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Gyn Flashcards

1
Q

When asking about timings of menstruation what info should be gathered?

A

Regular or irregular
Time of bleeding
Time between 1st day and 1st day

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2
Q

Questions other than timing, to ask about PV bleeding?

A 
Heavy?
Clots?
Number of pads at once? Bleeding overflowing pads?
Intramenstrual bleeding?
Post coital bleeding?
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3
Q

Aspects of a gyne history?

A 
PC
HPC
Menstrual history 
Obstetric history 
Sexual history 
Screening history (smears)
PMH (inc gynaecological) 
Contraception history 
DHx
FHx
SHx
ICE
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4
Q

Questions to ask regarding gyne HPC.

A

Cyclicality
Pain
Dysparaunia

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5
Q

What is the date of the last menstrual period?

A

The first day of the last episode of bleeding

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6
Q

Important aspects of obstetric history to be taken in a gyne case?

A 
Gravidity 
Parity 
Outcomes
Baby weights 
Modes of delivery 
Complications 
Post delivery
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7
Q

What is the term for the period of time a few weeks post delivery of the placenta?

A

Puerperium

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8
Q

In an obstetric history a patient states she had several miscarriages previously. What information needs to be gathered about these?

A

What stage in pregnancy
Why (terminations or spontanious? Any identified causes?)
If terminations what method used

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9
Q

Features of uterine pain?

A

Colicky and felt in the sacrum or groin

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10
Q

Features of ovarian pain

A

Illiac fossa down anterior thigh into knee

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11
Q

Questioning around dysparaunia?

A

Superfical or deep

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12
Q

Questioning around vaginal discharge?

A

Colour
Smell
Itch
Timing

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13
Q

What compromises the vulva?

A 
Entrance to vagina and urethra
Clitoris
Labia minor 
Labia majora
Perineum 
Hymen
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14
Q

Normal vaginal pH?

A

3.8-4.4

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15
Q

What makes the vagina acidic?

A

Lactobacilli

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16
Q

What surrounds the cervix in the vagina in a moat like fashion? What is it deepest?

A

Anterior, lateral and posterior fornices

Posterior biggest

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17
Q

What is the opening to the cervix called? How does its shape vary after giving birth?

A

Os

Circular in nulparous, oval in parous

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18
Q

What is gravida

A

Number of times pregnant regardless of outcome - including current pregnancy

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19
Q

What is parity

A

Number of pregnancies carried to >24 weeks - ie live and still births

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20
Q

What is normal uterine position?

A

Anteverted and antiflexed

Cervix points backwards - uterus points forward then flops down onto cervix

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21
Q

When do girls start menache?

A

Mean 13 yrs

As early as 10

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22
Q

At what age should absence of periods be investigated?

A

15 with signs of puberty

14 with no signs of puberty

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23
Q

What happens to FSH, LH, oestrogen and progesterone during a normal menstrual cycle of 28 days?

A

Initially no inhibition so rising FSH during menstruation. Follicle develops producing oestrogen. Oestrogen inhibits GNrH and FSH causing a decrease in FSH levels. Follicle grows. High levels of oestrogen switch to positive feedback. LH surge. Ovulation. Oestrogen decrease back to negative feedback lowering LH and corpus luteum produces progesterone further lowering LH. No fertilisation. Corpus luteum degrades. No more oestrogen or progesterone. No inhibition. FSH and LH begin to rise again.

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24
Q

What are the effects of cyclical oestrogen on the female reproductive tract?

A

Endometrial proliferation

Thinning of the cervical mucus

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25
Q

What are the effects of cyclical progesterone on the female reproductive tract?

A

Convolution of endometrial glands

Cervical mucus becomes viscous

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26
Q

What is normal blood loss in menstruation?

A

20-80ml. Mean 28ml

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27
Q

How can menstruation be prosponed? E.g.for a holiday?

A

Norethisterone taken 3 days before period is due until ready to bleed again.
Alternatively take OCP without break for withdrawal bleed

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28
Q

Types of amenorrhoea and definitions?

