GOSH 2 Flashcards
What is the 1st line investigation in post-menopausal bleeding?
TV US to look at endometrial thickness –> pipelle biopsy to sample endometrium (can be used to diagnose endometrial cancer in most cases).
What is the next investigation if a pipelle biopsy has been inconclusive when investigating endometrial cancer?
Hysteroscopy with biopsy
Mx of obstetric cholestasis?
Induction of labour at 37-38 weeks (due to increased risk of stillbirth)
Mx of Factor V Leiden in pregnancy?
LMWH antenatally + 6 weeks postpartum
What can be used in management of endometriosis if NSAIDs/COCP/progestogens have not been effective?
GnRH analogues (pseudo-menopause)
Define premature ovarian failure
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
2x samples of FSH required
Give some causes of oligohydramnios
1) PROM
2) Potter sequence: bilateral renal agenesis + pulmonary hypoplasia
3) IUGR
4) Post-term gestation
5) Pre-eclampsia
In a very athletic woman, what causes 2ary amenorrhoea?
Hypothalamic hypogonadism
Is diabetes a high risk factor for pre-eclampsia?
Yes
Are women with autoimmune conditions such as SLE or antiphospholipid syndrome at high risk of pre-eclampsia?
Yes
What are some normal lab findings in pregnancy?
1) reduced urea
2) reduced creatinine
3) increased urinary protein loss
This is due to increased perfusion to the kidneys in pregnancy.
Is aspirin safe in breastfeeding?
No - risk of Reye’s
How long can a urine pregnancy test remain positive following termination?
Up to 4 weeks
Why is COCP contraindicated 21 days post partum?
Increased VTE risk
What is a history of sudden collapse occurring soon after a rupture of membranes suggestive of?
Amniotic fluid embolism
Next step if suspicion of ovarian cancer but there IS an abdominal or pelvic mass?
CA125 and US test can be bypassed and the patient directly referred to gynaecology
Mx of GBS colonisation in pregnancy?
Intrapartum IV benzylpenicillin
What is the gold standard investigation for mycoplasma genitalium?
NAATs
What are 3 key features of 3ary syphilis?
1) Neurosyphilis e.g. labile mood, confusion, delusions, seizures, judgement impairment
2) Aortic aneurysms
3) Gummatous lesions
What is Argyll-Robertson pupil? What is it found in?
A specific finding in neurosyphilis.
It is a CONSTRICTED pupil that accomodates when focusing on a neear objct but does not react to light.
What can increase the risk of genital wart recurrence?
Smoking
1st line management of uncomplicated Mycoplasma genitalium?
Doxycycline for 7 days
Followed by azithromycin for 2 days
Management of complicated Mycoplasma genitalium?
Moxifloxacin 400mg daily for 14 days
What is the protein on the surface of HIV that binds to CD4+?
gp120
What is PrEP a combination of?
2x NRTIs
Emtricitabine + tenofovir disoproxil
Which form of contraception can increase the risk of BV?
Copper IUD
What criteria can be used for the diagnosis of BV?
Amsel criteria
What makes up the Amsel criteria? (4)
1) Homogenous discharge on examination
2) Microscopy showing ‘clue cells’
3) Vaginal pH >4.5
4) Fishy odour on adding 10% potassium hydroxide to vaginal fluid
Describe the ‘whiff test’
Presence of an amine odour when POTASSIUM HYDROXIDE is added to vaginal fluid.
What does a positive Whiff test indicate?
BV
What are the main component of the healthy vaginal bacterial flora?
Lactobacilli
Which form of contraception may be PROTECTIVE against BV?
COCP
What criteria can be used to grade the appearance of vaginal flora?
Hay/Ison Criteria
What are the 4 gradings of the Hay/Ison Criteria?
Grade I (normal) –> Lactobacilli predominate
Grade II (intermediate) –> Mixed flora with some lactobacilli but Gardnerella or Mobiluncus also present
Grade III (BV) –> Predominantly Gardnerella and/or Mobiluncus. Few or absent lactobacilli.
Grave IV –> Gram-positive bacteria predominate
What does the Hay/Ison criteria take into account?
The microscopic appearance of gram-stained vaginal smear.
What 2 criteria can be used in the diagnosis of BV?
1) Hay/Ison criteria
2) Amsel criteria
How many of the Amsel criteria must be met to diagnose BV?
3/4
What are 3 possible investigations in BV?
1) Whiff test
2) Vaginal pH test (using swab & pH paper)
3) Charcoal vaginal swab
What is a key complication of BV?
