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
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?
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
4
Q
Questions to ask regarding gyne HPC.
A
Cyclicality
Pain
Dysparaunia
5
Q
What is the date of the last menstrual period?
A
The first day of the last episode of bleeding
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
7
Q
What is the term for the period of time a few weeks post delivery of the placenta?
A
Puerperium
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
9
Q
Features of uterine pain?
A
Colicky and felt in the sacrum or groin
10
Q
Features of ovarian pain
A
Illiac fossa down anterior thigh into knee
11
Q
Questioning around dysparaunia?
A
Superfical or deep
12
Q
Questioning around vaginal discharge?
A
Colour
Smell
Itch
Timing
13
Q
What compromises the vulva?
A
Entrance to vagina and urethra Clitoris Labia minor Labia majora Perineum Hymen
14
Q
Normal vaginal pH?
A
3.8-4.4
15
Q
What makes the vagina acidic?
A
Lactobacilli
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
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
18
Q
What is gravida
A
Number of times pregnant regardless of outcome - including current pregnancy
19
Q
What is parity
A
Number of pregnancies carried to >24 weeks - ie live and still births
20
Q
What is normal uterine position?
A
Anteverted and antiflexed
Cervix points backwards - uterus points forward then flops down onto cervix
21
Q
When do girls start menache?
A
Mean 13 yrs
As early as 10
22
Q
At what age should absence of periods be investigated?
A
15 with signs of puberty
14 with no signs of puberty
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.
24
Q
What are the effects of cyclical oestrogen on the female reproductive tract?
A
Endometrial proliferation
Thinning of the cervical mucus
25
What are the effects of cyclical progesterone on the female reproductive tract?
Convolution of endometrial glands
| Cervical mucus becomes viscous
26
What is normal blood loss in menstruation?
20-80ml. Mean 28ml
27
How can menstruation be prosponed? E.g.for a holiday?
Norethisterone taken 3 days before period is due until ready to bleed again.
Alternatively take OCP without break for withdrawal bleed
28
Types of amenorrhoea and definitions?
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
29
What are causes of primary amenorrhoea (excluding those of secondary amenorrhoea - all of which can also be implicated)?
```
Late puberty - often familial
Turners syndrome
Testicular feminization (CAH, testosterone resistance)
Imperforate hymen
Mullarian agenesis
```
30
Causes of secondary amenorrhoea?
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)
31
Workup for secondary amenorrhoea
```
BetaHCG (pregnant)
Serum free androgens (PCOS)
FSH/LH (hypothalamic or pituitary)
Prolactin (hyperprolactinaemia, throid dysfunction, stress, medications)
TFTs (thyroid function)
Testosterone levels (CAH)
```
32
Additional workup in primary amenorrhoea
Karyotyping
33
System review symptoms to ask in gyne history
Urinary inc. incontinence
| Bowel inc. incontinence
34
Causes of menorrhagia?
```
Fibroids
Cancer
Clotting disorder
Hypothyroidism
Coil
Pelvic inflammatory disease
Endometrial polyps
Endometriosis
Dysfunctional uterine bleeding
```
35
When is dysfuctional uterine bleeding most common?
With anovulatory cycles - extremes of reproductive age
36
Investigations for menorrhagia?
Bloods - FBC, TFTs, clotting
| USS
37
Medical management options for menorrhagia?
```
Non-hormonal = NSAIDS, TXA
Hormonal = COCP, POP, danazole, GnRH analogue
```
38
Mechanism of action and main indication of danazole? Side effects?