A

Primary - never bled and over 14 with no secondary sexual characteristics or over 15 with secondary sexual characteristics
Secondary - stopped bleeding for 6 months or more and not pregnant

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29
Q

What are causes of primary amenorrhoea (excluding those of secondary amenorrhoea - all of which can also be implicated)?

A 
Late puberty - often familial 
Turners syndrome
Testicular feminization (CAH, testosterone resistance)
Imperforate hymen
Mullarian agenesis
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30
Q

Causes of secondary amenorrhoea?

A

Hypothalamic - stress, exercise, weight loss
Pituitary - hyperprolactinaemia, thyroid dysfunction, pituitary tumours, sheehan syndrome,
Ovarian - POCS, ovarian failure, premature menopause
Uterine - adhesions (e.g. Following dilation and cutterage)

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31
Q

Workup for secondary amenorrhoea

A 
BetaHCG (pregnant)
Serum free androgens (PCOS)
FSH/LH (hypothalamic or pituitary) 
Prolactin (hyperprolactinaemia, throid dysfunction, stress, medications)
TFTs (thyroid function)
Testosterone levels (CAH)
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32
Q

Additional workup in primary amenorrhoea

A

Karyotyping

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33
Q

System review symptoms to ask in gyne history

A

Urinary inc. incontinence

Bowel inc. incontinence

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34
Q

Causes of menorrhagia?

A 
Fibroids
Cancer
Clotting disorder
Hypothyroidism 
Coil
Pelvic inflammatory disease
Endometrial polyps 
Endometriosis 
Dysfunctional  uterine bleeding
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35
Q

When is dysfuctional uterine bleeding most common?

A

With anovulatory cycles - extremes of reproductive age

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36
Q

Investigations for menorrhagia?

A

Bloods - FBC, TFTs, clotting

USS

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37
Q

Medical management options for menorrhagia?

A 
Non-hormonal = NSAIDS, TXA
Hormonal = COCP, POP, danazole, GnRH analogue
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38
Q

Mechanism of action and main indication of danazole? Side effects?

A

Antioestrogen and antiprogesterone activity
Endometriosis
Side effects relate to androgenic activity (acne, hirsuitism, voice change) and menopausal like (mood, lowered libido, vaginal dryness)

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39
Q

Mechanism, main indications and side effects of GnRH agonists

A

Continuous pituitary stimulation resulting in down regulation of GnRH receptors and thus decreased LH and FSH release
Main indication is fibroids and menorrhagia with severe anaemia
Side effects are menopausal like including osteoporosis

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40
Q

Why are NSAIDs particularly useful in menorrhagia and dysmenorrhoea? Specific - non normal example

A

High levels of prostaglandins contribute to the bleeding

Mefenamic acid

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41
Q

Surgical options in menorrhagia

A

Coil
Endometrial ablation
Histerectomy
Uterine artery ligation

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42
Q

Causes of dysmenorrheoa

A 
Primary dysmenorrheoa
Endometriosis
Adenomyosis 
Fibroids
PID
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43
Q

Treatment of primary dysmenorrheoa

A 
Nsaid
COPC
Antispasmodic 
Mirena coil 
Treatment of underlying cause
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44
Q

Three cardinal features of PCOS

A

Clinical or haematological high androgens
USS showing multiple cysts on ovaries
Reduced, irregular or absent periods

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45
Q

Presentation of hyperandrogenaemia in PCOS

A

Acne
Male pattern baldness
Hirsuitism

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46
Q

Hormone changes in PCOS

A

Increased total and free testosterone (measured with ratio between total and serum testosterone binding globulin)
Increased LH

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47
Q

What hormones should be checked in suspected PCOS to rule out other causes?