At higher risk of acquiring and transmitting STIs.
What is the main complication of BV during pregnancy?
1st trimester miscarriage
How do lactobacili keep the vaginal pH low?
By producing lactic acid
What investigation can confirm the diagnosis of candidiasis?
Charcoal swab
Are routine investigations are not typically required for acute, uncomplicated vulvovaginal candidiasis cases?
No
Medical treatment is recommended for certain groups of individuals with BV.
What are these groups?
1) Anyone with symptoms
2) Any pregnant individuals (regardless of choice in continuation of pregnancy)
What defines recurrent vulvovaginal candidiasis?
≥4 episodes in 1 year
With at least 2 episodes confirmed by microscopy or culture when symptomatic.
What are ‘clue cells’?
Epithelial cells from cervix with bacteria stuck inside (typically Gardnerella vaginalis).
Key contraindication of oral antifungal tablets (e.g. fluconazole) for candidiasis?
pregnancy & breastfeeding
Increased levels of which hormone can increase the risk of candidiasis?
Oestrogen e.g. higher in pregnancy
Lower after menopause so risk is lower
When are antibiotics started in PID?
Empirically
Give 4 risk factors for candidiasis
1) Immunosuppression e.g. steroids, HIV
2) Higher oestrogen e.g. pregnancy
3) Poorly controlled diabetes
4) Broad spectrum Abx
What is Fitz-Hugh-Curtis Syndrome?
A complication of PID.
It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
How long are symptoms present for in bladder pain syndrome (AKA interstitial cystitis)?
> 6 weeks
What organs of the pelvis are affected in PID?
Endometritis –> endometrium
Salpingitis –> fallopian tubes
Parametritis –> parametrium
Oophoritis –> ovaries
Peritonitis –> peritoneal membrane
Typical outpatient Abx regime in PID?
1) Single IM dose of ceftriazone
2) Oral doxycyline 14 days (to cover chlamydia & mycoplasma genitalium)
3) Oral metronidazole 14 days (to cover anaerobes e.g. Gardnerella)
What should you always look for signs of in PID?
SEPSIS
In which cases of PID require admission for IV Abx? (2)
1) Sepsis
2) Pregnancy
What can be seen during cytoscopy in interstitial nephritis (in approx 20% of patients)?
1) Hunner lesions –> red, inflamed patches of the bladder mucosa associated with small blood vessels
2) Granulations –> tiny haemorrhages on the bladder wall
What is hydrodistension?
Purpose of it in interstitial nephritis?
Filling the bladder with water, to high pressure, during cystoscopy (requires GA).
This can give a temporary (3-6 month) improvement in symptoms.
PID can less commonly be caused by non-STIs, such as what?
(3)
1) Gardnerella vaginalis
2) H. influenzae
3) E. coli
Complications of PID?
1) Sepsis
2) Abscess
3) Infertility
4) Increased risk of ectopic
5) Fitz-Hugh-Curtis syndrome
6) Chronic pelvic pain
In patients presenting with urinary incontinence, what is it important to rule out? (2)
1) UTI
2) Diabetes
Get urinalysis
What age prematurity does retinopathy of prematurity affect?
<32 weeks gestation
What steroid is used to educe the chance of RDS in PROM?
Dexamethasone
What investigations may be required in recurrent candidiasis?
1) check compliance with previous treatment
2) confirm diagnosis: high vaginal swab (charcoal) for microscopy and culture
3) blood glucose test/HbA1c to exclude diabetes
4) exclude differential diagnoses such as lichen sclerosus
Are progestogen-only methods of contraception safe to use alongside sequential HRT?
Yes
What is the classic triad of vasa praevia?
1) Rupture of membranes
2) Painless vaginal bleeding
3) Foetal bradycardia
Maternal risk in vasa praevia vs placenta praevia?
Vasa praevia - no major maternal risk
Placenta praevia - materanl risk
Typical features of hydatidiform mole?
- May have bleeding in 1st or early 2nd trimester
- Associated with exaggerated symptoms of pregnancy e.g. hyperemesis.
- Uterus may be large for dates
- Serum hCG is very high
What Bishop’s score indicates that the cervix is ripe, or ‘favourable’?
≥8
What intervention should be performed in a Bishop’s score ≥8?
No interventions required
There is a high chance of spontaneous labour.
What does a Bishop’s score <5 indicate?
Indicates that labour is unlikely to progress without induction.
What is the preferred method of induction in a Bishop’s score <5?
