gynae Flashcards
What is abnormal uterine bleeding defined as?
Any bleeding that is either:
- Abnormal in volume (excessive duration or heavy),
- Irregularity, timing (delayed or frequent), or
- Non-menstrual bleeding: intermenstrual (IMB), post-coital (PCB) or post-menopausal (PMB) bleeding
This definition covers the whole spectrum of menstrual bleeding disorders.
What is the normal range of a menstrual cycle?
25-32 days
Definition of heavy menstrual bleeding?
heavy menstrual bleeding (HMB)
Menstrual blood loss that is considered to be excessive by the woman and interferes with her physical, emotional, social and marital quality of life. It can occur alone or in combination with other symptoms
what is the acronym to remember the different causes of abnormal uterine bleeding? 9 (4 structural, 5 non-structural)
also which women is this acronym relevant for?
PALM COEIN
PALM = structural causes
- POLYPS (endometrial / cervical)
- ADENOMYOSIS (ectopic endometrium in the muscle)
- LEIOMYOMA (fibroids)
- MALIGNANCY of genital tract, also pre-malignant endometrial hyperplasia
COIEN = non-structural causes
- COAGULOPATHY (systemic, eg thrombocytopenia, von willebrands)
- OVULATORY FUNCTION DISORDER (eg PCOS, hypothyroidism)
- ENDOMETRIAL DISORDERS (eg endometriosis, chronic endometritis - can be secondary to PID)
- IATROGENIC (exogenous hormones, eg COCP, also copper IUD, warfarin + other blood thinners)
- NOT YET CLASSIFIED (rare, eg AV malformations, sex steroid secreting ovarian neoplasm)
LEARN THESE REALLY WELL!
relevant to NON-GRAVID (ie not pregnant) women of REPRODUCTIVE AGE (ie not post-menopausal)
When someone is presenting with heavy menstrual bleeding (HMB), what systemic complication should you always ask if they’re experiencing symptoms of?
symptoms? 5
clinical signs? 6
blood test to always do with HMB?
anaemia
- feeling faint (esp when standing)
- tired / lack of energy
- palpitations
- SOB / poor exercise tolerance
- pale skin
= pallor
= palmar creases
= conjunctival pallor
= angular stomatis
= glossitis
= nail spooning (koilonychia)
may also have orthostatic hypotension
ALWAYS DO A FBC!
What are the three main types of leiomyoma (fibroid)? and where are they located in the uterus?
what are symptoms likely to be of each?
SUBSEROUSAL
= located under the peritoneum on the external aspect of the uterus
- no bleeding but may be pressure / heaviness / pain or frequency of bladder if large and sitting on that
INTRAMURAL
= within the myometrium
- likely to bleed heavily
SUBMUCOUSAL
= in the myometrium but also in the endometrium, they grow into the cavity of the womb
- often bleed heavily
nb can also have pedunculated submucosal
Symptoms of fibroids (leimyoma)? 7
How common are symptoms in fibroids?
- heavy periods (ie HMB, bleeding alines with cycle)
- painful periods
- abdo pain
- lower back pain
- pain or discomfort during sex (dyspareunia)
- frequency
- constipation
(also bloating)
only 1 in 3 women with fibroids have symptoms
- nb only tend to treat symptomatic fibroids
fibroids can very rarely lead to problems conceiving (eg if fibroid if pushing on fallopian tube or large mass in cavity)
nb fibroids more common in black ethnicity and overweight
they tend to shrink and disappear post-menopausally
examinations done if suspect fibroids? 3
- what expect to find on these?
- abdo
- speculum
- bimanual
bulky asymetrical uterus on bimanual (nb this may not be found in small fibroids or if woman is overweight)
First line investigation for fibroids?
2nd investigation if concerned that could be cancer?
ultrasound
(think this is abdominal not PV?*)
can do hysteroscopy with biopsy
management options for fibroids:
- first line if small and not distorting the cavity? 1
- medications to help with bleeding? 3
- medication to help with pain during period? 1
- more invasive management options? 4
- medication given to shrink fibroids before surgery? 1
- IUS (mirena) is first line if possible
- COCP
- POP
- tranexamic acid (take during period)
- mefanamic acid (or other nsaid)
nb just try one hormonal method at a time initially
- uterine artery embolisation (only if family finished)
- endometrial ablation
- myomectomy
- hysterectomy (only if fam finished)
OFTEN GIVE GNRH AGONISTS TO DHRINK FIBROIDS PRIOR TO SURGERY
need specialist / advanced management if really large, dyspareunia, uterine or bowel symptoms or problems with fertility etc
What’s the difference between adenomyosis and leiomyoma (fibroids)?
Because the symptoms are so similar, adenomyosis is often misdiagnosed as uterine fibroids. However, the two conditions are not the same. While fibroids are benign tumors growing in or on the uterine wall, adenomyosis is less of a defined mass of cells within the uterine wall
what sort of abnormal uterine bleeding does polyps normal present with?
light (sometimes heavy) bleeding which is unrelated to cycle
- can be IMB or PCB
How will adenomyosis tend to present?
