GOSH 5 Flashcards
What is the aim of hormonal treatment in endometriosis?
Prevent hormonal stimulation of ectopic endometrial tissue through the inhibition of ovarian hormone production.
Gold standard –> Mirena coil.
What are some surgical options for endometriosis?
1) Removal of endometriosis; ablation or excision
2) Adhesiolysis (resection of adhesions)
3) Bilateral oophorectomy
What are endometriomas on the ovaries known as?
Chocolate cysts
Role of GnRH analogues in endometriosis?
Induce menopause like state.
Should only be given to women close to menopause.
What causes ovulation?
LH surge
How are polycystic ovaries described on USS?
“string of pearls”
Describe hormone levels in PCOS
Increased LH
Decreased FSH
Decreased oestrogen
Increased androgens
Increased total testosterone
Decreased SHBG
What 3 tests can be done in PCOS to rule out other causes of oligo/amenorrhoea?
1) TFTs
2) Prolactin
3) Pregnancy test
What are 2 key long term complicatiosn of PCOS?
1) T2DM
2) CVS disease
3 mx options to induce ovulation in PCOS?
1) Weight loss +/- metformin
2) Clomifene
3) Gonadotrophins (if resistant to clomifene)
At what gestational age is expectant mx of miscarriage possible?
Only if <14 weeks gestation
What is a good resource for support following miscarriage? (e.g. in counselling OSCE stations)
Miscarriage association
Counselling tips in miscarriage OSCE:
- Relatively common (1 in 5 pregnancies end in miscarriage)
- Emphasise that there was likely nothing they could have done to prevent it
- Advise to try again when they feel they are ready as a couple
- Emphasise probable success on next attempt (only 14% will go on to have another miscarriage)
- Other lifestyle measures e.g. folic acid, smoking cessation, dietary mx
- Miscarriage association
Next step if TV USS report states a ‘pregnancy of unknown location’?
Serum hCG at 0 and 48 hours:
- hCG decrease >50% –> likely failing pregnancy, repeat PT in 3 weeks
- hCG increase <63% –> likely ectopic, clinical review within 24h
- hCG increase >63% –> likely thriving intrauterine pregnancy, repeat TV US in 7-14d
General staging for gynae cancer? (FIGO)
Stage 1 - confined to organ
Stage 2 - local spread but confined to pelvis
Stage 3 - abdo spread but confined to peritoneal cavity
Stage 4 - distant spread
How can the thyroid be affected in pregnancy?
During pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG).
This causes an increase in the levels of TOTAL thyroxine, but doesn’t affect the FREE thyroxine level.
What 2 infections can cause erythema nodosum?
- strep e.g. pharyngitis
- TB
What is the ommonest skin disorder found in pregnancy?
Atopic eruption of pregnancy
How does atopic eruption of pregnancy typically present?
An eczematous, itchy red rash.
Mx of atopic eruption of pregnancy?
no specific treatment is needed
Describe polymorphic eruption of pregnancy
- Pruritic condition associated with last trimester
- Lesions often first appear in abdominal striae
What does mx of polymorphic eruption of pregnancy depend on?
severity: emollients, mild potency topical steroids and oral steroids may be used
What skin condition during pregnancy can cause pruritic BLISTERING lesions?
Pemphigoid gestationis
Mx of Pemphigoid gestationis?
oral corticosteroids are usually required
When can a person assigned male at birth have breast cancer screening?
If they have been taking feminising hormones for 2 years or more
If analgesia doesn’t help in endometriosis, what should be tried next?
Hormonal (COCP or progestogens)
When is an US indicated for lochia?
If lochia persists >6 weeks
What should be given to all women with PPROM?
10 days erythromycin
After how many weeks gestation is same day delivery an option in pre-eclampsia?
34 weeks
1st line for 1ary dysmenorrhoea?