Antioestrogen and antiprogesterone activity
Endometriosis
Side effects relate to androgenic activity (acne, hirsuitism, voice change) and menopausal like (mood, lowered libido, vaginal dryness)
39
Mechanism, main indications and side effects of GnRH agonists
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
40
Why are NSAIDs particularly useful in menorrhagia and dysmenorrhoea? Specific - non normal example
High levels of prostaglandins contribute to the bleeding
| Mefenamic acid
41
Surgical options in menorrhagia
Coil
Endometrial ablation
Histerectomy
Uterine artery ligation
42
Causes of dysmenorrheoa
```
Primary dysmenorrheoa
Endometriosis
Adenomyosis
Fibroids
PID
```
43
Treatment of primary dysmenorrheoa
```
Nsaid
COPC
Antispasmodic
Mirena coil
Treatment of underlying cause
```
44
Three cardinal features of PCOS
Clinical or haematological high androgens
USS showing multiple cysts on ovaries
Reduced, irregular or absent periods
45
Presentation of hyperandrogenaemia in PCOS
Acne
Male pattern baldness
Hirsuitism
46
Hormone changes in PCOS
Increased total and free testosterone (measured with ratio between total and serum testosterone binding globulin)
Increased LH
47
What hormones should be checked in suspected PCOS to rule out other causes?
TFTs
Prolactin
17a hydroxyprogesterone - elevated in CAH
48
Other than core symptoms of PCOS other syndromes with presentation
Insulin resistance - acanthosis nigracans, DM/IGT,
HTN
Endometrial hyperplasia - risk of endometrial cancer
Risk of ovarian cancer
49
Differentials for PCOS
```
Thyroid dysfunction
Hyperprolactinaemia
Androgen secreting tumour
Cushings
Congenital adrenal hyperplasia
```
50
Conservative management of PCOS
Stop smoking
Manage co-morbidities
Encourage weight loss
Hair removal (plucking, bleaching, waxing, lazer)
51
Medical management of PCOS with reasons
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
52
Symptoms of PMS
Tension, irritiability, bloating, breast tenderness, cravings, headache, depression
All worse before period and relieved by it
53
Menopausal symptoms
```
Menstrual irregularity
Atrophy of breasts
Flushes, sweats
Dryness of skin and vagina (dysparaunia, bleeding, infection)
Osteoporosis
Mood change
```
54
Characteristics of flushes of menopause?
Brief, severe, occurs often
55
Management options for the menopause?
Councilling
Local oestrogen for vaginal dryness
Clondine for hot flushes
HRT
56
What does HRT help and not help?
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
57
If breast cancer is an issue in a lady wanting HRT for osteoporosis risk what could be used? What doesnt it help?
Selective oEstrogen Receptor Modifier - SERM
EG Raloxifene
Doesnt reduce flushes
58
Causes of labial itching (catagories and causes)
Any generalised cause (e.g. Liver failure)
SKIN CONDITIONS
Psoriasis
Eczema
Lichens planus
PATHOGENS
Scabies/lice
STI
Candidia
DYSTROPHY
Lichens sclerosis
Leukoplakia
Vulval cancer
59
What is lichen sclerosis? Presentation?
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
60
Risk of lichen sclerosis and treatment
5% progress to cancer
Clobetasol proprionate (steroid)
May need topical tacrolimus
61
What is leukoplakia? How does it present? How is it treated?
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.
62
What is lichen planus, presentation, treatment?
Unknown cause.
White, red or pink raised rash. Painless white lacy streaks. Erosions and ulceration
Can also effect skin and mouth.
May need steroids
63
Precursor of vulval cancer?
Common cause?
Treatment
Vulval Intraepithelial Neoplasia
HPV16
Wide excision with reconstruction. Consideration to imiquimod but it is less successful
64
General conservative care for vulval puritis
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
65
What is the eponymous name for cysts forming from the same named glands under the labia minora?
Clinical features?
Complications?
Treatment of complicated?
Bartholins cyst
Painless cyst
Can become infected forming an abscess
Incise and drain
66
Types of vulval carcinoma?
Squamous cell carcinoma
Melanoma
Basal cell carcinoma
67
Presentation of vulval carcinoma
| Treatment
Lump
Ulcer
Bleeding
Excise it +\- lymph nodes
Radiotherapy to shrink
Chemoradio if unsuitable for surgery
68
Causes of cervical ectropion
All increase oestrogen!