- heavy bleeding
- vague abdo / pelvic pain
bulky symmetrical uterus
(as opposed to asymmetrical in fibroids - though this is not always the case)
what is the most worrying cause of post-coital bleeding?
cervical cancer
What are the two different groups of causes of amenorrhoea? give some common examples for each?
PRIMARY AMENORRHOEA (never had menarche)
- turner’s syndrome
- congenital adrenal hyperplasia
- congenital malformations of genital tract
SECONDARY AMENORRHOEA (had periods but then stopped)
- Hypothalmic amenorrhoea (stress, excessive exercise, low weight - can be primary too)
- sheehan’s (PPH -> ischaemia of pituatory)
- hyperprolactinaemia
- hyper or hypothyroid
- PCOS
- premature ovarian failure
- asherman’s syndrome (intrauterine adhesions)
What is dysmenorrhoea?
what are the two groups of causes? and how to differentiate between these?
dysmenorrhoea
= excessive pain during menses
PRIMARY
- no underlying pelvic pathology
- 50% of women
- 1-2 years after menarche
- excessive endometrial prostaglandin
SECONDARY
- result of underlying pathology
- pain starts 3-4 days before period!! (always ask when pain starts)
- eg endometriosis, adenomyosis, fibroids, PID, copper IUD
How do you manage primary dysmenorrhoea 1st and 2nd line?
How do you manage (what appears to be) secondary dysmenorrhoea?
primary dysmenorrhoea
- 1st: NSAIDs (mefanamic acid or ibuprofen)
- 2nd: COCP
secondary dysmenorrhoea
- refer to gynae
Management options for heavy bleeding (once excluded cancer):
- conservative?
- medical?
- surgical?
can reassure women that it’s okay (this is all some people need)
- mefenamic acid (also helps with pain)
- TXA (will give clots)
- mirena IUS (also oral contraceptives)
- endometrial ablation
- hysterectomy
also polyp removal or myomectomy if polyp / fibroid
(also if thyroid
What two non-sex hormonal issues do you need to rule out for abnormal uterine bleeding?
- questions in hx?
- blood tests? 2
HYPO (or HYPER) THYROID
- ask about thyroid symptoms and do thyroid exam
- do TFT if any thyroid signs
PROLACTINAEMIA
- ask if any discharge from nipple
- do prolactin blood test if there is discharge
POST-MENOPAUSAL BLEEDING
- Commonest cause? (and how is this treated?)
- what you must rule out?
- 1st line investigation? (and findings)
Commonest cause of PMB
= atrophic vagina
- treat with oestrogen cream topically on vagina
must rule out endometrial cancer
(refer PMB on 2WW)
trans-vaginal USS looking for massess and endometrial thickness
- should be <4mm if not on HRT
- should be <5mm if on continuous HRT
- should be <8mm if not cyclical HRT
PREMENSTRUAL SYNDROME
What is it?
Common symptoms of PMS? 8
what % of women will experience severe PMS at some point?
cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms may extend into the first few days of menses
- abdominal bloating (very common - 90%)
- fatigue (v common)
- labile mood (ie mood swings - 80%)
- depressed mood and irritability (70%)
- increased appetite (70%)
- forgetfulness / difficulty concentrating (50%)
- breast tenderness (50%)
- headaches (50%)
(may also get change in bowel habits, insomnia, hot flushes and palpitations)
make sure this is just before (and start) of their periods, and not all the time - as this may indicate depression is constant
pre-menstrual syndrome
- 1st line management? 7
- 2nd line management options? 3
1ST LINE
- regular exercise
- healthy, balanced diet
- reduce stress (yoga, meditation)
- stop smoking
- reduce alcohol
- OTC analgesia
- symptom diary of 2-3 cycles
2ND LINE
- hormonal contraceptives (eg COCP)
- CBT
- antidepressants
if none of these work, refer to gynae
Polycystic ovarian syndrome (PCOS)
- syndrome it is linked to?
- secondary causes? 5
linked to metabolic syndrome (ie obesity, insulin resistance, hyperlipidaemia)
secondary causes
- androgen secreting neoplasms
- cushing’s syndrome
- thyroid dysfunction
- congenital adrenal hyperplasia (would have primary amenorrhoea)
- hyperprolactinaemia
be aware of secondary causes - but most cases are primary
polycystic ovarian syndrome:
- name and three features of criteria for diagnosis?
