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Year 4 - 1. Reproductive Health > Group B - Reproductive and Benign Gynaecology > Flashcards

Group B - Reproductive and Benign Gynaecology Flashcards

1
Q

Outline some investigations for suspected urinary incontinence

A

Urinalysis (infection)
Bladder diary (record intake, urine frequency / volume and any episodes of incontinence)
24 hr pad weighing (weigh before and after)
Ultrasound scan or cystoscopy
Invasive urodynamic testing (cystometry)

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2
Q

Outline the findings on invasive urodynamic testing for stress incontinence and urge incontinence in terms of:
- Bladder capacity
- Detrusor muscle activity increase
- Presence of leakage
- Provoked by…
- Volume of loss

A

Stress incontinence:
Bladder capacity = normal
Detrusor muscle activity increase = no large increase
Presence of leakage = present
Provoked by… = cough
Volume of loss = small-moderate

Urge incontinence:
Bladder capacity = decreased
Detrusor muscle activity increase = large increase
Presence of leakage = leakage with detrusor activity
Provoked by… = triggers e.g. washing hands
Volume of loss = often large

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3
Q

Outline management for urge incontinence

A

Often difficult to manage

Conservative:
- Sensible fluid intake
- Reduce caffeine and alcohol
- Alter home conditions e.g. downstairs toilets, commodes etc.
- Bladder retaining

Medical:
- Anticholinergic drugs e.g. Oxybutynin, Tolterodine, Propiverine, Solifenacin
- Botulinum toxin injections
- Electrical stimulation (posterior tibial nerve or sacral nerve)

Surgery:
- Enterocystoplasty (self-catheterisation)
- Urinary diversion e.g. ileostomy

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4
Q

Outline management for stress incontinence

A

Conservative:
- Sensible fluid intake
- Reduce caffeine and alcohol
- Alter home conditions e.g. downstairs toilets, commodes etc.
- Physiotherapy for pelvic floor exercises

Medical:
- Duloxetine (side effects)

Surgery (tend to skip medical):
- Tension free vaginal tape
- Burch colposuspension

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5
Q

Outline some symptoms associated with uterine prolapse

A
  • Sensation of dragging / heaviness
  • Lower back pain
  • Urinary symptoms
  • Urinary incontinence
  • Faecal incontinence
  • Bleeding / discharge
  • Difficulties with sex
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6
Q

Outline the grades of uterine prolapse

A

Relates to entrance of vagina (introitus)

Grade 0: no prolapse
Grade 1: lowest part more than 1cm above entrance to vagina
Grade 2: lowest part within 1cm of entrance to vagina
Grade 3: lowest part 1cm below entrance to vagina
Grade 4: full external eversion = uterine procidentia

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7
Q

Outline some predisposing factors for prolapse

A
  • Increase age
  • Postmenopausal
  • High parity
  • Connective tissue disease
  • Previous prolapse
  • Obesity
  • Smoking
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8
Q

Outline some complications of prolapse correction surgery

A
  • Recurrence / failure to resolve prolapse
  • Haemorrhage or vault prolapse
  • Damage to local structures
  • DVT
  • New onset incontinence
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9
Q

Outline the treatment options for prolapse

A

May do nothing if all they need is reassurance

Conservative:
- Weight loss
- Pelvic floor exercises (physiotherapy supervision)
- Vaginal oestrogen cream

Medical:
- Vaginal ring pessary

Surgical:
- Surgery - depends on type of prolapse etc.

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10
Q

List some risk factors for cervical ectropion

A
  • Adolescence
  • Pregnancy
  • COCP
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11
Q

Suggest examinations and further investigations for acute pelvic pain (gynae non-pregnancy related causes only)

A

Examinations:
- Abdominal / bimanual
- Speculum

Further investigations:
** PREGNANCY TEST**
- Clarify period timing for Mittelschmerz
- STI test for PID
- Urine dipstick
- Pelvic ultrasound (TVS/TA) for ectopic or cyst issues or PID abscess
- Consider MRI if suspect abscess
- Consider laparoscopic investigation in endometriosis