A

TFTs
Prolactin
17a hydroxyprogesterone - elevated in CAH

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48
Q

Other than core symptoms of PCOS other syndromes with presentation

A

Insulin resistance - acanthosis nigracans, DM/IGT,
HTN
Endometrial hyperplasia - risk of endometrial cancer
Risk of ovarian cancer

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49
Q

Differentials for PCOS

A 
Thyroid dysfunction
Hyperprolactinaemia 
Androgen secreting tumour 
Cushings 
Congenital adrenal hyperplasia
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50
Q

Conservative management of PCOS

A

Stop smoking
Manage co-morbidities
Encourage weight loss
Hair removal (plucking, bleaching, waxing, lazer)

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51
Q

Medical management of PCOS with reasons

A

Metformin - improves insulin sensitivity and ovulation
Clomifene - to induce ovulation if fertility wanted
Combined pill - control bleeding with withdrawal bleeds, suppresses ovarian androgen production
Cyproterone acitate - antiadrogen
Spironolactone - HTN and antiandrogen

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52
Q

Symptoms of PMS

A

Tension, irritiability, bloating, breast tenderness, cravings, headache, depression
All worse before period and relieved by it

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53
Q

Menopausal symptoms

A 
Menstrual irregularity 
Atrophy of breasts
Flushes, sweats
Dryness of skin and vagina (dysparaunia, bleeding, infection)
Osteoporosis 
Mood change
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54
Q

Characteristics of flushes of menopause?

A

Brief, severe, occurs often

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55
Q

Management options for the menopause?

A

Councilling
Local oestrogen for vaginal dryness
Clondine for hot flushes
HRT

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56
Q

What does HRT help and not help?

A

Helps - flushing, vaginal atrophy/dryness, prospones osteoporosis, endometrial cancer (if continuous combined)

Doesnt help - cardiovascular problems, endometrial cancer (if cyclic combined)

Increases - stroke/thromboemobolism, breast cancer, endometrial cancer (if oestrogen only), ovarian cancer

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57
Q

If breast cancer is an issue in a lady wanting HRT for osteoporosis risk what could be used? What doesnt it help?

A

Selective oEstrogen Receptor Modifier - SERM
EG Raloxifene
Doesnt reduce flushes

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58
Q

Causes of labial itching (catagories and causes)

A

Any generalised cause (e.g. Liver failure)

SKIN CONDITIONS
Psoriasis
Eczema
Lichens planus

PATHOGENS
Scabies/lice
STI
Candidia

DYSTROPHY
Lichens sclerosis
Leukoplakia
Vulval cancer

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59
Q

What is lichen sclerosis? Presentation?

A

Autoimmune disorder turning elastin to collagen in the genital area
Usually presents in middle age. Appears as flat white and shiny. On rubbing or scratching easily blisters or ulcerates. Itches, urine stings, dysparaunia

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60
Q

Risk of lichen sclerosis and treatment

A

5% progress to cancer
Clobetasol proprionate (steroid)
May need topical tacrolimus

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61
Q

What is leukoplakia? How does it present? How is it treated?

A

Follows prolonged candidia infection or friction. Causes hypertrophy of skin. Can also commonly effect mouth
White patches, raised, itchy
Biopsy as pre malignant. Treat with topical corticosteroids, methotrexate or ciclosporin.

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62
Q

What is lichen planus, presentation, treatment?

A

Unknown cause.
White, red or pink raised rash. Painless white lacy streaks. Erosions and ulceration
Can also effect skin and mouth.
May need steroids

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63
Q

Precursor of vulval cancer?
Common cause?
Treatment

A

Vulval Intraepithelial Neoplasia
HPV16
Wide excision with reconstruction. Consideration to imiquimod but it is less successful

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64
Q

General conservative care for vulval puritis

A

Soap substitutes rather than shampoo/bubble bath
Wash only once a day with hand not cloth and blow dry
Wear loose clothes and sleep without underwear
Emoliants or chilled aqueous cream

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65
Q

What is the eponymous name for cysts forming from the same named glands under the labia minora?
Clinical features?
Complications?
Treatment of complicated?

A

Bartholins cyst
Painless cyst
Can become infected forming an abscess
Incise and drain

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66
Q

Types of vulval carcinoma?