- other symptoms and signs that support diagnosis? 3
- investigations to do? 1
ROTTERDAM CRITERIA
(need 2 out of 3 for diagnosis)
- oligomenorrhoea
- hyperandrogenism (either clinical - acne, hirsuitism - or raised serum testosterone)
- polyscystic ovaries on TV USS (>9 cysts, each <9mm - pearl necklace)
other symptoms / signs
- obesity
- infertility
- acanthosis nigracans
most symptoms / signs are picked up in hx + exam then do TV USS (exclude ovarian tumour) see ‘string of pearls’
Very common! 5% of women of reproductive age
- big cause of infertility
What happens to LH, FSH and testosterone levels in PCOS?
chronically high LH
chronically low FSH
(bear in mind, bar ovulation, in normal menstrual cycle, FSH is norm higher than LH)
high testosterone
Management for PCOS if NOT trying to conceive:
- lifestyle? 1
- screen for? 4
- if less than one period every 3 months? 2
weight loss
explain that this will:
- Reduce hyperinsulinism and hyperandrogenism.
- Reduce the risk of DM + CVD.
- Result in menstrual regularity.
- Improve the chance of future pregnancy (if it is desired).
screen for:
- diabetes
- CVD risk factors
- obstructive sleep apnoea (daytime somnolence, snoring)
- depression / anxiety
if less than one period every 3 months:
- provera (synthetic progesterone) to induce a withdrawal bleed
- TV USS to see endometrial thickness
if thick or unusual appearance -> need endometrial sampling to exclude hyperplasia
if normal, have options:
- give provera for 2wks every 1 to 3 months
- COCP
- IUS mirena
nb regular USS required to keep checking thickness
basically: you need a bleed every 3 months with PCOS (or mirena)
PCOS management IF TRYING to conceive:
- what to test for?
- what medications to stop?
- where to refer?
- do OGTT for diabetes (and repeat again in early pregnancy)
- stop any hormones (eg COCP / provera)
also continue lifestyle of reducing weight
fertility clinic - to assess if ovulation occuring or not and then go from there
What are the four things you need for a viable pregnancy (3 mother, 1 father)?
functioning menstrual cycle
- ovulation
- endometrial thickening
- healthy fallopian tubes
- healthy sperm
Where in the female genital tract does ovulation normally occur?
ampulla
What % of couples will get pregnant from having unprotected sex 2-3 times a week:
- for a year?
- for 2 years?
What age does fertility really drop off in women?
what is subfertility?
1 year = 84%
2 years = 92%
fertility drops off fast after 35
subfertility = 1 year of regular sex with no conception
- refer to specialist at this point
nb if women 35-40 then refer after 6 months (if older than 40 or have conditions likely to affect fertility then refer sooner
Four main groups of causes of subfertility? (roughly what % for each)
- male factor (35%)
- disorders of ovulation (30%)
- pelvic pathology (30%)
- unexplained (15%)
if unexplained cause then only treatment is IVF
What is primary and secondary subfertility?
primary subfertility = female partner has never conceived
Secondary = she has previously conceived (eg in a prev relationship)
pre-conceptional health advice:
- for woman? 6 (incl 2 vitamins)
- for man? 4
WOMAN
- stop smoking (also cannabis)
- no alcohol intake
- BMI 19-30
- low caffeine
- vit D
- folic acid
MAN
- stop smoking (also canabis and anabolic steroids)
- 3-4 units alcohol a week
- BMI <30
- optimise scrotal temp (reduce tight fitting clothing maybe)
What is the best test to confirm ovulation?
what day of the cycle should it be done?
Day 21 progesterone test is most reliable
Actually you want the midpoint of the luteal phase - so if, eg, cycle is 21 days then want day 14 - basically want 7 days before period
What are the WHO classifications of different types of anovulatory infertility? 3
Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
FSH and LH
Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
Group III: ovarian failure.
What is AMH a test of?
What do oestrogen, FSH and AMH do with each different WHO classification of anovulation? (ie normal, high, low)
What two other blood tests should you always do if you suspect ovulation problems?
Anti-mullerian hormone (AMH)
= a test of roughly how many follicles a woman has left in her ovaries
Group I
- oestrogen = low
- FSH = low or normal
- AMH = normal
Group II
- oestrogen = normal
- FSH = normal
- AMH = high
Group III
- oestrogen = low
- FSH = high
- AMH = low
nb this makes sense as PCOS is commonest cause of group II so AMH high, whereas ovarian failure would cause low AMH
ALWAYS DO
- TFTs
- prolactin
What are the common causes of Group I ovulation disorders? 3
what is the management for these? 3
Hypothalamic pituitary failure
—> hypothalamic hypogonadism –> reduction in GnRH release.