Vaginal prostaglandin E2
What is the preferred method of induction in a Bishop’s score >6?
Amniotomy & IV oxytocin infusion
Describe the Bishop’s score
Cervical position:
- posterior (0)
- intermediate (1)
- anterior (2)
Cervical dilation:
- <1cm (0)
- 1-2cm (1)
- 3-4cm (2)
- >5cm (3)
Cervical consistency:
- firm (0)
- intermediate (1)
- soft (2)
Cervical effacement:
- 0-30% (0)
- 40-50% (1)
- 60-70% (2)
- 80% (3)
Foetal station:
- -3 (0)
- -2 (1)
- -1, 0 (2)
- +1, +2 (3)
What is the 1st line management of N&V in pregnancy/hyperemesis gravidarum?
Antihistamines e.g. oral cyclizine or promethazine
What is the 2nd line management of N&V in pregnancy/hyperemesis gravidarum?
1) Oral ondansetron
2) Oral metoclopramide or domperidone
What is there an increased risk of with use of ondansetron during pregnancy?
Cleft lip/palate
Why is metoclopramide not used for >5 days in pregnancy?
Can cause EPSEs
Fibroids under what size can be treated with medical management?
<3cm
When should post-term women be offered induction?
Women should be offered induction between 41-42 weeks of an uncomplicated pregnancy to avoid risks of prolonged pregnancy.
Stepwise investigations in reduced foetal movements?
1) Handheld doppler
2) If no foetal heartbeat detected –> immediate US
3) If foetal heartbeat present –> CTG for at least 20 minutes
To confirm ovulation, when should the serum progesterone level be taken?
7 days prior to expected next period
What conditions are associated with a raised maternal AFP? (3)
1) Neural tube defects (meningocele, myelomeningocele and anencephaly)
2) Abdominal wall defects (omphalocele and gastroschisis)
3) Multiple pregnancy
What conditions are associated with a decreased maternal AFP? (4)
1) Down’s syndrome
2) Maternal diabetes
3) Trisomy 18 (Edward’s)
4) Maternal diabetes mellitus
How does materal diabetes affect AFP?
Reduced AFP
Pregnant women with what BP are likely to be admitted and observed?
≥160/110 mmHg
Define gestational HTN
HTN >20/52
Define pre-eclampsia
Gestational HTN + proteinuria OR organ dysfunction
Mx of eclampsia?
Magnesium sulphate IV bolus
Treat for 24h after last seizure or 24h after delivery (whichever is later)
What can be given alongside Mg sulphate in eclampsia if it causes respiratory depression?
Calcium gluconate
Define eclampsia
Pre-eclampsia + seizures
Mx of HELLP syndrome?
Deliver the baby
3 key risk factors for placental abruption?
1) Pre-eclampsia
2) Cocaine use
3) Multiparity
Definitive mx of placental abruption?
Category 1 C-section
Colour of blood in placental abruption vs placenta praevia?
Abruption - dark red and less of it visible (blood has to travel further)
Praevia - lighter red and more of it visible (blood has less far to travel)
Define PPH
> 500ml blood loss
What are the 4 causes of PPH?
1) Tone (80%) i.e. uterine atony
2) Tissue i.e. retention of placental tissue which prevents contractions
3) Trauma e.g. vaginal or cervical tears
4) Thrombin
What are some risk factors for uterine atony causing PPH?
1) Overworked uterus: Age, BMI, multiple parity
2) Chorioamnionitis
3) Polyhydramnios
Time period for 1ary PPH?
<24h after delivery
Time period for 2ary PPH?
24h to 6 weeks after delivery
Stepwise mx of PPH caused by uterine atony?
1st line –> bimanual compression (palpating and rubbing fundus to stimulate contractions) & catheterise
2nd line –> pharmacological: IV oxytocin, IV or IM ergometrine, IM carboprost, sublingual misoprostol
3rd line –> intrauterine balloon tamponade
What is key preventative method of PPH?
Active mx of 3rd stage of labour –> IM oxytocin for vaginal and IM tranexamic for C-section
In PPH, what position should women be placed in?
Left lateral position
What are the 2 key risk factors for cord prolapse?
1) Artifical rupture of membranes (50% of cases happen after this)
2) Abnormal lie (breech, unstable)
Why should there be minimal handling of cord in cord prolapse?
Due to risk of vasospasms
Keep the cord warm and moist
Mx options in cord prolapse?