A

Squamous cell carcinoma
Melanoma
Basal cell carcinoma

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67
Q

Presentation of vulval carcinoma

Treatment

A

Lump
Ulcer
Bleeding

Excise it +- lymph nodes
Radiotherapy to shrink
Chemoradio if unsuitable for surgery

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68
Q

Causes of cervical ectropion

A

All increase oestrogen!
Puberty (temporary)
COPC
Pregnancy

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69
Q

Treatment of cervical ectropion

A

Cryotherapy if symptomatic

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70
Q

Presentation of cervical polyps

A

Mucus discharge

Post coital bleeding

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71
Q

Treatment and assessment of cervical polyps in young and old

A

Young - excise

Old - excise then also D+C of uterus to exclude further pathology

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72
Q

What are the grades of pre malignant and malignant cervical neoplasm

A

Cervical intraepithelial neoplasia (CIN) 1 - lower basal third of epithelium
CIN II - 1-2/3 basal epithelium
CIN III - >2/3 basal epithelium
Invasive carcinoma

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73
Q

Which HPV types are associated with CIN1?

Which HPV types are associated with CIN2 or higher?

A

Cin 1 - 6+11

Cin 2 or higher - 16-18

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74
Q

What is the usual outcome of cin 1?

A

Regresses

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75
Q

What is detected on cervical smear tests that is indicative of CIN? What information can be gleaned from it?

A

Dyskaryosis

Degree of dyskaryosis correlates with severity of cin

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76
Q

What is the cervical smear screening programme in the uk?

A 
3 yearly 25-49
5 yearly 50-65
Annually for 10 years if previous CIN 
Only screen after 65 if one was abnormal previously 
Annually in HIV positive
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77
Q

What is the follow up to dyskaryosis found on a cervical smear?

A

Colposcopy with biopsy

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78
Q

What HPV vaccine protects against cervical carcinoma alone?

A

Gardasil

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79
Q

Risk factors for cervical cancer?

A 
HPV 16/18
Prolonged COCP
High parity 
HIV
Smoker
Many partners
80
Q

What is used to stain cervix in colposcopy to. See abnormal. Areas?

A

Acetic acid

81
Q

How can CIN be treated?

A

Cryotherapy
Laser therapy
Large loop excision

82
Q

Is a normal cervical smear completely reassuring for cervical cancer? If not why not?

A

Nope.

Adenocarcinomas (10%) tend to be in the canal thus are missed

83
Q

Staging of cervical cancer

A

Stage 1 - cervix
Stage 2 - upper vagina
Stage 3 - lower vagina / pelvic wall
Stage 4 - bladder or rectum / distant metastasis

84
Q

Symptoms and signs of cervical cancer?

A

Non-menstrual bleeding

Firm friable mass on cervix

85
Q

For borderline changes found on cervical smear what investigation is warrented? Actions on positive and negative results?

A

HPV 16/18 testing
Positive gets colposcopy
Negative gets returned to normal screening

86
Q

Risk factors for endometritis? Why?

A 
Misscariage/abortion
Childbirth
IUCD insertion
Surgery 
All break the protective mucous plug
87
Q

What happens with unopposed or high oestrogen without progesterone? Why might you get this? Short and long term effects.

A

Anovulatory or infrequent heavy cycles leading to endometrial proliferation and hyperplasia. This causes irregular bleeding as it breaks down and is a risk factor for endometrial carcinoma in more elderly patients.

88
Q

Treatment of endometrial hyperplasia?

A

Cyclical progesterone

89
Q

How can the endometrium be visualised with imaging? What need to be taken into account when assessing thickness?

A

Transvaginal ultrasound

Time of cycle - normally 5mm early, 11mm proliferative and 15mm late cycle.

90
Q

Presentation of vaginal carcinoma

A

Usually bleeding

91
Q

Medical name for uterine fibroid. Where do they form from?

A

Leiomyoma

Uterine smooth muscle

92
Q

What factors will increase the size of fibroids? Why?