- stress
- intense exercise
- low BMI, low bone mass (eg anorexia)
(can also get Kallmann’s syndrome – GnRH secreting neurones fail to develop)
- increase BMI to >19
- reduce exercise
- treat with gonadotrophins (for ovulation induction)
What is the female athlete triad?
get in female athletes but also low BMI
- Low energy availability / eating disorder
- Low bone mass
- Menstrual disturbance
need to increase BMI and periods will norm start again, may need gonadotrophins as well though
What are the common causes of Group II ovulation disorders? 3
Management options for these? 3
Dysfunction of Hypothalamic-pituitary -ovarian axis
- PCOS
- hyperprolactinaemia
- Sheehan’s syndrome (PPH -> necrosis of pituatory)
- if overweight, loose weight
- if BMI normal, Clomiphene Citrate or Letrozole
2nd line = gonadotrophins or CC + metformin or laprascopic ovarian drilling
test for diabetes, if have, treat
What is the commonest cause of Group III ovulation disorders?
diagnostic criteria for this?
Management for conceiving? 1
management to preserve women’s health? 1
Premature ovarian insufficiency (POI) (ie super early menopause)
POI Diagnostic criteria:
1) Oligo/amenorrhea for at least 4 months
2) An elevated FSH level >25 IU/l on two occasions >4 weeks apart
- IVF with donor egg
- give HRT for CV and osteoporosis risk
nb this runs in families
nb remember FSH and LH rise in menopause (as no neg feedback from ovaries / endometrium)
What are the age cut offs for:
- premature ovarian insufficiency (POI)?
- Early menopause?
POI = <40
early menopause = 40-45
nb both run in families
What are the four commonest causes of pelvic pathology (as causes of subfertility)?
- Pelvic inflammatory disease (norm dt chlamydia)
- endometriosis
- past abdominal / pelvic infection or surgery
- tubal disease (-> hydro-salpinges - remove before IVF as contains cytokine which can damage pregnancy)
Three methods for investigating possible pelvic pathology (in context of subfertility)?
Hysterosalpingography
- Appropriate for low risk women
- xray with dye being squirted into cavity
Hysterosalpingo-contrast-ultrasonography
- Alternative to HSG with no radiation exposure
- same dye but look with USS instead of x-ray
Laparoscopy
- The gold standard BUT need GA with all those risks etc
What first line investigation is done to investigate male fertility?
What are the three main things that are measured in this test?
What are the proper names for each of these?
semen analysis
- fresh sample from masturbation (abstinence 3-5 days prior)
oligozooapermia
= low sperm count
asthenozoospermia
= low motility
teratozoosperma
= poor morphology
(also have azoospermia - so no sperm)
Male factor infertility:
- most common cause?
- other causes? 7
commonest cause
= idiopathic
- hypogonadism (only one can treat)
- genetic causes (need to be excluded before ICSI)
- cryptorchidism
- Testicular trauma / surgery
- obstructive (surgery - vasectomy / infection)
- anabolic steroid induced (not always reversible)
- previous chemo / radiation
When investigating the woman in a couple for infertility, what things are looked for on examination? 4
- BMI
- hirsutism, acne, acanthosis
- hyper / hypothyroid
- galactorrhoea
What are the first line investigations for a subfertile woman with no known health conditions:
- blood tests? 5
- blood test that can be added on by paying? 1
- other blood tests that can be done if clinical suspicion on hx / exam? 4
- imaging? 1
day 1-5 of cycle:
- FSH
- LH
- Oestrogen
- chlamydia antibodies
- rubella immunity
- can add AMH on (£70)
if clinical suspision:
- testosterone
- SHBG
- prolactin
- TFTs
all women get TV USS
Can also do antral follicle count! (?on USS)
Management options in fertility treatment and who most appropriate for:
- lifestyle? 1
- medication? 2
- surgery? 2
- procedural? 3
- other options (which don’t use both native sperm and egg)? 3
loose / gain weight
- women BMI >30 or <19
- PCOS
letrozole or clomiphene (stimulate ovulation)
- decent ovarian reserves
- eg in PCOS after weight loss
gonadotrophins
- hypogonadism in men
salpingectomy
- significant tubal disease
laproscopy and ablation
- significant endometriosis
IVF
- unexplained infertility
- other methods failed
ICSI (with IVF)
- low sperm quality or number
IUI
- physical disability
- Psychosexual issues (eg vaginismus)
- Donor sperm (especially in WSW)
- moderate sperm quality / number
Sperm donation
- WSW
- azoospermia
egg donation
- Premature ovarian failure
adoption
- anyone or all other methods failed / run out of money
What is the most serious complication of IVF?
Symptoms of mild, moderate and severe disease
Ovarian hyperstimulation syndrome
mild
- abdo bloating
- mild abdo pain
- ovarian size <8cm
moderate
- moderate abdo pain
- nausea / vomiting
- USS evidence ascites
- ovaries 8-12 cm
severe / critical
- clinical ascites
- oliguria
- hyponatraemia
- hyperkalaemia
- hypoproteinaemia
- ovaries >12cm
critical = hydrothorax, ARDS, VTE
OVARIAN CYSTS:
- possible symptoms? 6
- three exams to do? 3
- 1st line investigation? 1
nb pelvic cysts can be malignant or benign
- pelvic pain (normally dull)
- dysparenuia
- bloating
- difficulty emptying bowels
- urinary frequency
- changes to menstrual cycle (heavier, lighter, irregular)
- abdo
- speculum
- bimanual
TV USS
OVARIAN CYSTS:
- two complications?