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12
Q

Suggest examinations and further investigations for chronic pelvic pain (gynae related causes only)

A

Examinations:
- Abdominal / bimanual (PID, endometriosis)
- Speculum

Further investigations:
** PREGNANCY TEST**
- STI test for PID
- Pelvic ultrasound (TVS/TA) for fibroids, cysts or PID abscess
- Consider hysteroscopy for smaller fibroids
- Consider laparoscopic investigation in endometriosis
- Consider MRI

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13
Q

Suggest some potential causes of sporadic and recurrent early pregnancy loss

A

** Idiopathic **

1st trimester pregnancy loss:
- Abnormal (aneuploid) karyotype
- Placental issues
- Genetic factors in parents e.g. balanced translocations

2nd trimester pregnancy loss:
- Weakened cervix
- Uterine abnormalities
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Chronic disorder e.g. diabetes, HTN, thyroid and SLE
- Infection e.g. rubella, syphilis
- Medication e.g. NSAIDs, Methotrexate

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14
Q

Suggest some investigations for sporadic and recurrent early pregnancy loss

A

(B) Screen for preexisting disease e.g. diabetes, thyroid
(L) Blood test for antiphospholipid antibodies and hereditary thrombophilias
(I) Vaginal ultrasound for uterine abnormalities
(P) Hysteroscopy / hysterosalpingography / sonohysterograms
(P) Cytogenetic analysis of products of conception (if abnormal then the parents should be karyotyped)

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15
Q

List some investigations to consider in suspected miscarriage

A
  • Transvaginal ultrasound (establish foetal heartbeat and whether there are any foetal components within the uterine cavity)

If not present, check b-HCG
- Normal rise in b-HCG indicates normal growth but doesn’t exclude ectopic
- Fall in b-HCG may indicate miscarriage
- Only slight increase or a plateau may indicate ectopic

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16
Q

List some risk factors for ectopic pregnancy (factors making ectopic pregnancy more likely)

A
  • Previous ectopic pregnancy!
  • PID / scarring / genital infection
  • Endometriosis
  • Previous ovarian / tubal surgery
  • Intrauterine device in situ (copper coil)
  • PCOS
  • IVF
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17
Q

Explain the different types of miscarriage
- Missed
- Threatened
- Inevitable
- Incomplete
- Complete
- Anembryonic

A

Missed miscarriage = foetus currently intrauterine but loss of foetal heartbeat (death) but absence of miscarriage symptoms

Threatened miscarriage = foetus currently intrauterine, PV bleeding but closed cervical os

Inevitable miscarriage = foetus currently intrauterine but heavy bleeding and pain, with open cervical os

Incomplete miscarriage = some expulsion of pregnancy tissue but evidence of retained tissue on USS

Complete miscarriage = full expulsion of pregnancy and no evidence of retained tissue on USS

Anembryonic miscarriage = gestational sac present, but no embryo

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18
Q

Outline the 3 main methods of miscarriage management

A
  1. Expectant management
    - Allow 1-2 weeks for miscarriage to occur spontaneously
    - Repeat b-hCG 3 weeks after symptoms settle
  2. Medical management
    - Misoprostol (prostaglandin receptor stimulator), single dose = softens cervix + uterine contractions
    - Oral or vaginal suppository
  3. Surgical management
    - Manual vacuum aspiration only if < 10 weeks (local anaesthetic)
    - Electric vacuum aspiration (general anaesthetic)
    - Prostaglandins prior, soften cervix
    - Provide anti-D prophylaxis if required
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19
Q

Outline the 3 main methods of ectopic management

A
  1. Expectant management
    - Strict criteria (see next notes)
  2. Medical management
    - IM Methotrexate
    - Cannot get pregnant for next 3 months
  3. Surgical management
    - Laparoscopic salpingectomy
    - Laparoscopic salpingotomy
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20
Q

Outline the criteria for expectant management of ectopic pregnancy

A
  • Easy and open access to gynae service
  • Not ruptured
  • Small <3.5cm
  • No heartbeat
  • No significant pain
  • Low b-HCG

If want medical:
- Need to show absence of intrauterine pregnancy on USS
- Low-medium b-HCG

21
Q

When does uncomplicated nausea and vomiting peak in pregnancy

A

Begins: 4-7 weeks

Peaks: 8-12 weeks

Resolves: 16-20 weeks

22
Q

What pregnancy hormone is responsible for nausea and vomiting?