NSAIDs e.g. ibuprofen, mefenamic acid
Then you would trial the COCP
What is 1ary dysmenorrhoea?
When there is no underlying pelvic pathology.
Give some causes of 2ary dysmenorrhoea
- endometriosis
- adenomyosis
- PID
- IUD (copper)
- fibroids
What is the most common complication of a myomectomy?
Adhesions
What ovarian tumour is associated with the development of endometrial hyperplasia?
Granulosa cell tumour
If 2 pills are missed in week 1, when should you consider emergency contraception?
If they have had unprotected sex during the pill free interval or week 1
What are the 2 phases of the 1st stage of labour?
Latent phase = 0-3cm dilation
Active phase = 3-10cm dilation
When should women who have been treated for CIN (I, II or III) be invited back for cervical screening?
6 months after treatment for a test of cure repeat cervical sample.
Regarding surrogacy, who is the legal mother?
The party GIVING BIRTH to the child is its legal mother.
Is amiodarone safe in breatfeeding?
No
It is highly lipid-soluble and therefore, extensively stored in body tissues, including breast milk.
This can result in neonatal hypothyroidism or hyperthyroidism.
When does a deceleration become foetal bradycardia?
After 3 minutes
What is the most common gynae cancer?
Endometrial cancer
What scan is used to stage endometrial cancer?
MRI
Is BRCA 1 or BRCA 2 mutation a greater risk for ovarian cancer?
BRCA 1
Some questions to ask regarding ovarian cancer symptoms:
- Abdo distension or bloating
- Early satiety or anorexia
- Changes to bowel habit
- Urinary symptoms e.g. frequency or urgency
- Dyspareunia
- Weight loss
Next step if a MASS is found on abdo examination at GP in potential ovarian cancer?
2 week wait referral (for USS abdo + pelvis)
Next step if NO mass is found on abdo examination at GP in potential ovarian cancer?
Ca-125
If this is raised –> urgent abdo and pelvic US
What type of cancer are the majority of cervical cancer?
Squamous cell carcinomas
Risk factors for cervical cancer?
- HPV (16 & 18)
- Multiple partners
- COCP (more likely to not use barrier contraception)
- Immunocompromised e.g. (body can’t clear HPV)
- Smoking
Some presenting complaints of cervical cancer?
- PCB
- IMB
- PMB
- Dyspareunia
- Pelvic pain
- Unexplained vaginal discharge
- Dysuria
Define dysplasia
Abnormal cells, usually a pre-cancerous change
Define CIN
Cervical intra-epithelial neoplasia (cancer precursor) detected on colposcopy
This can be low grade (CIN I) or high grade (CIN II & III)
Define carcinoma in situ
Early stage cancer
How does HPV predispose to cervical cancer?
HPV causes the down regulation of tumour suppressor genes (like p53).
Which strain of HPV is responsible for most cervical cancers?
16 (followed by 18)
What happens during cervical screening?
Cells from the transformation zone are collected using a small brush and then reviewed under a microscope.
They are reviewed for:
1) HPV status
2) Cytology (i.e. dysplasia) –> depth & severity of dysplasia predicts cancer risk.
Should patients presenting with red flag cervical cancer symptoms be referred for a smear?
No - refer straight to colposcopy via 2WW
How is a diagnosis of cervical cancer made?
Using colposcopy + biopsy (+/- staging CT)
Typical mx of pre-cancerous lesions in the cervix?
LLETZ –> note, this increaes the chance of preterm labour due to incompetent cervix (shortened)
Mx of early stage cervical cancer?
1) Trachelectomy –> for those who wish to preserve fertility
2) Radical hysterectomy +/- radiotherapy
What is involved in a trachelectomy?
Removal of cervix, pelvic lymph nodes with preservation of the uterus for those who wish to preserve fertility.
Why is ciprofloxacin generally avoided in breastfeeding?
Due to its potential to cause arthropathy.
Placenta accreta vs increta vs percreta?