- symptoms to tell women to look out for? 2
- cyst rupture
- ovarian torsion
- sudden onset sharp pain in iliac fossa (can radiate to loin, groin or back)
- nausea and vomiting (esp torsion)
OVARIAN CYSTS:
- three management options?
- which option is normally taken, based on cyst appearance and age of woman?
conservative (watch and rescan - if growing, consider surgery)
- premenopausal: <10cm, simple, mobile, unilateral, no ascites
- simple cysts post-menopause
periodic drainage
- for benign cysts causing mass symptoms where surgery not an option
surgical excision
- premenopausal: >10cm, solid or complex, fixed, bilateral, ascites
- complex cysts post-menopause
nb most pre-menopausal simple cysts self-resolve
Menopause:
- definition?
- average age?
- what happens to FSH, LH and oestrogen levels?
amenorrhoea for 12 months (diagnosed in retrospect)
nb perimenopause is before menopause
average age is 51
- oestrogen drops
- FSH and LH rise
(nb this is because ovary stops producing oestrogen and so FSH and LH increase to try and stimulate it, but to no avail…)
Perimenopausal symptoms:
- early symptoms? 7
- medium term? 5
- long term risks? 2
- how long do symptoms last?
EARLY
- irregular menstrual cycle (10% stop abruptly, may be heavy or light)
- hot flushes
- night sweats
^known as vasomotor symptoms - irritability and mood swings
- mild memory impairment
- insomnia
- fat redistribution (abdo weight gain)
MEDIUM TERM
- vaginal dryness / itching
- dyspareunia
- bladder frequency
- urgency
- frequent UTIs (dt dryness)
LONG TERM RISKS
- osteoporosis
- cardiovascular disease
symptoms last 4-8 years
Management of menopause:
- non-pharm? 6
- vitamins?
- exercise
- yoga
- stop smoking
- reduce alcohol
- sleep in cooler room
- vit D and calcium
can also try acupuncture, hypnotherapy, reflexology etc - no evidence but helps some people
Management of menopause:
- different types of HRT? 5 (and their effects)
- topical treatment?
1) OESTROGEN ONLY
- With absent uterus only!
COMBINED HRT (OESTROGEN + PRGESTERONE)
2) Continuous combined
- Every day
- No bleeding
- Only give if >54 years old or >1yr amenorrhoea
3) Sequential combined cyclical
- Oestrogen daily, progesterone for last 10-14 days of cycle
- Withdrawal bleed every month
4) Sequential long cyclical
- Oestrogen for 3 months every day, progesterone for second half of third month
- Withdrawal every 3 months
TIBOLONE (*look this up)
- Synthetic steroids w estrogenic, androgenic and progestational activity
- No withdrawal bleed
TOPICAL OESTROGEN
- for vaginal symptoms
- can have in addition to oral HRT
MISCARRIAGE:
- definition?
- what % of pregnancies miscarry?
- recurrent miscarriage definition?
- commonest reason for miscarriage?
miscarriage
= loss of pregnancy before 24 weeks
20% of known pregnancies miscarry (but actual no may be higher)
Recurrent miscarriage
= loss of 3+ consecutive pregnancies (ie no babies in between) with the same partner
foetal abnormality is commonest reason for miscarriage
On a TV USS, at what gestation should you be able to:
- see gestation sac?
- see foetal pole and heart beat?
gestation sac
= 5 weeks
foetal pole AND heart beat
= 6 weeks
MISCARRIAGE
- symptoms? 3
- bilateral abdo cramping / pain
- bleeding / expulsion of clots
- regression of pregnancy symptoms (N+V, breast tenderness)
nb can have no symptoms - esp if missed
MISCARRIAGE
- blood tests? 3
- imaging?
- HCG (get serum so can compare in 48 hours if need to)
- FBC (anaemia)
- group + save (rhesus status)
TV USS (abdo if later)
What are the five different types of miscarriage?
incl if os is opened or closed
- which two need no treatment?
THREATENED MISCARRIAGE
- Bleeding +/- pain, but pregnancy continues
- On examination the os is closed
- Uterine size correct for dates
- Cause unknown
- No long-term harm to baby/ implications for pregnancy
= no treatment needed
INEVITABLE MISCARRIAGE - Presents in process of miscarriage - Nothing can be done to save pregnancy - Vaginal bleeding Cervical os is open
COMPLETE MISCARRIAGE
- Process completed without intervention
- Present with bleeding, but will have lessened on completion
- Uterus returned to near normal size
- Cervix closed
- Bleeding + pain + empty uterus on scan = confirmation. However, ensure no ectopic. (check HCG levels)
= no treatment needed
INCOMPLETE MISCARRIAGE
- Not all products of conception have been expelled
- Continued bleeding
- Cervical os open (?or closed)
- Scan shows mixed debris in uterus
- Medical or surgical treatment offered to complete the miscarriage
MISSED (OR DELAYED) MISCARRIAGE
- Entire gestation sac is retained within the uterus
- Pregnancy has stopped growing
- No foetal heart beat
- Minimal bleeding
- Cervical os closed
- Uterus/ foetus smaller than gestational age
- Found on routine scan.
