GOSH 3 Flashcards
How soon before urodynamic tests should patients stop taking any anticholinergic and bladder related medications?
5 days before
What investigation measures the detrusor muscle contraction and pressure?
Cystometry
I.e. cystometry measures the contractile force of the bladder when voiding
What outcome measures are taken in urodynamic tests?
(4)
1) Cystometry –> detrusor muscle contraction
2) Uroflowmetry –> flow rate
3) Post-voidal bladder volume –> incomplete emptying (w/ bladder scan)
4) Leak point pressure
What happens in urodynamic tests?
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison.
The bladder is filled with liquid, and various outcome measures are taken.
How long must pelvic floor exercises be done before considering surgery in stress incontinence?
3 months (and must be supervised)
Stepwise management of urge incontinence (and overactive bladder)?
1) Bladder retraining
2) Anticholinergics e.g. oxybutynin, solfenacin
3) Mirabegron
4) Surgery e.g. botulinum toxin injection
What is an alternative to anticholinergic medications used in urge incontinence?
Mirabegron
What must be monitired regularly during treatment with mirabegron?
BP (can cause HTN)
What type of incontinence can Botulinum injection be used in?
Urge incontinence
What is leak point pressure?
The point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities.
This assesses for stress incontinence.
How are the strength of the pelvic muscle contractions graded?
Oxford grading system
What system is used to grade uterine prolapses?
Pelvic organ prolapse quantification (POP-Q)
What is the most important investigation in bleeding in the 1st trimester?
TV US
Describe the 4 stages of ovarian cancer
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
What is the treatment of choice for stage I and II endometrial carcinoma?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
What is the cut off for Hb levels for for oral iron therapy in pregnancy:
a) 1st trimester
b) 2nd/3rd trimester
c) postpartum
a) <110 g/L
b) <105 g/L
cc) <100 g/L
How long should treatment of anaemia with oral ferrous sulphate be continued for after iron deficiency is corrected?
3 months, to allow iron stores to be replenished
When can a miscarriage be confirmed on an US? (2)
No cardiac activity PLUS:
1) Crown rump length is >7mm
OR
2) Gestational sac is >25mm
What is hCG secreted by in pregnancy?
The syncytiotrophoblasts
Is cervical screening indicated for lesbians/bisexual women?
Yes - as HPV can be transmitted during genital contact or oral sex.
What is the treatment for vaginal vault prolapse?
Sacrocolpoplexy –> this procedure suspends the vaginal apex to the sacral promontory.
How long does the implant take to become effective?
7 days (unless inserted on day 1-5 of cycle)
How long does the IUS take to become effective?
7 days
Why should cooked liver or pate be avoided in pregnancy?
Due to vitamin A
When should women with uncomplicated, multiple pregnancies avoid flying?
Once >32 weeks
How many years from start of puberty do menstrual periods typically begin?
2 years
At what age is 1ary amenorrhoea defined where there are other signs of puberty, such as breast bud development?
15 y/o
Inheritance of congenital adrenal hyperplasia?
Autosomal recessive
At what age is 1ary amenorrhoea defined when there is NO other evidence of pubertal development?
13 y/o
Which hormones are OVERPRODUCED in congenital adrenal hyperplasia?
Androgen
What 2 features are seen in Kallman syndrome?
1) delayed puberty
2) anosmia
What hormonal blood tests can be done in 1ary amenorrhoea?
1) FSH/LH
2) Testosterone
3) IGF-1
4) prolactin
5) TFTs
Is Kallman syndrome associated with hypo- or hypergonadotrophic hypogonadism?
Hypo
In milder cases, when will congenital adrenal hyperplasia present?
What symptoms?
Female patients can present later in childhood or at puberty with typical features:
- tall for age
- deep voice
- hirsutism
- 1ary amenorrhoea
- early puberty
How does hyperprolactinaemia cause amenorrhoea?
Raised prolactin PREVENTS release of GnRH which prevents the release of LH/FSH.
define 2ary amenorrhoea
no menstruation for more than 3 months after previous regular menstrual periods
What does a raised testosterone in amenorhoea indicate?