A

Pregnancy
COCP
Fibroids are oestrogen dependant

93
Q

Presentation of fibroids

A

Asymptomatic
Menorrhagia (heavy and prolonged)
Distorted uterine cavity effecting implantation and IUCD
Pain (chronic or can tort causing severe sudden pain)
Urinary urgency or retention
Oedematous legs
Obstruction of labour

94
Q

Treatment of fibroids

A 
Mirina coil if able to fit
GNrH analogues eg goserelin 
Hysterectomy 
Myomectomy 
Embolisation of fibroids
95
Q

Risks of fibroids around pregnancy

A

PROBLEMS WITH PREGNANCY DUE TO FIBROID
Obstruction of labour (rare - plan c-section if near cervix)
Miscarriage
Infertility due to implantation problems
Treatment induced infertility
PROBLEMS WITH FIBROID DUE TO PREGNANCY
Increase in size of fibroid during pregnancy
Torsion
Red degeneration

96
Q

What is red degeneration of a fibroid

Presentation

A

Thrombosis of capsular vessels leading to venous engorgement and swelling of fibroid then degradation
Pain, vomiting, fever, localised peritoneal tenderness

97
Q

Usual presentation of nendometrial carcinoma

A

Postmenopausal bleeding
Initially scant but increasing to heavy and frequent
Intermenstrual bleeding in premenopausal women

98
Q

Staging of endometrial carcinoma

A

1 Body of uterus only
2 Body and cervix
3 Beyond uterus but within pelvis
4 Into bowels, bladder, or distal mets

99
Q

What hormone therapy may be used in advanced endometrial carcinoma to shrink the tumour?

A

High dose progesterone

100
Q

Risk factors for endometrial cancer

A 
Unopposed oestrogen (meds, functional ovarian tumour, obesity) 
PCOS
FHx
Nulliparity 
Late menopause
DM
Tamoxifen therapy
101
Q

Symptoms of ovarian cancer?

A 
Bloating, ascites and abdo distension
Pressure effect (low appetite, early satiety, urinary frequency)  
Weight loss
Fatigue 
Change in bowel habits
IBS (new onset >50) 
Acute abdo (from torsion or rupture)
102
Q

Initial work up and action for suspected ovarian cancer

A

Abdo exam - any masses or ascites 2ww
Ca125 - if +ve urgent USS abdo/pelvis, if +ve 2ww
If under 40 also measure AFP and HCG for non-epitheial cancer

103
Q

Proportion of ovarian tumours that are malignant?

A

6%

104
Q

Types of malignant ovarian tumours

A

Malignant Cystadenoma
Poorly differentiated teratoma
Choriocarcinoma
Ectodermal sinus tumour

105
Q

Types of benign ovarian tumours

A 
Functional cysts
Endometriotic cysts 
Endothelial cell tumours (mucinous and serous cystadenomas) 
Mature teratomas 
Fibromas
106
Q

What is a functional cyst (benign ovarian tumour)

Presentation

A

Enlarged persisting follicles/corpus luteum cysts
Can be painful on rupture, failure to rupture or torsion
Can be considered normal if

107
Q

What is a serous cystadenoma (benign ovarian tumour)

Risk

A

Cysts with papillary growths that can appear solid

30% become malignant

108
Q

What is a mucinous cystadenoma (benign ovarian tumour)

Risks

A

Large (to enormous) multilocular mucinous cyst
Rupture can cause peritonitis
5% risk of malignancy

109
Q

What should be removed along with a mucinous cystadenoma?

A

The appendix

110
Q

What is a ovarian fibroma? Associated syndrome and components?

A

Benign fibrous tissue tumours

Meigs syndrome - benign ovarian fibroma, right sided pleural effusion and ascites

111
Q

What is a mature teratoma? Another name? Is it malignant or benign?

A

A primitive germ cell tumour with well differentiated tissues. Dermoid cyst
Benign

112
Q

Other than mature teratoma (dermoid cyst) what other teratomas exist in female? Are they benign or malignant?

A

All malignant:

  • choriocarcioma
  • ectodermal sinus tumour (yoke sac)
113
Q

Where do ovarian secondaries come from (metastisis)

A

Uterus
Stomach
Transcelomic spread

114
Q

Complications of ovarian tumours in pregnancy?

A

Increased torsion
Tumour necrosis
Can obstruct labour

115
Q

What is more sensitive for ovarian cancer? Ca125 or USS?

A

USS (90 vs 80%)

116
Q

What genetic mutation is associated with ovarian cancer?

