Gynae 2 - Infection and Malignancy Flashcards by Lucy Searle

What is a hyatidiform mole?

Abnormal conception - growing mass of tissue in the womb that will not develop into a foetus

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What are the two types of hyatidiform mole and what are the risk factors?

Complete - extremes of reproductive life, previous history

Partial - previous history

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What is the karyotype in complete and partial moles?

Complete - 46XX

Partial - 69XXX, XXY, XYY

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What are the signs of hyatidiform mole?

Irregular first trimester bleeding 90%
Uterus large for dates
Exaggerated pregnancy symptoms

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What is the serum hCG in hyatidiform moles?

Complete - excessively high

Partial - normal to high

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What is seen on USS in Hyatidiform moles?

Snowstorm appearance

Large theca lutein cysts

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What is the treatment of complete moles?

Surgical curettage and anti-D prophylaxis

Chemotherapy if persistently raised hCG/persistent symptoms

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What is the treatment of partial moles?

Surgical or medical evacuation

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What is the name of the tumour consisting of syncytiotrophoblasts and cytotrophoblasts?

Choriocarcinoma - cancer of the placenta

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Where does choriocarcinoma metastasise to early?

Lung

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What are the risk factors for choriocarcinoma?

Hyatidiform mole,
Normal pregnancy
Ectopic

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What are the symptoms of choriocarcinoma?

Vaginal bleeding
Abdominal/vaginal swelling
Amenorhoea
Dyspnoea and haemoptysis

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What is the treatment of choriocarcinoma?

Chemo and then hysterectomy

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What is the most common form of ovarian cancer?

Epithelial

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What demographic gets ovarian cancer?

75-84 years

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What factors increase the risk of ovarian cancer?

Multiple ovulations (early menarche, late menopause)
BRCA1 and BRCA2 mutations
Lynch Syndrome lifetime risk 12%

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What are the symptoms of Ovarian cancer?

Vague
Abdo distension
Urinary/bowel change
Abnormal vaginal bleeding

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How is ovarian cancer diagnosed?

Increased CA125, CA19.9 raised in mucinous tumours
Abdo/pelvic USS
CT

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What surgery is required in ovarian cancer?

Hysterectomy with bilateral salpingo-opherectomy

Stages 2-4

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What is a risk factor for vulval squamous cell cancer?

Lichen sclerosis

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What is seen in lichen sclerosis?

Burning pain or itching
White thickening, figure of 8
Hyperkeratosis and purpura

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What is the treatment of lichen sclerosis?

Reducing course of clobetasol proprionate 0.05% OD

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Give three risk factors for endometrial cancer

Endo/exogenous unopposed oestrogen - PCOS, HRT
Obesity
Nulliparity (reduced progesterone)
Lynch syndrome (40-60%)

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What type of tumour is the most common endometrial cancer?

Adenocarcinoma

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What staging is used in endometrial cancer?

Figo

How does endometrial cancer present?

PMB | Unless younger - menstrual disturbance

What thickness of endometrium indicates no pathology?

<4mm

What is the necessary precursor lesion for carcinoma of the cervix?

Cervical intraepithelial neoplasia (CIN)

What are the most common oncogenic subtypes of HPV?

16, 18, 31, 33

What are the risk factors for CIN and cervical cancer?

Persistent HPV Multiple partners Smoking Immunocompromise

What is the transformation zone (TZ)?

The glandular epithelium of the endocervix is pushed out onto the ectocervix, and in response to low pH, undergoes physiological squamous metaplasia

How often are women called for their cervical screening tests?

25-49 - every 3 years | 50-64 - every 5 years

What may be seen on abnormal smears?

Abnormal nuclei shape/density Increased nuclear/cytoplasmic ratio Inflammation Dyskaryosis

Application of what in colposcopy magnifies the TZ?

5% acetic acid or Lugol's iodine

Detail the histological types of CIN

CIN 1 - bottom 1/3 of squamous epithelium CIN II - bottom 2/3 of squamous epithelium CIN III - full thickness dysplasia

How does cervical cancer present?

PCB/PMB | Weight loss or bowel/urinary change

What is LLETZ?

Large loop excision of the transformation zone

What are uterine fibroids?