Four options of management for incomplete or missed miscarriage? (describe each)
what test should be done following any miscarriage? how long after?
EXPECTANT / CONSERVATIVE
- allow body to do it by itself
- can take up to 14 days
MEDICAL MANAGEMENT
- PO mifeprostone (anti-progesterone)
- then PV misoprolol (prostaglandins) 48 hours later
- can -> heavy bleeding and moderate pain
- 5% risk of retained product
SURGICAL MANAGEMENT (SMM)
1) Under GA
2) Under LA - Manual vacuum aspiration (MVA)
- complications of retained products, damage to cervix, trauma, haemorrhage for both
Do pregnancy test (urine) 3wks after miscarriage - should be negative
recurrent miscarriage:
- what % are unknown cause?
- known causes? 4
- possible causes? 6
50% are unknown cause
KNOWN
- antiphospholipid syndrome
- inherited thrombophilias (factor V leiden etc)
- cervical incompetence (cause of late miscarriages)
- chromosomal abnormalities in parents (eg translocation)
POSSIBLE
- abnormal shape uterus
- PCOS
- infection
- immune problems
- uncontrolled diabetes
- untreated thyroid disease
nb don’t worry too much about knowing this!
What is it called when person has a positive pregnancy test but foetus can’t be visualised on scan?
what are the three possible reasons behind this?
investigation (and results) to find out which one it is?
PREGNANCY OF UNKNOWN LOCATION (PUL)
do serum HCG testing 48 hours apart and see if rise or fall
1) ectopic
= HCG stays same or rises or falls a bit
2) complete miscarriage
= HCG falls a lot
3) v. early foetus (<5wks)
= HCG rises a lot
- rescan in 2 weeks
Symptoms of ectopic pregnancy? 2
- additional symptoms in ruptured ectopic? 5
- additional signs in ruptures ectopic? 4
what % of pregnancies are ectopics
- constant lower abdo pain (normally on R or L)
- PV bleeding (usually less than a normal period)
norm get pain at 6-8 weeks as this is when foetus starts stretching tube
may have no symptoms! (esp if early)
RUPTURED ECTOPIC
- shoulder tip pain
- nausea + vomiting
- diarrhoea
- pain on defecation / urination (also urge to defecate)
- collapse
- high HR, low BP
- lower abdo guarding
- cervical motion tenderness
- unilateral adnexal tenderness
1% of pregnancies are ectopic (and 90% of ectopics are tubal)
nb ectopic and miscarriage can be clinically quite difficult to differentiate
Investigations for ectopic pregnancy:
- first line blood?
- imaging?
- 2nd line blood?
- definitive / emergency investigation?
1) pregnancy test (if negative, excludes ectopic)
TV USS
- purpose to confirm intrauterine pregnancy
- if PUL, do:
2) serum HCG and repeat after 48 hours
- if plateau or slightly rising or falling = ectopic (if high rise = intrauterine, if steep fall = miscarriage)
laparoscopy if any doubt
- or need for emergency treatment anyway
Four management options for ectopic pregnancy?
when is each done?
EXPECTANT / CONSERVATIVE
- ie watch and monitor hcg (rare to do)
- If hCG level is static or low (<1000) then consider doing this (also obs normal)
MEDICAL
- methotrexate
- If hCG is 1000-5000 (also obs normal) then woman’s choice between medical or surgical
- Medical is a long process (have to monitor hCG levels and that they’re falling - take a few weeks) - 5% need surgical anyway
- also need contraception for 3 months to protect future pregnancies from methotrexate
SURGICAL
1) Salpingectomy
- if first ectopic
- if ruptured
2) salpingtomy
- if already had one tube removed
- increases risk of future ectopic though but if have both tube removed then can only conceive with IVF
DDx for lower abdo pain in early pregnancy? 5
- threatened miscarriage
- miscarriage
- ectopic pregnancy
- appendicitis
- UTI
DDx for abdominal pain in late pregnancy? 7
where is pain in each
- labour (cramping)
- placental abruption (constant pain and shock - disproportionate to visible blood loss)
- symphisis pubis dyfunction (Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs)
- pre-eclampsia / HELLP syndrome (epigastric or RUQ)
- uterine rupture (shock and abdo pain)
- appendicitis (RIF)
- UTI
What is Gestational Trophoblastic Disease?
What is a hydatidiform mole? how common? two different types?