A

BRCA

117
Q

Risk factors for ovarian cancer?

A 
Many ovulations - nullparous, late menopause 
FHx (2 close relatives = 40% chance)
Fertility treatment 
HRT
Never used OCP
118
Q

Commonest cause of PID.

A

Chlamydia

119
Q

What are risk factors for vaginal infection spreading up causing PID

A

Childbirth

Instrumentation (colposcopy, IUCD)

120
Q

Other than the vagina where can PID organisms arise?

A

GI - appendix

Blood bourn e.g. TB

121
Q

What feature of cervical motion examination suggests PID

A

Bilateral pain on excitation

122
Q

Treatment of stable PID

A

Ofloxacin and metronidazole orally

Contact trace

123
Q

Treatment of severe PID

A

Ceftrioxone iv and doxycyclin po switching to doxy and metronidazole po.
Admit for stabilisation
Remove IUCD
Contact trace

124
Q

Complications of PID and presentation

A 
Abscess - resistance to ABX - drain 
Tubal blockage - sub fertility - IVF
Ectopic pregnancy 
Pelvic fibrosis and adhesions 
Perihepatic adhesions - RUQ pain
125
Q

What is the eponymous name for perihepatic adhesions in PID? Causative organism?

A

Fitz-Hugh-Curtis syndrome

Gonorrheoa

126
Q

Questions to ask in a patient who presents with incontinance

A 
Trigger - cough, laugh, exercise
Urge
Volumes passed
Effect on life 
Prolapse symptoms
127
Q

What do you look for in a pelvic exam in a patient with urinary incontinance?

A

Masses - eg fibroids
Prolapse
Infection - eg discharge
Atrophy

128
Q

Investigations to perform in a patient with urinary incontinance

A

Urine dip
Fasting glucose
Bladder diary

129
Q

Lifestyle changes that can help incontinance

A

Weight loss
Smoking cessation
Decrease caffeine intake

130
Q

Conservative management of stress urinary incontinence

A

Pelvic floor exercise

131
Q

Useful medication for stress urinary incontinence? Mechanism

A

Duloxetine

SNRI - decrease 5HT and NA in spinal cord activating pudendal nerve increasing external urinary sphincter contraction

132
Q

Surgical options for stress incontinence

A

Tension free tape to hold urethra in position

Urethral bulking

133
Q

Management of urge urinary incontinence - MOA of meds

A 
Lifestyle changes
Scheduled voiding 
Oxybutynin - anticholinergic 
Desmopressin - vasopressin analogue reducing urine production 
Botulinum toxin 
Sacral nerve stimulation 
Urinary diversion to bag
134
Q

Names of the different sorts of things that can prolapse into the vagina

A 
Cystocele
Rectocele
Urethrocele
Enterocele
Uterovagainal
135
Q

What is a cystocele, presentation.

A

Protrusion of bladder and upper front wall of vagina. Causes retained urine with increased urinary frequency and dysuria.

136
Q

What is a retiocele, presentation

A

Rectum and middle back wall of bowel protrude. May need to be pushed back by patient prior to defication

137
Q

What is a urethricele. Presentation

A

Urethra buldges forwards with lower front wall of vagina resulting in stress incontinence

138
Q

What is an enterocele.

A

Bowel and upper back wall of vagina protudes

139
Q

What are the degrees of uterine prolapse?

A

1st - cervix remains in vagina
2nd - cervix protrudes on standing or straining
3rd - uterus protrudes

140
Q

Symptoms of uterine prolapse

A

Something coming down
Worse during the day/standing
Urinary frequency and SUI
Difficulty in deification

141
Q

Conservative and medical management of uterine prolapse?

A

Loose weight, stop smoking, pelvic floor exercises
Topical oestrogen if post menopausal
Ring pessary for support

142
Q

Surgical management of uterine prolapse?

A

Hysterectomy

Colporrhaphy - excision of redundant mucosa and fascia repair

143
Q

What is chronic pelvic pain?