Common benign tumours of the myometrium | Smooth muscle and fibrous tissue

What is the presentation of fibroids?

``` Dysmenorrhoea/menorrhagia Pressure symptoms e.g. frequency Pelvic pain Infertility Red degeneration in pregnancy ```

Give three types of fibroid

Submucous Intramural Pedunculated

How are symptomatic fibroids treated?

Tranexamic acid or Mirena IUS | GnRH analogues shrink fibroid before laparoscopic myomectomy or hysterectomy

What is a focal overgrowth of the endometrium?

Endometrial polyp/adenoma

What features would indicate abnormal ovarian cysts?

Woman not having periods Symptomatic Cyst over 5cm in size

What does the risk of malignancy index (RMI) use in ovarian cysts?

Ultrasound features CA125 Menopausal status

What are the symptoms of ovarian cysts?

Chronic pain - dull ache Acute pain - bleeding or rupture DUB

What are the risk factors for vulval cancer?

Lichen sclerosis | Vulval intraepithelial neoplasia (VIN)

What infection is associated with VIN?

HPV 16

Exposure to what in utero can cause vaginal cancer in adolescents?

Diethylstilbestrol (DES)

What are the risk factors for vaginal cancer?

Other cancers of the genital tract HPV 16 Smoking HIV

What is trichomonas vaginalis?

Flagellated protozoan

What discharge is seen in trichomonas?

Frothy, green, offensive smelling

How is trichomonas diagnosed?

Wet smear -Posterior fornix swab - Diamond's TYM culture Strawberry cervix

What is the treatment of trichomonas?

Metronidazole 2g single dose/500mg 5-7d

What management is important in all STIs?

Contact tracing | Abstinence until treatment course is finished

What are the risks of STIs in pregnancy?

PROM and prematurity Low birth weight Perinatal acquisition

Which viruses cause genital warts?

HPV 6 and HPV 11

What is the treatment of genital warts?

Podophyllotoxin paint/imiquimod 5% cream self application | Cryotherapy

Which spirochaete causes syphilis?

Treponemum pallidum

What occurs in primary syphilis?

Painless genital ulcer (chancre) | Inguinal lymphadenopathy

What occurs in secondary syphilis?

Polymorphic rash on palms and soles Condyloma lata Anterior uveitis

What are the three components of tertiary syphilis?

Neurosyphilis Aortic root disease Gummata

Give one diagnostic test for syphilis

Rapid plasma reagin test (screening) | Fluorescent treponemal antibody absorption test (FTA-abs)

How is syphilis eradicated?

IM benzathine penicillin OR azithromycin

What are the symptoms of herpes simplex infection?

Flu Inguinal lymphadenopathy Vulvitis and pain Small characteristic vesicles on the vulva

Where does the HSV virus reside in latent periods?

Sacral ganglia

How is HSV diagnosed?

Viral culture of vesicle fluid

What medication reduces severity and duration of primary attack?

Aciclovir

What type of bacteria is Neisseria gonorrhoea?

Intracellular Gram negative diplococcus

What discharge is seen in Gonorrhoea?

Greenish, 2-7 days after infection

What antibiotics are used to treat gonorrhoea?

IM Ceftriaxone single dose PLUS azithromycin single dose

How is gonorrhoea diagnosed

Endocervical/urethral swabs | Nucleic-acid amplification test (NAAT)

Which organism causes chlamydia?

Chlamydia trachomatis parasite

What are the symptoms of chlamydia?

Increased vaginal discharge secondary to cervicitis, yellow/milky white/bleeding Asymptomatic

What antibiotic is used for chlamydia?

Azithromycin

What is a consequence of chlamydia?

Tubal infertility

What is the presentation of candida infection?

Vulval itching and soreness Thick curd like white vaginal discharge Dysuria Superficial dyspareunia

What is the treatment of candida?

Clotrimazole pessary and topical cream

What causes bacterial vaginosis?

Overgrowth of mixed anaerobes including Gardnerella and mycoplasma hominis Replaces the usually dominant bacterial vaginal lactobacilli

What are the symptoms of BV?

Profuse white-grey offensive discharge | Fishy smell from amines

How is BV diagnosed?

Increased vaginal pH>5.5 | Vaginal wall swab - clue cells on microscopy

What is the treatment of BV?

Metronidazole

Infection of the upper genital tract is known as?

Pelvic inflammatory disease

What are the risk factors for PID?

Previous STI Multiple partners Uterine instrumentation Postpartum endometritis

What are the signs of PID?

Cervical excitation and adnexal tenderness fever Vaginal discharge Dyspareunia

Laparoscopy is gold standard for PID. When is it indicated?

Tubo-ovarian abscess

What antibiotics are needed in PID?

Ceftriaxone and doxycycline and metronidazole

What are elementary bodies?

Attach to sperm in chlamydia

What is the treatment of chlamydia in pregnancy?

Erythromycin

What are the chances of conception per cycle?

14%

What is a delayed miscarriage?

"missed" Fetal demise occurs but body's rejection of dead fetus is delayed Slight brown discharge

What is the first line investigation in PMB?

TVUS for endometrial thickness

What is first line and second line treatment for atrophic vaginitis?

1st: oestrogen cream 2nd: lubricants and moisturizers

What is the risk of chickenpox in pregnancy?

Maternal - 5x risk of pneumonitis | Foetal varicella syndrome - LD, skin scarring, microphthalmia

What is the first and second line management of contact with someone with chicken pox in pregnancy?

Check varicella antibodies | Give varicella immunoglobulin

What is the management of thrush in pregnancy?

Clotrimazole pessary | Fluconazole CI in pregnancy

What is an absolute contraindication to the copper IUD?

PID

What is the appropriate management of a woman over 45 on hormonal contraception with change in pattern of bleeding?

Endometrial biopsy

Which STIs are diagnosed with a nucleic acid amplification test (first void urine)?

Gonorrhoea | Chlamydia

What is the incubation for chlamydia and gonorrhoea?

2 weeks

What are the symptoms of chlamydia in men?

Asymptomatic Discharge Dysuria

What must you avoid when taking metronidazole?

Avoid alcohol

Which antibiotics interact with the pill?

Rifampicin

What are the long term complications of sexually transmitted diseases?

PID women Subfertility Urethral strictures men Neurosyphilis etc

What is the whirlpool sign?

Seen on ultrasound in ovarian torsion

When should a woman with CIN have another smear?

6 months later