Puberty (temporary)
COPC
Pregnancy
69
Treatment of cervical ectropion
Cryotherapy if symptomatic
70
Presentation of cervical polyps
Mucus discharge
| Post coital bleeding
71
Treatment and assessment of cervical polyps in young and old
Young - excise
| Old - excise then also D+C of uterus to exclude further pathology
72
What are the grades of pre malignant and malignant cervical neoplasm
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
73
Which HPV types are associated with CIN1?
| Which HPV types are associated with CIN2 or higher?
Cin 1 - 6+11
| Cin 2 or higher - 16-18
74
What is the usual outcome of cin 1?
Regresses
75
What is detected on cervical smear tests that is indicative of CIN? What information can be gleaned from it?
Dyskaryosis
| Degree of dyskaryosis correlates with severity of cin
76
What is the cervical smear screening programme in the uk?
```
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
```
77
What is the follow up to dyskaryosis found on a cervical smear?
Colposcopy with biopsy
78
What HPV vaccine protects against cervical carcinoma alone?
Gardasil
79
Risk factors for cervical cancer?
```
HPV 16/18
Prolonged COCP
High parity
HIV
Smoker
Many partners
```
80
What is used to stain cervix in colposcopy to. See abnormal. Areas?
Acetic acid
81
How can CIN be treated?
Cryotherapy
Laser therapy
Large loop excision
82
Is a normal cervical smear completely reassuring for cervical cancer? If not why not?
Nope.
| Adenocarcinomas (10%) tend to be in the canal thus are missed
83
Staging of cervical cancer
Stage 1 - cervix
Stage 2 - upper vagina
Stage 3 - lower vagina / pelvic wall
Stage 4 - bladder or rectum / distant metastasis
84
Symptoms and signs of cervical cancer?
Non-menstrual bleeding
| Firm friable mass on cervix
85
For borderline changes found on cervical smear what investigation is warrented? Actions on positive and negative results?
HPV 16/18 testing
Positive gets colposcopy
Negative gets returned to normal screening
86
Risk factors for endometritis? Why?
```
Misscariage/abortion
Childbirth
IUCD insertion
Surgery
All break the protective mucous plug
```
87
What happens with unopposed or high oestrogen without progesterone? Why might you get this? Short and long term effects.
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
Treatment of endometrial hyperplasia?
Cyclical progesterone
89
How can the endometrium be visualised with imaging? What need to be taken into account when assessing thickness?
Transvaginal ultrasound
| Time of cycle - normally 5mm early, 11mm proliferative and 15mm late cycle.
90
Presentation of vaginal carcinoma
Usually bleeding
91
Medical name for uterine fibroid. Where do they form from?
Leiomyoma
| Uterine smooth muscle
92
What factors will increase the size of fibroids? Why?
Pregnancy
COCP
Fibroids are oestrogen dependant
93
Presentation of fibroids
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
Treatment of fibroids
```
Mirina coil if able to fit
GNrH analogues eg goserelin
Hysterectomy
Myomectomy
Embolisation of fibroids
```
95
Risks of fibroids around pregnancy
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
What is red degeneration of a fibroid
| Presentation
Thrombosis of capsular vessels leading to venous engorgement and swelling of fibroid then degradation
Pain, vomiting, fever, localised peritoneal tenderness
97
Usual presentation of nendometrial carcinoma
Postmenopausal bleeding
Initially scant but increasing to heavy and frequent
Intermenstrual bleeding in premenopausal women
98
Staging of endometrial carcinoma
1 Body of uterus only
2 Body and cervix
3 Beyond uterus but within pelvis
4 Into bowels, bladder, or distal mets
99
What hormone therapy may be used in advanced endometrial carcinoma to shrink the tumour?
High dose progesterone
100
Risk factors for endometrial cancer
```
Unopposed oestrogen (meds, functional ovarian tumour, obesity)
PCOS
FHx
Nulliparity
Late menopause
DM
Tamoxifen therapy
```
101
Symptoms of ovarian cancer?
```
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
Initial work up and action for suspected ovarian cancer
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
Proportion of ovarian tumours that are malignant?