A

Pain either constant or interrmittent for >6 months not associated exclusively with mensturation, intercourse or pregnancy

144
Q

Physical causes of chronic pelvic pain

A 
Endometriosis 
Adenomyosis 
Adhesions
Ibs
Congested pelvic veins
145
Q

How does congested pelvic veins present

A

Chronic pelvic pain worse on standing or walking

146
Q

What is mid cycle pain termed?

A

Mittleschimers

147
Q

Commonest cause of chronic pelvic pain

A

Psychosexual

148
Q

When is the uterus usually palpable in the abdomen when pregnant? Causes of large for date in the first trimester?

A

12 weeks
Wrong date!
Uterine fibroid
Molar pregnancy

149
Q

Definition of miscarriage

A

loss of pregnancy before 24 weeks

150
Q

What can be done if a patient has a miscarriage but continues to bleed persistantly or heavily

A

Evacuation of Retained Products of Conception

151
Q

What are the types of miscarriage with brief description

A

Threatened - milder symptoms with closed os. 75% settle with rest
Inevitable - severe symptoms and os open
Incomplete - some retained products
Complete - all expelled
Missed - foetus dead but all retained

152
Q

Complication of a threatened miscarriage that has resolved later in pregnancy?

A

PPROM

153
Q

Management of an incomplete miscarriage

A

Perfuse bleeding - ergometrine

Retained products 50mm - ERPC

154
Q

Management options for a missed miscarriage?

A

Mifepristone and misoprostol

ERPC

155
Q

Cause of late miscarriage? Fix if suspected early?

A

Cervical incompetence

Cervical suture

156
Q

Definition of recurrent miscarriage

A

3 or more consecutive pregnancies lost before 24 weeks

157
Q

Causes of recurrent miscarriage

A 
Infections (bacterial vaginosis) 
Parental chromosomal abnormality (balanced translocation) 
Uterine abnormality 
Antiphospholipid syndrome
Thrombophilia
158
Q

Assessment and management of recurrent miscarriage

A

Antiphospholipid antibody testing
Thrombophillia testing
Pelvic ultrasound
Karyotyping both partners

159
Q

Management of antiphospholipid syndrome

A

Aspirin as soon as pregnancy diagnosed

LMWH as soon as fetal heart beat seen

160
Q

Predisposing factors for ectopic pregnancy

A

Salpingitis, previous surgery, previous ectopic, endometriosis, iucd, pop, tubal ligation

161
Q

Presentation of ectopic pregnancy

A 
Amenorrheoa 
Abdo pain with shoulder tip pain
Collapse
D+V
PV bleed (dark in colour)
162
Q

Examination findings of ectopic pregnancy

A

Enlarged uterus
Cervical excitation
Adenaxal mass

163
Q

Management of an ectopic

A

Consideration to anti D prophylaxis
If rupture suspected - immediate laparotomy
Large non emergency ectopic - laparoscopy
Small non emergency ectopic - methotrexate
Very small with falling HCG - expectant is possible

164
Q

Diagnosing an ectopic pregnancy

A

Urine pregnancy test
Serum HCG
USS

165
Q

What changes should be seen with serum HCG normally? What would suggest an ectopic (both in trend and comparision with USS)

A

Should double every 2 days
Less than doubling suggests ectopic
>6000 without sac in uterus on USS,1000-1500 without sac on TVUSS - very likely ectopic

166
Q

What should be given post ectopic surgery? Why?

A

Methotraxate - risk of persisting trophoblast

167
Q

What should be used to treat ectopics surgically? Salpingotomy or salpingectomy? When does this change?

A

Salpingectomy

Salpingotomy if other tube not healthy

168
Q

What is a hydradidiform mole?

Presentation?

A

A chorionic villus tumour
Early miscarriage
Abdominal pain (chronic with sudden torsion)
High levels of HCG - strong pregnancy symptoms and hyperthyroid

169
Q

What should occur after a hydradidiform mole is removed? Include change in HCG levels

A

Monitoring at specialist centre
Decline in HCG over 6 months
Avoid pregnancy for a year!

170
Q

What is a choriocarcinoma. How does it present?