Gestational Trophoblastic Disease = spectrum of histologically distinct diseases originating from placenta:
- Partial and complete Hydatidiform mole
- Choriocarcinoma
- Placental – Site trophoblastic tumour.
Molar pregnancy aka hydatiform mole
- 1 in 600 pregnancies
COMPLETE hydatiform mole
- no foetal tissue
- Correct number of chromosomes – 46,XX
- All nuclear genetic material from father = androgenetic in origin
PARTIAL hydatiform mole
- non-viable foetus
- 69 chromosomes, 23 from mother + 46 from father –> where 2 sperm enter the ovum.
Possible symptoms of molar pregnancy? 3
- hyperemesis (dt high HCG levels)
- PV bleeding
- uterus large for gestational age
(may also have enlarged ovaries on USS, dt very high hcg)
(may also have abdo pain)
nb always scan women with hyperemesis to see if molar
often undetected, especially partial, until have 12 week dating scan
investigations if suspect molar pregnancy:
- bloods? 2
- imaging? 1
(and findings)
management of molar pregnancy? (2 components)
HCG
- will be very high
group and save
- rhesus status (see if need anti-D)
TV USS
- snow-storm appearance of the uterine cavity and absence of foetal parts (complete molar); or a small placenta with partial foetal development (partial molar).
Surgical management!
- need to continually check HCG levels afterwards until undetectable - if not falling enough or start rising, may need chemo for choriocarcinoma
- can’t conceive until hcg levels back down to zero (need contraception)
(nb can do hysterectomy if sterility desired)
What test is does following any miscarriage? why?
histological examination of miscarriage tissue
to see if was a molar pregnancy - as need to monitor hcg levels if it is!
What are the indications for giving anti-D to a rhesus -ve mother? 6
- any surgical procedure (SMM, MVA, surgical TOP)
- medical TOP (though not med management of miscarriage)
- any PV bleeding after 12 wks
- chorionic villus sampling or amniocentesis
- following abdo trauma in preg
- normal pregnancy (at 28-30wks - and again after birth if baby is rh +ve)
REMEMBER ONLY NEED TO GIVE IF MOTHER RH -VE!
nb anti-D only works for about 2 weeks - so if repeated bleeding, may need repeated doses
Questions to ask in urogynae history:
- urinary symptoms? 9
- sys review? 5
- gynae / obs hx? 4
- PMHx? 1
- DHx? 4
- SHx? 6
- frequency (anything >5 a day is bad)
- nocturia (once okay but more or change is not)
- dysuria
- haematuria
- urgency /urge incontinence
- stress incontinence (leak when laughing, coughing, exercising, lifting)
- difficulty initiating urination
- incomplete emptying
IF BOTH, which of urge or stress AFFECTS you the most?
SYS REVIEW
- neuro problems? (cauda equina)
- chronic cough (stress incontinence)
- constipation (ie bowel symptoms)
- Prolapse symptoms (something dragging, woman can push back in)
- problems with intercourse (ask if sexually active first)
OBGYN HX
- pre / post menopausal?
- smear tests up to date?
- how many babies? (parity really important) delivery method?
- any abdo / pelvic surgery (incl hysterectomy)?
PMHx
- diabetes? controlled?
DHx
- allergies
- diuretics
- laxatives (show may already be constipated)
- tried any medication for urinary symptoms already (what? help? side effects?)
SHx - ASD OhA Dot
- alcohol
- smoking
- drugs (esp ketamine)
- occupation (heavy lifting?)
- ADLs (how affecting life)
- Diet (caffeine, carbonated drinks)
Examination in urogynae:
- exams to do? 3
- extra thing to do during exam? 1
- what looking for in exams?
- bedside investigations? 2
1) ABDO
- BMI - need to loose weight
- any masses?
2) SPECULUM
- get to COUGH (any leakage - do before speculum in)
- assess for prolapse
- opportunistic smear (if needed)
3) BIMANUAL
- feel for fibroid uterus (can cause urge)
- assess vaginal atrophy
- urine dipstick
- MSU
can also use sims speculum to assess for prolapse
Main investigation for either type of incontinence?
What does it tell you?