(3)
1) PCOS
2) Androgen insensitivity syndrome
3) Congenital adrenal hyperplasia
Tests in 2ary amenorrhoea?
1) hCG (rule out pregnancy)
2) LH:FSH ratio
3) TFTs
4) Prolactin level
5) Testosterone
What can be used to stimulate a withdrawal bleed in women with PCOS?
(2)
1) Regular use of COCP
2) Medroxyprogesterone for 14 days
In severe cases of congenital adrenal hyperplasia, how will the neonate present?
Neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia.
When do women with amenorrhoea require management to reduce risk of osteoporosis?
> 12 months
What is premenstrual dysphoric disorder
Severe PMS –> impact on quality of life
What type of fibroids require a hysteroscopy to look at?
Submucosal
COCPs containing what are recommended 1st line in PMS?
Drosperinone (antimineralocorticoid)
How much blood do women lose (on average) during menstruation?
40ml
What can be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating?
Spironolactone
Imaging in possible Kallman syndrome?
MRI –> assess for olfactory bulbs
What ml is defined as exessive menstrual blood loss?
> 80ml
What can be given for cyclical breast pain in PMS?
(2)
1) Danazole
2) Tamoxifen
These will be given under specialist guidance.
What dose of folic acid is required in pregnancy in pre-existing diabetes?
folic acid 5 mg/day from pre-conception to 12 weeks gestation
Mx of a suspected PE in a pregnant woman with a confirmed DVT?
Treat with LMWH immediately
Then get a CTPA to rule in/out
When should absent foetal movements be referred?
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
What is acute fatty liver of pregnancy?
A rare complication which may occur in the 3rd trimester or the period immediately following delivery.
Features of acute fatty liver of pregnancy?
- abdominal pain
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre-eclampsia
Mx of ovarian tumours which are stage 2-4?
Treated primarily by surgical excision of the tumour.
Mx of pregnant women who are <6 weeks gestation and present with vaginal bleeding and no pain?
Manage expectantly, advise to repeat pregnancy test in 7 days.
If negative - confirm miscarriage
If positive, or continued or worsening symptoms - refer to early pregnancy assessment unit.
What type of anaemia can phenytoin cause?
Macrocytic, megaloblastic (due to folic acid deficiency)
Mx of all patients with 2ary dysmenorrhoea?
All patients with 2ary dysmenorrhoea need to be referred to gynaecology for investigation
When should a category 2 c-section occur?
Within 75 minutes of making the decision
What is the most important investigation in bleeding in the 1st trimester?
TV US
When should you only expect the fundal height to increase by 1cm a week?
After 24 weeks gestation
The ABSENCE of what on a swab from the vagina or endocervix EXCLUDES a diagnosis of PID?
Pus cells
The rupture of what type of cyst can cause pseudomyxoma peritonei?
Mucinous cystadenoma
What is pseudomyxoma peritonei?
When a mucinous cystadenoma ruptures, it can cause a build up of mucin (a jelly-like substance) in the abdomen and pelvis, giving rise to the name “jelly belly”.
What are the 2 types of benign epithelial tumour ovarian cysts?
1) Serous cystadenoma
2) Mucinous cystadenoma
define an ‘early’ and a ‘late’ miscarriage
‘early’: <13 weeks gestation
‘late’: 13-24 weeks
Define ‘recurrent’ miscarriage
3 or more
Give the 5 criteria for ‘medical’ management of an ectopic?
1) hCG <1500
2) No foetal heartbeat
3) unruptured
4) no significant pain
5) <35mm
1st line medical management of miscarriage?
Vaginal misoprostol
What is the minimum hCG level at which an intrauterine pregnancy should be visible on transvaginal ultrasonography?
1500-2000
What type of ovarian cyst is ovarian torsion most likely?
Dermoid cyst (teratoma)
What should you ALWAYS do with complex (i.e. multi-loculated) ovarian cysts?
Biopsy to exclude malignancy
What is an incomplete miscarriage?
When is it more likely to occur?
What: the gestation sac ruptures and the fetus is then expelled while parts of the placenta remain in the uterus.