6%
104
Types of malignant ovarian tumours
Malignant Cystadenoma
Poorly differentiated teratoma
Choriocarcinoma
Ectodermal sinus tumour
105
Types of benign ovarian tumours
```
Functional cysts
Endometriotic cysts
Endothelial cell tumours (mucinous and serous cystadenomas)
Mature teratomas
Fibromas
```
106
What is a functional cyst (benign ovarian tumour)
| Presentation
Enlarged persisting follicles/corpus luteum cysts
Can be painful on rupture, failure to rupture or torsion
Can be considered normal if
107
What is a serous cystadenoma (benign ovarian tumour)
| Risk
Cysts with papillary growths that can appear solid
| 30% become malignant
108
What is a mucinous cystadenoma (benign ovarian tumour)
| Risks
Large (to enormous) multilocular mucinous cyst
Rupture can cause peritonitis
5% risk of malignancy
109
What should be removed along with a mucinous cystadenoma?
The appendix
110
What is a ovarian fibroma? Associated syndrome and components?
Benign fibrous tissue tumours
| Meigs syndrome - benign ovarian fibroma, right sided pleural effusion and ascites
111
What is a mature teratoma? Another name? Is it malignant or benign?
A primitive germ cell tumour with well differentiated tissues. Dermoid cyst
Benign
112
Other than mature teratoma (dermoid cyst) what other teratomas exist in female? Are they benign or malignant?
All malignant:
- choriocarcioma
- ectodermal sinus tumour (yoke sac)
113
Where do ovarian secondaries come from (metastisis)
Uterus
Stomach
Transcelomic spread
114
Complications of ovarian tumours in pregnancy?
Increased torsion
Tumour necrosis
Can obstruct labour
115
What is more sensitive for ovarian cancer? Ca125 or USS?
USS (90 vs 80%)
116
What genetic mutation is associated with ovarian cancer?
BRCA
117
Risk factors for ovarian cancer?
```
Many ovulations - nullparous, late menopause
FHx (2 close relatives = 40% chance)
Fertility treatment
HRT
Never used OCP
```
118
Commonest cause of PID.
Chlamydia
119
What are risk factors for vaginal infection spreading up causing PID
Childbirth
| Instrumentation (colposcopy, IUCD)
120
Other than the vagina where can PID organisms arise?
GI - appendix
| Blood bourn e.g. TB
121
What feature of cervical motion examination suggests PID
Bilateral pain on excitation
122
Treatment of stable PID
Ofloxacin and metronidazole orally
| Contact trace
123
Treatment of severe PID
Ceftrioxone iv and doxycyclin po switching to doxy and metronidazole po.
Admit for stabilisation
Remove IUCD
Contact trace
124
Complications of PID and presentation
```
Abscess - resistance to ABX - drain
Tubal blockage - sub fertility - IVF
Ectopic pregnancy
Pelvic fibrosis and adhesions
Perihepatic adhesions - RUQ pain
```
125
What is the eponymous name for perihepatic adhesions in PID? Causative organism?
Fitz-Hugh-Curtis syndrome
| Gonorrheoa
126
Questions to ask in a patient who presents with incontinance
```
Trigger - cough, laugh, exercise
Urge
Volumes passed
Effect on life
Prolapse symptoms
```
127
What do you look for in a pelvic exam in a patient with urinary incontinance?
Masses - eg fibroids
Prolapse
Infection - eg discharge
Atrophy
128
Investigations to perform in a patient with urinary incontinance
Urine dip
Fasting glucose
Bladder diary
129
Lifestyle changes that can help incontinance
Weight loss
Smoking cessation
Decrease caffeine intake
130
Conservative management of stress urinary incontinence
Pelvic floor exercise
131
Useful medication for stress urinary incontinence? Mechanism
Duloxetine
| SNRI - decrease 5HT and NA in spinal cord activating pudendal nerve increasing external urinary sphincter contraction
132
Surgical options for stress incontinence
Tension free tape to hold urethra in position
| Urethral bulking
133
Management of urge urinary incontinence - MOA of meds
```
Lifestyle changes
Scheduled voiding
Oxybutynin - anticholinergic
Desmopressin - vasopressin analogue reducing urine production
Botulinum toxin
Sacral nerve stimulation
Urinary diversion to bag
```
134
Names of the different sorts of things that can prolapse into the vagina
```
Cystocele
Rectocele
Urethrocele
Enterocele
Uterovagainal
```
135
What is a cystocele, presentation.