Accreta - chorionic villi of placenta attach to the myometrium
Increta - chorionic villi invade INTO the myometrium
Accreta - chorionic villi invade THROUGH the perimetrium
Next step in suspected cases of rubella in pregnancy?
Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
What is the benefit of catheterising the woman in prolapsed cord and filling the bladder with saline?
As this will lift the presenting part off the cord.
Otherwise, the presenting part should be lifted manually to prevent cord compression.
How is the thyrotoxicosis phase of postpartum thyroiditis generally managed?
Propanolol
Next step if abnormal cytology is found on a smear?
Refer to colposcopy
Mx of endometritis?
If endometritis is suspected, the patient should be referred to hospital for IV Abx (clindamycin and gentamicin until afebrile for greater than 24 hours).
Is PPH defined as after delivery of the baby or delivery of the placenta?
Delivery of the baby
What is the mechanism of action of terbutaline (tocolytic)?
Beta agonist
In cardiac arrest in pregnancy, when should delivery of the baby occur?
After 4 minutes and within 5 minutes of starting CPR
what is the most common type of uterine fibroid?
Intramural (confined to the myometrial layer of the uterus)
When is bleeding concerning in postmenopausal women?
If haven’t had a period for OVER 1 year
What contraception can patients who have had a gastric sleeve/bypass/duodenal switch NOT have?
Oral contraception - due to lack of efficacy, including emergency contraception.
Mx of trace glycosuria in pregnancy?
Reassurance and safetynet.
Trace glycosuria is common in pregnancy due to the increased GFR and reduction in tubular reabsorption of filtered glucose.
When is CVS done in pregnancy?
11 - 13+6
When is amniocentesis performed in pregnancy?
From week 15 onwards
Appearance of VIN vs vulval carcinoma?
VIN - tend to be white or plaque like and DON’T tend to ulcerate
Vulval carcinoma - commonly ulcerated
When is dating scan done in pregnancy? (also to exclude multiple pregnancy)
10-13+6
What drug is typically used in patient controlled analgesia (PCA) in labour?
Remifentanl (short acting opiate)
Give some options for pain relief in labour
1) Simple analgesia (e.g. paracetamol but NOT ibuprofen)
2) Gas & air
3) Epidural
4) IM pethidine/diamorphine
5) PCA with remifentanil
Define delay in 3rd stage of labour
> 30 mins with active mx
> 60 mins with physiological mx
What 2 medications must be accessible if giving a PCAwith remifentanil in labour?
1) Naloxone (for respiratory depression)
2) Atropine (for bradycardia)
Define delay in 2nd stage of labour
> 2 hours in nulliparous
> 1 hour in multiparous
Mechanism of tranexamic acid?
Tranexamic acid binds to plasminogen and STOPS it from converting to plasmin.
Plasmin normally dissolves fibrin in blood clots (TXA therefore stops breakdown of blood clots).
Define delay in 1st stage of labour
Either:
1) <2cm dilation in 4 hours
2) Slowing of progress in multiparous
What are the 2 anaesthetic options for an epidural?
Levobupivacaine or bupivacaine mixed with fentanyl.
When are steroids indicated in pregnancy?
In all cases of PPROM (i.e. <37 weeks)
How are steroids given for prematurity in pregnancy?
IM dexamethasone
is lithium safe in breastfeeding?
no
What should women with pyrexia (>38 degrees) during labour receive?
GBS prophylaxis with benzylpenicillin
To use the ventouse, where is the cup applied?
In the midline, 3cm anterior from the posterior fontanelle.
Or 6cm posterior to anterior fontanelle.
What is an operative vaginal delivery defined as?
The use of an instrument to aid delivery of the foetus
How are operative vaginal deliveries classified?
By the degree of foetal descent –> lower classification = less risk of complications
What are the 3 classfications of operative vaginal deliveries?