1) Left lateral position or on all fours
2) Minimal handling of cord, keep it warm and moist
3) Presenting part of foetus can be pushed back to avoid cord compression
4) Can fill bladder with 500ml normal saline
5) Tocolytics e.g. terbutaline (to reduce contractions)
6) Definitive mx: c-section
What is the definitive mx of cord prolapse?
C-section
Define shoulder dystocia
After delivery of the foetal head, the ANTERIOR shoulder of the foetus becomes impacted on the PUBIC SYMPHYSIS.
2 key complications of shoulder dystocia?
1) Brachial plexus injury
2) 3rd/4th degree tear
Some ffeatures of Erb’s palsy?
1) Forward rotated shoulder
2) Upper arm redness
3) Muscle atrophy and diminished arm length
4) Waiter tip deformity of wrist
5) Winged scapula
6) Horner’s: ptosis & miosis
2 best SSRIs in breastfeeding?
Paroxetine & sertraline
peak incidence of puerperal psychosis?
2-3 weeks post birth
What tool is used for postnatal depression?
Edinburgh postnatal depression scale?
Mx of puerperal psychosis?
Admit to mother & baby unit!
Is the nexplanon implant affected by enzyme inducers?
Yes
Most common type of ovarian cancer?
Serous cystadenocarcinoma
What infection is implicated in the pathogenesis of Burkitt’s lymphoma?
EBV infection
Microscopy findings in Burkitt’s lymphoma?
‘starry sky’ appearance: lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells
Management of lichen sclerosis?
Potent topical steroid e.g. dermovate
What is the most common infective cause of diarrhoea in HIV patients?
Cryptosporidium
What lobe does HSV encephalitis typically affect?
Temporal lobe (e.g. may have symptoms such as aphasia or rising feeling in stomach before seizure).
What is the mainstay of treatment of Cryptosporidium diarrhoea?
Supportive
Give some causes of erythema nodosum
(4)
1) TB
2) Sarcoidosis
3) IBD
4) Pregnancy
1st line investigation in suspected ovarian cancer?
Ca125
At what BMI should the standard dose of levonorgestrel (1.5mg) be doubled?
BMI >26 (or weight >70kg)
1st line investigation to look for source of infection in discitis due to Staphylococcus?
Echocardiogram
If not breastfeeding, how soon after birth can the COCP be prescribed?
3 weeks (due to increased VTE risk)
Is the Depo-Provera injection affected by enzyme inducers?
No
What is UKMEC for COCP for patients in wheelchair?
3
Triad of features of disseminated gonococcal infection?
1) Dermatitis
2) Migratory polyarthritis
3) Tenosynovitis
What endometrial thickness is a high negative predictive value for endometrial cancer in PMB?
<4mm
What is a rare but recognised side effect of lamotrigine?
Steven Johnson syndrome –> look out for a rash
Which contraceptive method (aside from coils) is not affected by enzyme inducers/inhibitors?
Depot injection
How soon after surgery can the COCP be restarted?
2 weeks
In early pregnancy, what type of ovarian cysts are common?
Corpus luteum cysts.
What is required for diagnosis of premature ovarian insufficiency?
1) <40 y/o
2) 2x raised FSH levels taken 4 weeks apart
What should all men presenting with ED have checked?
Morning testosterone
What investigation may be done in cryptosporidium infection?
Modified Ziehl-Neelsen stain (acid-fast stain) of the stool –> will reveal characteristic RED cysts of Cryptosporidium.
What score can be used to classify the severity of N&V in pregnancy?
The Pregnancy-Unique Quantification of Emesis (PUQE) score
COCP containing what can be beneficial for PMS?
Drosperinone
At what age should a woman with PMB be referred under the 2ww pathway?
≥55 y/o
1st line investigation in PMB?
TV US to look at endometrial thickness
What is next investigation in PMB if endometrial thickness is ≥4mm?
Hysteroscopy with endometrial biopsy
What is next investigation in PMB if endometrial thickness is <4mm?
High negative predictive value
What drug can lead to false negative results on the urea breath test?
Abx used to treat H. pylori e.g. amoxicillin
Recommended that patients haven’t taken Abx for 4 weeks prior to test.
What triad is seen in PCOS?
1) Polycystic ovaries
2) Hyperandrogenism
3) Oligo/anovulation
Only 2/3 required to be present for a diagnosis.
What criteria is used to diagnose PCOS?
Rotterdam criteria
What is the most common symptom of PCOS?
Hirsutism
How are insulin and androgens related?
Insulin promotes release of androgens from ovaries & adrenal glands.