When: between 12-24 weeks (as placenta developing)
What is the most common type of ovarian malignancy?
Serous cystadenoma
What % of women who undergo a salpingotomy for an ectopic require further treatment (methotrexate and/or a salpingectomy)?
20%
Management of Fitz-Hugh-Curtis syndrome?
Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
When is a complete miscarriage more likely to occur?
<12 weeks gestation (as placenta not developed)
What type of physiological cyst is more likely to present with intraperitoneal bleeding?
Corpus luteum cyst
What is the most common benign ovarian tumour in woman under the age of 30 years?
Dermoid cyst (germ cell)
What uterine conditons can cause a miscarriage?
(3)
- bicornuate
- septate
- arcuate
What type of ovarian cyst are typically large and may become massive?
Mucinous cystadenoma (epithelial)
What is the risk of miscarriage in women aged ≥45?
93%
How can pyelonephritis affect pregnancy?
Can cause preterm labour
What are the key causes of a neurogenic bladder? (6)
1) MS
2) Spinal cord injury
3) Diabetes
4) Stroke / brain injury
5) Parkinson’s
6) Spina bifida
Interaction between LH and insulin?
Raised LH increases insulin resistance
What cells does LH act on in males?
Leydig cells to produce testosterone.
What are the 3 groups of disorders of ovulation causing infertility?
Group I - hypogonadotrophic hypogonadism i.e. problem with the pituitary or hypothalamus e.g. Sheehan’s, low BMI
Group II - PCOS
Group III - hypergonadotrophic hypogonadism i.e. primary ovarian failure
What is the pathway in sperm development?
1) GnRH released from hypothalamus
2) LH and FSH released from anterior pituitary
3) LH acts on Leydig cells to secrete testosterone
4) Testosterone acts on Sertoli cells to produce sperm
What type of infertility can a variocele cause?
Non-obstructive –> associated with impaired testicular function and infertility
Give 3 genetic causes of non-obstructive azoospermia
1) Klinefelter’s syndrome
2) Kallman syndrome
3) Androgen insensitivity syndrome
What is the most common genetic disorder associated with infertility?
Klinefelter’s syndrome (47, XXY)
Testes in Fragile X syndrome vs Klinefelter’s syndrome?
Fragile X - macroorchidism
Klinefelter’s - small testes
What is Kallman syndrome?
A cause of delayed puberty 2ary to hypogonadotropic hypogonadism.
Features:
- delayed puberty
- hypogonadism, cryptorchidism
- anosmia
- sex hormones a re low
- LH, FSH levels are inappropriately low/normal
How is Kallman syndrome inherited?
X-linked recessive
When is serum LH and FSH measured in female infertility tests?
Days 2-5
What is Klinefelter’s syndrome?
A boy is born with an extra copy of the X chromosome.
Features:
- small, firm testes
- lack of 2ary sexual characteristics e.g. reduced facial and body hair
- infertile
- gynaecomastia (increased risk of breast cancer)
- elevated gonadotrophin levels but LOW testosterone
How does clomiphene stimulate ovulation?
Clomiphene is an anti-oestrogen.
By inhibiting oestrogen, GnRH levels and LH & FSH levels rise.
This stimmulates ovulation.
What may a rise in progesterone on day 21 indicate in fertility tests?
indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
What is anti mullerian hormone (AMH)?
The most accurate marker of ovarian reserve.
Released by granulosa cells in the follicles and falls as the eggs are depleted
High AMH = good ovarian reserve
How does Cushing’s syndrome lead to hyperandrogenism?
Excess ACTH causes your adrenal glands to release excess androgens.
Pregnancy is a diabetogenic state. What does that mean?
All patients (diabetic or not) have increased insulin resistance.
In patients with known diabetes –> increased insulin requirements.
In patients on threshold –> tipped into diabetic-like state.
When is GDM onset?
2nd trimester or later
Folic acid requirements in women with pre-existing diabetes?
High dose 5mg
At what HbA1c level is contraception recommended in diabetes?
≥48 mmol/mol
What are some effects of pregnancy on pre-existing diabetes?