1) Outlet
2) Low
3) Midline
Define the ‘outlet’ classification operative vaginal delivery
Any of the following:
- Foetal scalp visible with the labia parted
- Foetal skull reached the pelvic floor
- Foetal head on perineum
Define the ‘low’ classification operative vaginal delivery
Lowest presenting part (not caput) is +2, or further below the ischial spines.
Subdivided to:
a) >45 degrees - rotation needed
b) <45 degrees - no rotation needed
Define the ‘midline’ classification operative vaginal delivery
- 1/5 palpable abdominally
- Lowest part is above +2, but is lower than the ischial spines
Subdivided to:
a) >45 degrees - rotation needed
b) <45 degrees - no rotation needed
Define foetal station
Fetal station refers to how far a baby’s head has descended into your pelvis.
Stations range from -5 to +5, with 0 station meaning the head is aligned with the ischial spines.
-5 = 5cm above ischial spines
0 = at ischial spines
+5 = 5cm below ischial spines (i.e. at vaginal opening)
What is recommended after instrumental delivery to reduce the risk of maternal infection?
Single dose of co-amoxiclav
In patients with hyperemesis gravidarum, why should fluids containing dextrose NOT be given?
As dextrose increases the body’s need for thiamine (B1) which might precipitate Wernicke’s encephalopathy.
When is the foetus said to be ‘engaged’?
When the largest part of the head has entered the pelvis.
What terminology is used to describe the head in relation to the ischial spine?
Station
What is the linea nigra?
A physiological form of hyperpigmentation commonly seen in the first trimester of pregnancy.
A dark vertical line that runs down the middle of the abdomen and it can be one of the earliest indicators of pregnancy.
How is a diagnosis of endometrial cancer made?
1) TV US with pipelle biopsy
In most cases a pipelle biopsy can be used to diagnose endometrial cancer.
If pipelle has been inconclusive:
2) Hysteroscopy with biopsy
Give 3 causes of a raised AFP in pregnancy
1) Abdominal wall defect e.g. omphalocele
2) Neural tube defect
3) Multiple pregnancy
Define cat 2 vs cat 3 c-section
Cat 2 - maternal or fetal compromise which is not immediately life-threatening
Cat 3 - delivery is required, but mother and baby are stable
What is a cat 4 c-section?
elective caesarean
When does vaginal bleeding count as a potentially sensitising event in a Rh-ve woman?
- Vaginal bleeding <12 weeks, only if painful, heavy or persistent
- Any vaginal bleeding >12 weeks
What is foetal fibronectin?
A protein that is released from the gestational sac.
Having a high level has been shown to be related with early labour.
T1DM and pre-eclampsia?
T1DM is a high risk factor for pre-eclampsia
1st line investigation in possible vesicovaginal fistula?
Urinary die studies –> a dye stains the urine and identifies the presence of a fistula.
Mx of any woman in whom pre-eclampsia is suspected?
Urgent 2ary care assessment
Is maternal colonisation with GBS a risk factor for neonatal sepsis?
It is a minor risk factor for early onset sepsis in the newborn.
Mx of newborns with:
a) 1 minor risk factor for early onset sepsis
b) 2 or more minor risk factors or one red flag
a) Remain in hospital for at least 24 hours with regular observations
b) Empirical Abx therapy with benpen + gent & full septic screen
What is lichen sclerosus?
An autoimmune inflammatory skin condition that predominantly affects the genitalia in post-menopausal women.
This inflammation leads to atrophy of the epidermis and the formation of white ‘plaques’.
What is a hallmark symptom of lichen sclerosus?
Pruritus vulvae –> can be severe enough to disturb a patient’s sleep.
Can also cause dyspareunia and dysuria.
Mx of lichen sclerosus?
High-potency topical corticosteroids complemented by emollients to address dryness.
Can HIV be transmitted via breastfeeding?
YES
Can hep B be transmitted via breastfeeding?
No