A

Malignant tumour that follows pregnancy (miscarriage or delivery)
Presents with PV bleeding years post pregnancy with malaise, metastasis,

171
Q

Management options for severe PMS

A 
Vit B6
Reduce saturated fats
Bromocriptine
COCP
CBT
SSRI
172
Q

When can a pregnancy be terminated in the uk

A
  • risk to mothers life if continued
  • termination is necessary to prevent grave injury to mother mentally or physically
  • continuing risks mental or physical health of woman or existing children more than continuing (and fetus not >24 weeks)
  • substantial risk that child would be born with severe physical or mental handicap
173
Q

What should be considered when performing a termination of pregnancy on top of the meds to cause termination

A 
Councilling
Antibiotics
Anti-D
Discuss contraception 
Assess vte risk
174
Q

What meds are used for termination? What needs to be considered if fetus 22 weeks or older? What needs to be done after medical abortion?

A

Mifpristone
Misoprostol
Feticide to ensure it is born dead - intracardiac potassium or intraamniotic digoxin (less effective but easier)
USS to ensure termination as meds teratogenic

175
Q

What surgical abortion options are there?

A

Vacuum aspiration

Dilation and evacuation

176
Q

Risk factors for endometriosis

A 
Age (40s)
Long duration iucd
Long duration tampon use
No pregnancy
OCP
Genetics
177
Q

At what times in a women’s life will endometriosis usually regress

A

Pregnancy

Menopause

178
Q

What happens cyclically to endometriosis foci?

A

Grow and bleed causing fibrosis, adhesions and subfertility

179
Q

Presentation of endometriosis

A 
Asymptomatic
Cyclical pelvic pain - can be constant if adhesions
Dysmenorrheoa 
Dysparaunia 
Menorrhagia 
Subfertility 
Bleeding elsewhere - eg haemothorax
180
Q

Examination and investigation findings of endometriosis?

A

Fixed retroverted uterus
General tenderness
Laparoscopic cysts, adhesions and black deposits

181
Q

Medical treatment of endometriosis

A

Analegesia and nsaids
COCP
POP/injections/mirena coil
GNRH analogues

182
Q

Mechanism of cycle supression in endometriosis

A

Decreased cycles decreases symptoms

Suppressed ovulation causes lesion atrophy allowing cycles to resume if pregnancy desired

183
Q

Surgical management of endometriosis

A

Excision or laser ablation

Total hysterectomy and bilateral salpingooophorectomy

184
Q

Subclassification of dysparaunia

A

Superficial and deep

185
Q

Causes of superficial dysparaunia

A

Infection
Dryness
Episiotomy or tear
Vulval disorders

186
Q

Causes of deep dysparaunia

A 
Endometriosis
Infection (inc endometritis)
Ovaries lying close to vagina post hysterectomy 
Fibroids
Cancers
187
Q

Define infertility. Differentiate 1o and 2o

A

Unable to conceive after 1yr of unprotected intercourse
1o never had a baby
2o had a baby before

188
Q

Causes of infertility (broad)

A

FEMALE
Anovulation
Anatomical

MALE
Sperm problems
Sexual dysfunction

189
Q

Risk factors for miscarriage

A 
Age
Extremes of weight
Smoking
Diabetes
Antiphospholipid syndrom
Thrombophillia 
Alcohol
Genetics
Cervical incompetence 
Thyroid dysfunction
190
Q

What would be suggested by dark coloured PV bleeding with positive pregnancy test

A

Ectopic pregnancy - blood is old

191
Q

What size of gestational sac on ultrasound would you expect to see a fetus? What if you cant?

A

> 25mm, anembryonic pregnancy

192
Q

What length of fetus would you expect to see a heart beat on ultrasound?

A

7mm

193
Q

Complications of miscarriage

A

Psychological
Infection
Perforation (with treatment)
Anti D production

194
Q

Treatment options for sperm mediated infertility

A

Azoospermia - avoid alcohol and smoking, donor interuterine insemination
Erectile dysfunction/retrograde ejeculation - interuterine insemination

195
Q

Treatment of Anovulation infertility

A

Stimulation of failing part with hormones e.g. Clomphene
Intrauterine insemination
Ivf

FPE (11 decks)

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