Insulin also suppresses SHBG production by liver. SHBG usually binds to androgens and suppresses their function.
Via what 3 mechanisms is there hyperandrogenism in PCOS?
1) Elevated LH levels
2) High insulin promoting release of androgens
3) High insulin suppressing SHBG production by liver
Where is sex hormone binding globulin (SHBG) usually produced?
Liver
What is impact of SHBG on androgens?
Normally binds to androgens and SUPPRESSES their function.
What is the leading environmental contributor in PCOS?
Post-natal obesity
What is the role of SHBG in women?
Serves to LIMIT exposure to both androgens and oestrogens.
Low SHBG levels in women have been associated with HYPERANDROGENISM and ENDOMETRIAL CANCER due to heightened exposure to androgens and estrogens, respectively.
What are 4 key differentials for PCOS?
1) Congenital adrenal hyperplasia
2) Hypothyroidism
3) Cushing’s syndrome
4) Hyperprolactinaemia
How will LH be affected in PCOS?
Raised
Cause of cysts in PCOS?
Elevated baseline LH level –> lack of LH surge
How may Cushing’s syndrome present similarly to PCOS?
Excess cortisol production, leading to many features similar to PCOS (e.g. weight gain, acne, hypertension, insulin resistance).
How may CAH present similarly to PCOS?
Causes cortisol deficiency and may also lead to androgen excess, leading to a clinical picture indistinguishable from that of PCOS.
How can hyperprolactinaemia present similarly to PCOS?
Amenorrhoea
What 2 mechanisms can lead to excess androgen production in PCOS?
1) Elevated LH level
2) Insulin resistance & hyperinsulinaemia
Gold standard investigation for visualising the ovaries?
TV US
What is the screening test of choice for diabetes in patients with PCOS?
OGTT
What glucose level implies an IMPAIRED fasting glucose?
6.1-6.9
Women with PCOS that become pregnant require screening for what?
Gestational diabetes
What is the initial step for improving fertility in PCOS?
Weight loss
What endometrial thickness needs a referral to exclude endometrial hyperplasia or cancer in PCOS?
> 10mm
Why can PCOS increase risk of endometrial cancer?
1) Women with PCOS do not ovulate (or ovulate infrequently),
2) Therefore do not produce sufficient progesterone due to no corpus luteum
3) They continue to produce oestrogen and do not experience regular menstruation.
4) Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation.
5) Endometrial hyperplasia and significant risk of endometrial cancer
How will LH to FSH ratio be affected in PCOS?
Raised LH:FSH
Diagnostic criteria for PCOS from pelvic US?
1) ≥12 follicles on one ovary on US
OR
2) Ovarian volume >10 cm3
What can be used to treat facial hirsutism in PCOS?
Topical eflornithine
What OGTT result implies an impaired glucose tolerance?
Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
What is licensed for the treatment of hirsutism and acne in PCOS?
Co-cyprindiol (Dianette) –> COCP
What guides the management of simple ovarian cysts?
their size
How long is co-cyprindiol (Dianette) taken for in PCOS?
Only 3 months (due to VTE risk)
Premenopausal women with a simple ovarian cyst less than what size do not need further investigations?
<5cm on US
What tumour markers are required for women under 40 with a complex ovarian mass?
(3)
1) AFP
2) HCG
3) LDH
What size ovarian masses typically cause ovarian torsion?
> 5cm
Definitive diagnosis of ovarian torsion?
Laparoscopic surgery
How are 5-7cm ovarian cysts managed?
routine referral to gynae, yearly US
Give 2 types of sex cord-stromal tumours?
1) Sertoli-Leydig
2) Granulosa cell
At what age should pelvic US not be used for the diagnosis of PCOS?
In those with a gynaecological age <8 years (i.e. <8 years post-menarche) due to high incidence of multi-follicular ovaries in this life stage.
When is ovarian torsion most likely to occur?
During pregnancy
How are cysts in postmenopausal women managed?
Get Ca125
If raised –> 2ww referral
What type of ovarian cyst can become huge, taking up lots of space in the pelvis and abdomen?
Mucinous cystadenoma
Is ovarian torsion more common with benign or malignant cysts?
BENIGN
When can ovarian torsion occur with NORMAL ovaries (i.e. no tumour)?
Why?
Before menarche
Girls have longer infundibulopelvic ligaments that can twist more easily.
What are the 2 first line bisphosphonate treatments in osteoporosis?
1) Alendronate
2) Risedronate
What should be corrected before starting bisphosphonates?
Hypocalcemia/vitamin D deficiency