Protrusion of bladder and upper front wall of vagina. Causes retained urine with increased urinary frequency and dysuria.
136
What is a retiocele, presentation
Rectum and middle back wall of bowel protrude. May need to be pushed back by patient prior to defication
137
What is a urethricele. Presentation
Urethra buldges forwards with lower front wall of vagina resulting in stress incontinence
138
What is an enterocele.
Bowel and upper back wall of vagina protudes
139
What are the degrees of uterine prolapse?
1st - cervix remains in vagina
2nd - cervix protrudes on standing or straining
3rd - uterus protrudes
140
Symptoms of uterine prolapse
Something coming down
Worse during the day/standing
Urinary frequency and SUI
Difficulty in deification
141
Conservative and medical management of uterine prolapse?
Loose weight, stop smoking, pelvic floor exercises
Topical oestrogen if post menopausal
Ring pessary for support
142
Surgical management of uterine prolapse?
Hysterectomy
| Colporrhaphy - excision of redundant mucosa and fascia repair
143
What is chronic pelvic pain?
Pain either constant or interrmittent for >6 months not associated exclusively with mensturation, intercourse or pregnancy
144
Physical causes of chronic pelvic pain
```
Endometriosis
Adenomyosis
Adhesions
Ibs
Congested pelvic veins
```
145
How does congested pelvic veins present
Chronic pelvic pain worse on standing or walking
146
What is mid cycle pain termed?
Mittleschimers
147
Commonest cause of chronic pelvic pain
Psychosexual
148
When is the uterus usually palpable in the abdomen when pregnant? Causes of large for date in the first trimester?
12 weeks
Wrong date!
Uterine fibroid
Molar pregnancy
149
Definition of miscarriage
loss of pregnancy before 24 weeks
150
What can be done if a patient has a miscarriage but continues to bleed persistantly or heavily
Evacuation of Retained Products of Conception
151
What are the types of miscarriage with brief description
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
Complication of a threatened miscarriage that has resolved later in pregnancy?
PPROM
153
Management of an incomplete miscarriage
Perfuse bleeding - ergometrine
| Retained products 50mm - ERPC
154
Management options for a missed miscarriage?
Mifepristone and misoprostol
| ERPC
155
Cause of late miscarriage? Fix if suspected early?
Cervical incompetence
| Cervical suture
156
Definition of recurrent miscarriage
3 or more consecutive pregnancies lost before 24 weeks
157
Causes of recurrent miscarriage
```
Infections (bacterial vaginosis)
Parental chromosomal abnormality (balanced translocation)
Uterine abnormality
Antiphospholipid syndrome
Thrombophilia
```
158
Assessment and management of recurrent miscarriage
Antiphospholipid antibody testing
Thrombophillia testing
Pelvic ultrasound
Karyotyping both partners
159
Management of antiphospholipid syndrome
Aspirin as soon as pregnancy diagnosed
| LMWH as soon as fetal heart beat seen
160
Predisposing factors for ectopic pregnancy
Salpingitis, previous surgery, previous ectopic, endometriosis, iucd, pop, tubal ligation
161
Presentation of ectopic pregnancy
```
Amenorrheoa
Abdo pain with shoulder tip pain
Collapse
D+V
PV bleed (dark in colour)
```
162
Examination findings of ectopic pregnancy
Enlarged uterus
Cervical excitation
Adenaxal mass
163
Management of an ectopic
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
Diagnosing an ectopic pregnancy
Urine pregnancy test
Serum HCG
USS
165
What changes should be seen with serum HCG normally? What would suggest an ectopic (both in trend and comparision with USS)
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
What should be given post ectopic surgery? Why?