A

Hormone: human chorionic gonadotropin (hCG)

23
Q

What conditions/situations can make nausea and vomiting worse during pregnancy?

A
  • Molar pregnancy
  • Multiple pregnancy
  • First pregnancy
  • Obesity
24
Q

Outline hyperemesis gravidarum and state 3 factors that differentiates hyperemesis gravidarum from normal N&V

A

Hyperemesis gravidarum = severe form of nausea and vomiting that occurs <20 weeks

  1. Weight loss > 5% (compared to pre-pregnancy)
  2. Dehydration
  3. Electrolyte imbalance
25
Q

What scoring system assesses the severity of hyperemesis gravidarum

A

PUQE - pregnancy-unique quantification of emesis

26
Q

State some life-threatening complications of hyperemesis gravidarum
- Dehydration related
- GI
- Metabolic disturbances
- Psychological impact
- Impact on foetus

A

Dehydration:
- VTE events
- AKI

GI problems:
- Mallory-Weiss tears
- Malnutrition

Metabolic disturbances:
- Ketosis
- Hyponatraemia
- Wernicke’s encephalopathy
- Hypoglycaemia

Psychological impact:
- Depression / PTSD
- Resentment towards the pregnancy

If severe, can impact foetal development:
- Low birth weight
- Intrauterine growth restriction
- Premature labour

27
Q

Outline some antiemetics that can be used in hyperemesis gravidarum

A
  1. Prochlorperazine
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide
28
Q

Outline how mild vs moderate-severe hyperemesis gravidarum is managed differently

A

Mild: oral emetics at home

Moderate-severe (or if raised ketones / unable to keep fluids down):
- IV fluids (plus K+)
- IM / IV antiemetics e.g. Cyclizine
- Thiamine supplementation (prevent Wernickes)
- Daily U&E monitoring
- VTE prophylaxis

29
Q

Outline the 2 types of molar pregnancy and briefly explain them

A
  1. Complete mole
    - 2 sperm fertilise an egg with no genetic material (empty egg)
    - Sperm combine genetic material and cells divide to form a tumour
    - No foetal material will form
  2. Incomplete mole
    - 2 sperm fertilise a normal egg with 3 sets of chromosomes
    - Cells divide to form a tumour
    - Foetal material may form
30
Q

Suggest some features of a pregnancy that might make you suspect a molar pregnancy

A
  • Extreme morning sickness (increased b-hCG)
  • Abnormally high b-hCG
  • Vaginal bleeding
  • Increased enlargement of uterus
31
Q

How is a suspected molar pregnancy investigated and what will it show?

A

Transvaginal ultrasound - showing snowstorm appearance

32
Q

How is a molar pregnancy managed?

A
  • Evacuation of uterus to remove the mle
  • Histological analysis of foetus/mole
  • Monitor b-hCG levels to ensure return to normal
  • Referral to gestational trophoblastic disease centre

If metastasis, may need chemotherapy

33
Q

List some contraindications to starting COCP

A
  • Migraine with aura
  • Breast cancer
  • Age >35 and smoking > 15/day
  • HTN
  • VTE (personal or 1st degree relative)
  • Major surgery / immobility
  • Vascular disease / stroke
  • SLE / antiphospholipid
  • Liver cirrhosis
34
Q

List some contraindications to starting POP

A
  • Current breast cancer
  • Severe liver cirrhosis / liver tumour
35
Q

List some contraindications to starting intrauterine coils

A
  • Existing pregnancy
  • Existing pelvic infection or PID
  • Immunosuppression
  • Pelvic cancer
  • Uterine cavity distortion
  • Unexplained bleeding
  • Wilson’s disease if copper IUD
36
Q

State some lifestyle factors that can contribute to infertility

A

BMI (under or over)
Smoking - reduce sperm quality and egg production
Psychological stress
Alcohol
Illicit drugs and others e.g. anabolic steroids
Diet - antioxidant protection
Exercise
Caffeine (females)