1) Increased insulin requirement
2) Acceleration of retinopathy
3) Deterioration in renal function (can manifest as HTN in pregnancy)
4) Maternal hypoglycaemia in early pregnancy
When should patients with DM deliver by?
Patients with DM should not deliver later than 40+6
What are 6 antepartum risks of diabetes in pregnancy?
1) Pre-eclampsia / HTN
2) Miscarriage
3) Macrosomia
4) Congenital malformations (diabetes embryopathy)
5) Polyhydramnios
6) Intrauterine death
When should patients with GDM/DM be offered induction of labour?
38/40
How can GDM cause polyhydramnios?
Due to increased urine production
What are 2 intrapartum risk factors of GDM/DM?
1) Stillbirth
2) Shoulder dystocia
What is a key postpartum risk factor of diabetes in pregnancy?
Neonatal hypoglycaemia (due to foetal hyperinsulinaemia)
What are some ‘high’ risk factors for GDM? (5)
1) BMI >30
2) Previous gestational diabetes
3) Previous macrosomic baby
4) FH (1st degree relative)
5) Ethnicity with high prevalence of diabetes
Is arterial or venous sample taken in OGTT?
Venous plasma glucose measurement
Why is HbA1c not used to diagnose diabetes in pregnancy?
As HbA1c looks at glucose over the past 3 months
Diabetes risk mneumonic –> SMASHHH
S - shoulder dystocia
M - macrosomia
A - amniotic fluid excess (polyhydramnios)
S - stillbirth
H - HTN
H - haemorrhage (PPH)
H - hypoglycaemia of newborn
When should serial growth scans be offered in GDM?
Every 4 weeks from 28-36 weeks
How can polyhydramnios be diagnosed? (2)
On US either:
1) Largest single unobstructed pool >8cm depth
or
2) Combined 4 quadrant unobstructed pool depth >24cm
What are 6 key complications of polyhydramnios? (6 P’s)
1) Pretty wonky lie - malrepresentation/unstable like
2) Premature rupture of membranes (PROM) - due to increased uterine pressure
3) Placental abruption - due to increased risk of PPROM
4) Prolapsed cord - due to increased pressure during ROM
5) Premature labour - due to increased risk of PPROM
6) PPH - overdisteded uterus (atony)
Stepwise mx of shoulder dystocia?
1) Call for help
2) Suprapubic pressure + McRobert’s manoeuvre
3) Woodscrew manoeuvre (trying to push posterior shoulder out the way to anterior shoulder can come out)
4) Break clavicle
5) Zavanelli manoeuvre (put head back inside and do a Cat 1 section)
What is the Zavanelli manouevre?
An obstetric manoeuvre that involves pushing back the delivered foetal head into the birth canal in anticipation of performing a cesarean section in cases of shoulder dystocia.
What 3 factors define the diagnosis of pre-eclampsia?
1) >20 weeks gestation
2) BP >140/90
3) Proteinuria
What are the 3 types/causes of elevated BP in pregnancy?
1) Pre-existing HTN
2) HTN in pregnancy (gestational HTN)
3) Pre-eclampsia
When does pre-eclampsia resolve?
<1w after delivery
BP in pre-eclampsia vs severe pre-eclampsia?
Pre-eclampsia: >140/90
Severe: >160/110
What is a key risk factor for pre-existing HTN in pregnancy?
Older maternal age
When can gestational HTN be diagnosed?
After 20/40
What BP warrants admission in pregnancy?
≥160/110
2 ways of diagnosing proteinuria in pre-eclampsia?
1) Proteinuria ++
2) PCR ≥35 mg/mmol
Prophylaxis of pre-eclampsia?
Aspirin 75mg from 12w gestation until birth
Who is given pre-eclampsia prophylaxis?
If HIGH RISK population or HIGH risk for complications:
1) HTN or pre-eclampsia in previous pregnancy
2) CKD
3) SLE or antiphospholipid syndrome
4) Diabetes
5) Pre-existing HTN
What are some RED FLAG signs and symptoms in pre-eclampsia?
