What is the window period for syphilis?
12 weeks
What is the window period for HIV?
4 weeks
Mx of syphilis?
Single dose of IM benzathine benzylpenicillin
Which sensory nerve ganglia is affected in cold sores?
Trigeminal nerve
Which sensory nerve ganglia is affected in genital herpes?
Sacral nerve
When is asymptomatic shedding (i.e. virus being shed when no symptoms are present) in HSV infection more common?
1) In first 12 months of infection
2) Where recurrent symptoms are present
When is HSV-1 normally contracted?
In childhood (before five years)
Give some features of HSV
Initial episode is often severe, and subsequent episodes are milder.
1) Cold sores
2) Genital sores
3) Neuropathic type pain (tingling, burning or shooting)
4) Flu-like symptoms (e.g. fatigue and headaches)
5) Dysuria
6) Inguinal lymphadenopathy
How is HSV infection diagnosed?
PCR swab of lesions
The lesion should be BURST and a swab taken from the BASE of the ulcer.
What is the main issue with genital herpes during pregnancy?
The risk of neonatal herpes simplex infection contracted during labour and delivery –> high morbidity and mortality
What is HSV keratitis?
dendritic lesion on the cornea
What is a herpetic whitlow?
a painful infection of the finger caused by the herpes virus.
What risk factor is known to increase the risk of genital wart recurrence?
Smoking
Mx of genital warts:
a) single keratinised wart
b) multiple non-keratinised warts
a) cryotherapy
b) topical podophyllum or topical imiquimod
What is a key complication of genital warts?
Ano-genital cancer
What type of organism is trichomonas vaginalis?
Parasite (protozoa)
Describe cervix that can be seen in trichomonas infection
‘Strawberry cervix’ –> inflammation & punctate haemorrhages over the vagina and cervix.
In what 2 gynae conditions is there a raised vaginal pH (>4.5)?
1) Bacterial vaginosis
2) Trichomonas vaginalis
1st line investigation in trichomonas?
Charcoal swab, taken from posterior fornix of vagina (i.e. behind the cervix).
Where is swab taken from in trichomonas?
Posterior fornix of vagina
What is a key feature of mycoplasma genitalium?
Urethritis
What is the gold standard investigation for mycoplasma genitalium?
NAAT swab
Women –> vulvovaginal
Men –> first catch urine
1st line management of uncomplicated Mycoplasma genitalium?
1) Doxycycline 7 days
followed by
2) Azithromycin 2 days
Management of complicated Mycoplasma genitalium?
Moxifloxacin (14 days)
What is the protein on the surface of HIV that binds to CD4+?
gp120
What CD4+ cell count is sufficient for a diagnosis of AIDS?
<200
Give 7 examples of AIDS-defining illnesses
1) PCP
2) TB
3) Kaposi’s sarcoma
4) CMV infection
5) Lymphomas
6) Candidiasis (oesophageal or bronchial)
7) Toxoplasmosis
What lymphoma is an AIDS-defining illness?
AIDS-related non-Hodgkin’s lymphoma
What 4 conditions may be seen in AIDS patients with CD4 count between 200-500?
1) oral thrush (candidiasis)
2) shingles (herpes zoster)
3) hairy leukoplakia (EBV)
4) Kaposi sarcoma (HHV-8)
What can EBV lead to in patients with HIV?
Hairy leukoplakia
Describe hairy leukoplakia
White plaques on the lateral tongue which do NOT wipe off.
What is the most common opportunistic infection in AIDS?
PCP
When should patients with HIV receive PCP prophylaxis?
CD4+ <200
What is a common complication of PCP?
Pneumothorax
What is a key dermatological complication of HIV?
Kaposi’s sarcoma
What is Kaposi’s sarcoma caused by?
HHV-8
How does Kaposi’s sarcoma present?
Purple papules or plaques on the skin or mucosa (e.g. GI and respiratory tract).
Lesions may later ulcerate.
Respiratory involvement may cause massive haemoptysis and pleural effusion
1st line management of Kaposi’s sarcoma?
Radiotherapy + resection
What is a key ocular complication in HIV?
CMV retinitis
How may CMV retinitis present?
Visual impairment eg. blurred vision
Characteristic appearance of CMV retinitis on fundoscopy?
Retinal haemorrhages and necrosis
1st line management of CMV retinitis?
IV ganciclovir
What are 2 key neurological complications of HIV?
1) Toxoplasmosis (accounts for around 50% of cerebral lesions in patients with HIV)
2) Primary CNS lymphoma
Symptoms of cerebral toxoplasmosis?
- constitutional symptoms
- headache
- confusion
- drowsiness
1st line management of cerebral toxoplasmosis?
sulfadiazine and pyrimethamine
What infection is primary CNS lymphoma in HIV patients associated with?
EBV infection
What is the regimen of choice of ART?
1) A backbone of two nucleoside reverse transcriptase inhibitors (NRTIs) e.g. tenofovir disoproxil plus emtricitabine
Combined with either;
2) An integrase inhibitor (e.g. bictegravir) or;
3) A non-nucleoside reverse transcriptase inhibitor or;
4) A boosted protease inhibitor
What are the 2 aims of ART therapy in HIV?
1) Achieve normal CD4+ count
2) Viral load undetectable
What is PrEP a combination of?
Emtricitabine + tenofovir disoproxil (both NRTIs)
How does viral load affect mode of delivery for pregnant women?
<50: normal vaginal birth
> 50: c-section considered
> 400: c-section recommended
What is given as an infusion during labour and delivery if the HIV viral load is unknown or above 1000 copies/ml?
IV zidovudine (ART)
What is it important to counsel new mothers with HIV about?
Avoid breastfeeding
Can still be passed to newborn even if viral load is low.
What does standard STI screening consist of?
1) NAAT –> Chlamydia & gonorrhoea
2) Serology –> HIV & syphilis
What is the tailored STI screen for MSM?
Standard STI screen
+
3 site testing for chlamydia & gonorrhoea (NAAT): urine, rectum & pharynx.
What is Fitz-Hugh-Curtis syndrome?
A chronic manifestation of PID.
Inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation.
Causes RUQ pain.
When is a test of cure for gonorrhoea recommended?
Pregnancy
What are 3 complications of gonorrhoea in males?
1) epididymo-orchitis
2) proctitis
3) disseminated gonorrhoea
What are the 2 most common causes of non-gonococcal urethritis?
1) Chlamydia
2) Mycoplasma genitalium
What symptom typically accompanies a chancre?
Local lymphadenopathy