Methotraxate - risk of persisting trophoblast
167
What should be used to treat ectopics surgically? Salpingotomy or salpingectomy? When does this change?
Salpingectomy
| Salpingotomy if other tube not healthy
168
What is a hydradidiform mole?
| Presentation?
A chorionic villus tumour
Early miscarriage
Abdominal pain (chronic with sudden torsion)
High levels of HCG - strong pregnancy symptoms and hyperthyroid
169
What should occur after a hydradidiform mole is removed? Include change in HCG levels
Monitoring at specialist centre
Decline in HCG over 6 months
Avoid pregnancy for a year!
170
What is a choriocarcinoma. How does it present?
Malignant tumour that follows pregnancy (miscarriage or delivery)
Presents with PV bleeding years post pregnancy with malaise, metastasis,
171
Management options for severe PMS
```
Vit B6
Reduce saturated fats
Bromocriptine
COCP
CBT
SSRI
```
172
When can a pregnancy be terminated in the uk
- 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
What should be considered when performing a termination of pregnancy on top of the meds to cause termination
```
Councilling
Antibiotics
Anti-D
Discuss contraception
Assess vte risk
```
174
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?
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
What surgical abortion options are there?
Vacuum aspiration
| Dilation and evacuation
176
Risk factors for endometriosis
```
Age (40s)
Long duration iucd
Long duration tampon use
No pregnancy
OCP
Genetics
```
177
At what times in a women's life will endometriosis usually regress
Pregnancy
| Menopause
178
What happens cyclically to endometriosis foci?
Grow and bleed causing fibrosis, adhesions and subfertility
179
Presentation of endometriosis
```
Asymptomatic
Cyclical pelvic pain - can be constant if adhesions
Dysmenorrheoa
Dysparaunia
Menorrhagia
Subfertility
Bleeding elsewhere - eg haemothorax
```
180
Examination and investigation findings of endometriosis?
Fixed retroverted uterus
General tenderness
Laparoscopic cysts, adhesions and black deposits
181
Medical treatment of endometriosis
Analegesia and nsaids
COCP
POP/injections/mirena coil
GNRH analogues
182
Mechanism of cycle supression in endometriosis
Decreased cycles decreases symptoms
| Suppressed ovulation causes lesion atrophy allowing cycles to resume if pregnancy desired
183
Surgical management of endometriosis
Excision or laser ablation
| Total hysterectomy and bilateral salpingooophorectomy
184
Subclassification of dysparaunia
Superficial and deep
185
Causes of superficial dysparaunia
Infection
Dryness
Episiotomy or tear
Vulval disorders
186
Causes of deep dysparaunia
```
Endometriosis
Infection (inc endometritis)
Ovaries lying close to vagina post hysterectomy
Fibroids
Cancers
```
187
Define infertility. Differentiate 1o and 2o
Unable to conceive after 1yr of unprotected intercourse
1o never had a baby
2o had a baby before
188
Causes of infertility (broad)
FEMALE
Anovulation
Anatomical
MALE
Sperm problems
Sexual dysfunction
189
Risk factors for miscarriage
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Age
Extremes of weight
Smoking
Diabetes
Antiphospholipid syndrom
Thrombophillia
Alcohol
Genetics
Cervical incompetence
Thyroid dysfunction
```
190
What would be suggested by dark coloured PV bleeding with positive pregnancy test
Ectopic pregnancy - blood is old
191
What size of gestational sac on ultrasound would you expect to see a fetus? What if you cant?
>25mm, anembryonic pregnancy
192
What length of fetus would you expect to see a heart beat on ultrasound?
7mm
193
Complications of miscarriage
Psychological
Infection
Perforation (with treatment)
Anti D production
194
Treatment options for sperm mediated infertility
Azoospermia - avoid alcohol and smoking, donor interuterine insemination
Erectile dysfunction/retrograde ejeculation - interuterine insemination
195
Treatment of Anovulation infertility
Stimulation of failing part with hormones e.g. Clomphene
Intrauterine insemination
Ivf