Symptoms:
- headache
- blurred vision
- swelling of hands, feet, face
- breathlessness
- RUQ pain
Signs:
- periorbital oedema
- hyperreflexia
- clonus
- seizures
Pathophysiology of pre-eclampsia?
Disease of the placenta that results from abnormal placentation:
1) Failure of uncoiling and dilation of spiral arteries (around 20/40)
2) Hypoperfusion of placenta
3) This triggers release of pro-inflammatory proteins
4) Proinflammatory proteins cause endothelial dysfunction & vasospasm –> cause rise in BP
Note –> symptoms of pre-eclampsia relate to the ENDOTHELIAL DYSFUNCTION and VASOSPASM caused by the release of pro-inflammatory proteins.
What causes headache in pre-eclampsia?
Due to fluid accumulation in the brain and meningeal irritation.
What are some visual disturbances seen in pre-eclampsia?
- blurred vision
- scotoma
- flashing lights
- visual field floaters
Cause of visual disturbances in pre-eclampsia?
Due to retinal artery vasospasm
What causes HELLP syndrome in pre-eclampsia?
Endothelial damage –> microthrombi formation –> platelet consumption & haemolysis –> HELLP syndrome.
What causes oedema in pre-eclampsia?
Endothelial damage –> increased vessel permeability –> protein leakage –> oedema
What is the main principle of treatment in pre-eclampsia?
Stroke prevention & maintain BP ≤135/85
Note - medication doesn’t alter underlying disease process
What 3 medications are involved in the mx of pre-eclampsia?
1) labetalol
2) nifedipine (asthmatics)
3) methyldopa (but increased risk of PND and suicide)
What is a key risk of using methyldopa in the mx of pre-eclamsia?
Increased risk of postpartum depression & suicide
What is the mx of severe pre-eclampsia (≥160/110)?
1) Admit
2) IV labetalol/nifedipine
3) IV MgSO4
4) Steroids if concerned about early delivery
5) Definitive –> delivery
What is HELLP syndrome?
A complication of severe pre-eclampsia.
Caused by endothelial injury and dysfunction –> results in unregulated activation of the clotting cascade.
Can progress to DIC & multiorgan failure.
What can HELLP syndrome progress to?
DIC
Define eclampsia
New onset seizures in a patient with pre-eclampsia.
What is the mx of eclampsia?
1) ABCDE approach:
- airway is key
- put patient in left lateral position
2) Continuous CTG monitoring
3) Seizure treatment:
- IV magnesium sulphate loading dose followed by infusion (if contraindicated then IV lorazepam)
4) HTN treatment: IV labetalol or nifedipine
5) Consider risks vs benefits of expediting delivery
Define antepartum haemorrhage (APH)
Bleeding from genital tract occuring from 24 weeks gestation
What are the 2 most significant causes of APH?
1) Placenta praevia
2) Placental abruption
What is 1st line mx of candidiasis in non-pregnant women?
Oral fluconazole (single dose)
How long should you give MgSO4 for in eclampsia?
For 24h after last seizure or 24h after delivery (whatever is longest)
When are pregnant women screened for anaemia? (2)
1) Booking visit
2) 28 weeks
What is the gold standard investigation for diagnosis of placenta praevia?
TV US
Bleeding in the 1st trimester:
a) <6 weeks gestation
b) ≥6 weeks gestation
a) if bleeding but NO pain or risk factors for ectopic pregnancy –> expectant mx and repeat pregnancy test in 7-10d
b) refer to EPAU
Is all hormonal contraception contraindicated in patients undergoing testosterone therapy?
No - only contraceptives containing oestrogen
What is the 1st line investigation for PPROM?
Speculum exam to look for pooling of amniotic fluid in posterior vaginal vault.
What is recommended for women with pre-eclampsia with mild or moderate hypertension after 37 weeks?
What about severe ?
Mild to mod - delivery within 24-48 hours
Severe - IV magnesium sulphate and plan immediate delivery
When should the measurement of the symphysis-fundal height closely match the foetal gestational age in weeks within 1-2cm?
From 20 weeks gestation
Is it safe for a woman with Hep B to breastfeed?
Yes