urodynamics
fill up bladder with a catheter and, if pressure also increases in probe in vagina or rectum (ie in abdo) then is stress incontinence - if not, is urge incontinence
basically just tells you if the problem is mainly urge or stress incontinence
- as these have different management
you do this investigation AFTER you have tried lifestyle, physio and medical management for the type which you think, from hx, is most likely - this is just to confirm the type before you do any procedures or surgery
Management for urge incontinence:
- lifestyle? 6
- physio? 1
- medical? 1
- procedural options? 2
- reduce / stop caffeine
- reduce / stop fizzy drinks
- reduce / stop alcohol
- loose weight
- stop smoking
- bladder diary (incl intake and output) and the training, increasing time between voiding
- pelvic floor exercises with physio
- oxybutynin (1st line anticholinergics - try a different one if this not tolerated)
- cystoscopy and botox (every 6 months)
- percutaneous sacral nerve stimulation
nb urge incontinence is due to detrusor muscle overactivity (smooth muscle in wall of bladder)
nb other procedures can do further down the line but v specialist and don’t need to know
Management for stress incontinence:
- lifestyle? 5
- other issues to fix if relevant? 2
- physio? 1
- medical options? 2
- surgery? 1
- reduce / stop caffeine
- reduce / stop fizzy drinks
- reduce / stop alcohol
- loose weight
- stop smoking
- manage chronic cough
- manage chronic constipation (laxatives)
- pelvic floor exercises with physio (for 6 months)
- duloxetine (actually a SNRI anti-depressant, but useful)
- topical vaginal oestrogen (strengthens muscle)
surgery (eg tension-free vagiinal tape - TVT)
nb stress incontinence is due to weak pelvic floor muscles
nb can also inject bulking agents (bulkamid) to semi-obstruct bladder neck
What are the three different groups of pelvic prolapse? (and the 2 subtypes for first two and 2 subtypes for last one)
VERTICAL
- uterovaginal prolapse
- vault prolapse (if had TAH)
ANTERIOR
- lower 1/3 = cystocele
- upper 2/3 = urethrocele
POSTERIOR
- lower 1/3 = deficient perineum
- middle 1/3 = rectocele
- upper 1/3 = enterocele
What are the different grades of prolapse?
what is this system called?
BADEN-WALKER SYSTEM
0 - Normal position for each respective site
1 - Descent halfway to the hymen
2 - Descent to the hymen
3 - Descent halfway past the hymen
4 - Maximum possible descent. Procidentia.
look up pictures!!
How do patients describe pelvic prolapse?
What do patients say
Feels like something’s coming down
- Worse on lifting/walking/at the end of the day
Usually not painful just uncomfortable
Can see a bulge vaginally/has to push it back in
- Do you have to push it back to have to poo - posterior wall
- Do you have to push it back to have to wee - anterior wall
Generalised lower backache
Discomfort during intercourse (always ask this!)
Management options for pelvic prolapse:
- lifestyle changes? 3
- other issues to fix if relevant? 2
- minor procedure? (2 types - when each used)
- surgical options? 3
- weight loss
- avoid heavy lifting
- pelvic floor exercises
- manage chronic cough
- manage chronic constipation (laxatives)
PESSARY (change every 6 months)
- ring pessary (if sexually active)
- gell horn pessary (if not sexually active or no womb)
SURGERY
- anterior / posterior vaginal wall repair
- hysterectomy
- slings (abdo/laproscopic, not vaginal)
EXAMINE FOR PROLAPSE USING SIMS SPECULUM
nb other types of pessary too, but these main two ones
What is the NEW cervical smear process? incl recall details?
exactly the same swab is taken
1) all swabs are tested for high risk HPV strains (hrHPV)
- If negative, normal + go back to normal recall
- if positive, look at cytology on same sample
2) cytology for hrHPV +ve samples
- if cytology normal, recall in a year to check HPV infection cleared
- if cytology abnormal (shows dysplasia) go for colposcopy!
at colposcopy, see affected area using acetic acid
CERVICAL SMEARS
- age range done in?
- frequency done in each age range?
- who gets recalled every year (regardless of prev results)? 2
aged 25-49
- every 3 years
aged 50-64
- every 5 years
people who get recalled every year:
- HIV positive
- long term immunosuppression (eg following organ transplant)
nb trans men who have a cervix should get normal recall! - but often aren’t due to automatic nature - so always ask!!
HPV Vaccination
- current vaccine offered?
- which strains are covered? 4
- who mainly offered it?
- other high-risk group offered?
GARDASIL (quadravalent) - 6 - 11 - 16 - 18 (6+11 warts, 16+18 cancer)
female AND male year 8 students (then 6-12months later)
also can give to MSM in SH clinic who are too old to have been covered
When doing a cervical smear, how many times do you turn it in the os?
turn it 5 times (all one direction) in the os
CERVICAL CANCER
- possible initial symptoms? 4
- possible later symptoms? 3
- differential diagnoses? 4
- PCB (post-coital)
- IMB (inter-menstrual)
- PMB (post-menopausal)
- persistent, offensive blood-stained discharge
later:
- pain in late disease
- swollen leg (thrombosis in pelvis)
- renal failure
DDx
- STI (chlamydia, gonorrhoea)
- ectropian (esp in pregnancy)
- cervical polyp
- other abnormal uterine bleeding (eg fibroids)
CERVICAL CANCER
- examinations required? 4
- initial investigations? 1
- abdo (feel for fibroids)
- speculum
- bimanual
- digital rectal (check for local spread, not norm at first presentation)
needs colposcopy
- with cervical biopsy
then do MRI/CT for staging before any management plan