37
Q

List some female health issues that can contribute to infertility

A

Endocrine:
- PCOS
- Thyroid problems
- Premature ovarian failure

Physical:
- Endometriosis
- PID / scarring from surgery
- Fibroids / polyps

Genetic conditions e.g. Turner’s syndrome

38
Q

List some male health issues that can contribute to infertility

A

Endocrine:
- Hypogonadism (low testosterone)

Physical:
- Testicular conditions e.g. infection and scarring, cancer, undescended, previous operations
- Ejaculation disorders

Genetic conditions e.g. Klinefelter syndrome

39
Q

List some medications that can contribute to infertility

A

Female:
- NSAIDs
- Antipsychotics
- Spironolactone

Male:
- Sulfasalazine
- Anabolic steroids

Both
- Chemotherapy
- Illegal drugs e.g. weed or cocaine

40
Q

State the difference between primary and secondary female infertility

A

Primary infertility - pregnancy has never been achieved

Secondary infertility is when at least one prior pregnancy has been achieved

41
Q

State causes of female infertility

A

Lifestyle factors:
- BMI (under or over)
Smoking, alcohol or illicit drugs
- Stress

Endocrine:
- PCOS
- Thyroid problems
- Premature ovarian failure

Physical:
- Endometriosis
- PID / scarring from surgery
- Fibroids / polyps

Genetic conditions e.g. Turner’s syndrome

42
Q

State causes of male infertility

A

Lifestyle factors:
- Tight underwear / hot baths
Smoking, alcohol or illicit drugs
- Stress

Endocrine:
- Hypogonadism (low testosterone)
- Sperm problems e.g. low count, motility, pH

Physical:
- Testicular conditions e.g. infection and scarring, cancer, undescended, previous operations
- Ejaculation disorders

Genetic conditions e.g. Klinefelter syndrome

43
Q

Suggest some first line investigations in couples with infertility

A
  • BMI
  • Chlamydia screen
  • Semen analysis
  • Rubella immunity in mother
  • Female hormone testing
    e.g. thyroid function, serum LH/FSH, serum progesterone, anti-mullerian hormone, prolactin
44
Q

Suggest some further investigations in couples with infertility (once first line tests have come back clear)

A
  • Pelvic ultrasound
  • Hysterosalpingogram
  • Laparoscopy and dye test
45
Q

Suggest some management strategies for couples with the following causes:
- Anovulation
- Tube issues
- Uterine issues

A

Depends on cause

Anovulation:
- Weight loss
- Clomiphene
- Ovarian drilling in PCOS

Tube issues:
- Tubal cannulation
- IVF

Uterine issues:
- Surgery to correct underlying causes

46
Q

Suggest some first line management strategies for couples with the following causes:
- Sperm problems
- Pre-testicular problems
- Testicular problems
- Post-testicular problems

A

Depends on cause

Sperm problems:
- Surgical sperm retrieval
- IVF depending on problem

Testicular problems:
- IVF e.g. surgical sperm retrieval, surgical correction if abnormality, insemination etc.

47
Q

State drugs used to treat female infertility, including mode of action and side effects

A

Clomiphene: stimulate ovulation, stimulates anterior pituitary gland to secrete more FSH and LH
Side effects: bloating, abdo pain, hot flushes
** Risk of ovarian hyperstimulation syndrome

Letrozole: stimulate ovulation, aromatase inhibitor, inhibits oestrogen production
Side effects: sweating, hot flushes, arthralgia, fatigue

Gonadotropins: synthetic FSH and LH can help trigger ovulation

48
Q

List some general side effects of antimuscarinics

A
  • Dry mouth
  • Hot flushed skin
  • Blurred vision
  • Urinary retention / constipation
  • Dizziness / drowsiness
49
Q

List some general side effects of alpha blockers

A
  • Hypotension / dizziness / falls
  • Headache
  • N&V
  • Swollen legs
  • Dizziness / drowsiness
  • Tremor

Year 4 - 1. Reproductive Health (7 decks)

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