Gynaecology Flashcards
What is fragile X syndrome
fragile area on the FMR1 gene on the X chromosome
causes a problem with brain development
What is being tested in the 3 gene prenatal screening panel
cystic fibrosis
spinal muscular atrophy
fragile x syndrome
Pros and cons of adding in pre conception screening to pre conception care
pros: easy to assess risk prenatally, potentially avoid children suffering
Cons: difficult for parents to understand, extra time for counselling, can’t change genetics, may get results after becoming pregnant, expensive
What is cystic fibrosis
mutation in CFTR gene
autosomal recessive
affects secretions in lungs and GIT
What is spinal muscular atrophy
- recessive or dominant
- lower or upper motor neurone
- what part of the spinal cord
autosomal recessive
lower motor neurone disease
affects cells in the anterior horn of the spinal cord creating atrophy in skeletal muscles, including those for breathing
Vaccinations recommended for pregnant women (prior to pregnancy)
MMRV
DTPa
Hep B
When should folic acid be taken in terms of pregnancy and what dose
1 month prior to conception
first 3 months of pregnancy
0.4mg daily
What is the nuchal translucency scan and what information does it provide
nuchal area of baby from 11 - 13 weeks +6 days there is fluid caught between developing skin
the thicker this fluid measurement is, the greater chance of a problem i.e. problem with placentation, anatomy, heart, GIT
Boundaries of the pelvic inlet
anterior - superior surface of pubic bones
poster - superior sacrum
Lateral - arcuate line of inner surface of the ilium
Boundaries of the pelvic outlet
anterior - pubic symphysis
posterior - tip of coccyx
lateral - ischial tuberosity
Layers of the urogenital triangle (anterior perineum)
- skin
- perineal fascia
- superior perineal pouch
- perineal membrane
- deep perineal pouch
simplified:
- urogenital triangle muscles
- urogenital diaphragm / triangular ligament
- levator ani
Contents of the anal triangle (posterior perineum)
anus, external anal sphincter, ischioanal fossa
Levator ani muscles
puborectalis
pubococcygeus
iliococcygeus
Superficial perineal muscles
bulbospongiosus
superficial transverse perineal muscle
ischiocavernosus
Blood supply for perineum, vagina, uterus and ovaries
perineum - internal pudendal off internal iliac
vagina - vaginal a off internal iliac
uterus - uterine off internal iliac
fallopian tubes - ovarian and uterine arteries
ovaries - ovarian off abdominal aorta
Nerve supply to perineum, posterior vulva and anterior vulva
perineum - pudendal nerve (S2-4)
anterior vulva - ilioinguinal and genitofemoral
posterior vulva - pudendal
Location of Bartholin’s and Skene’s glands
Skene’s - periurethral
Bartholin’s - either side of vaginal opening
Ligaments supporting the uterus and their location
Round - anterior uterus, through inguinal canal to labia majora
Uterosacral - posterior inferior uterus to sacral fascia
Cardinal - lateral cervix and vagina to lateral pelvic walls
Broad - reflected folds of peritoneum from lateral uterus to lateral pelvic wall
Contents of the broad ligament
fallopian tube round ligaments ovarian ligaments nerves BV lymphatics
Ligaments of the ovary
suspensory - attaches to lateral pelvic wall, contains ovarian artery and vein, ovarian nerve plexus, lymphatics
ovarian ligament - connects to body of uterus
Location ovarian veins drain into
L ovarian vein –> L renal vein
R ovarian vein –> IVC
Describe hormonal control of ovulation
- Increased pulsatile secretion of GnRH
- GnRH –> increased FSH and LH
- LH –> theca cells –> androgens
- FSH –> granulose cells –> androgens to oestrogen, inhibin
- increased oestrogen –> FSH and LH surge
- oestrogen + inhibin –> less FSH
- less FSH –> dominant follicle with most FSH receptors survives
- LH causes follicle rupture (ovulation)
- corpus luteum is formed –> progesterone
- LH and oestrogen decreases
4 stages of endometrial cycle
Regenerative phase
- during menstruation –> 2-3 days after
- 2mm
- cuboid epithelium, neovascularisation, glands regenerate
Proliferative
- oestrogen builds endometrium
- 3-4mm
- columnar epithelium, BV spiral, tubular glands
Secretory
- progesterone stimulated
6-8mm
- ciliated columnar epithelium, increased gland size, BV markedly spiral
Menstrual
- less progesterone
- degeneration and sloughing
Stages of cervical cycle
Follicular - internal os open, thin and watery mucus, increased elasticity, glycoproteins facilitate sperm penetration
Luteal - internal os tightly closed, mucus thick and viscous, decreased elasticity, glycoproteins prevent sperm penetration
Points to mention to patient post CST
After effects: spotting up to 48 hours, any discharge or heavy flow need to return
CST F/U: 7-10 days arrange a follow up to discuss results
Register: results automatically go to a database
Repeat: every 5 years from 25
Refer colposcopy: symptomatic or abnormal findings
Ddx AUB
PALM - structural
Polyps, adenomyosis, leiomyosis, malignancy
COINE - non structural
Coagulopathy, ovulatory dysfunction, iatrogenic, not yet classified, endometrial (endometriosis, hyperplasia)
Causes of 1st and 2nd trimester bleeding
Implantation of placenta Ectopic Spontaneous abortion Molar Genital lesion (fibroid, polyp, cancer)
Gynae ddx for acute pelvic pain
Adnexal: ectopic, torsion, ruptured ovarian cyst
Uterine: PID, torsion of pedunculate fibroid
Pregnancy related: ectopic, labour, spontaneous abortion, placental abruption
Gynae ddx for chronic pelvic pain
primary dysmenorrhoea endometriosis and adenomyosis ovarian neoplasms fibroid chronic PID uterine prolapse ovarian remnant syndrome
Vulval pruritus ddx
infectious: candidiasis, BV
dermatological: dermatitis, psoriasis, lichen sclerosis, lichen planus
neoplastic: skin cancer
inflammatory: irritants, atrophic vaginitis
Ddx for superficial and deep dyspareunia
superficial: inadequate lubrication, STI, lichen sclerosis, bartholin gland abscess
deep: endometriosis and adenomyosis, PID, tubo-ovarian abscesses, ovarian cyst, fibroids and polyps
Diagnostic criteria for PCOS
2/3 of
oligo/anovulation - >35 day cycles or short cycle <21 days
hyperandrogenism - biochemical (increased free testosterone, FAI, DHES) OR clinical (acne, hirsutism, virilisation)
polycystic ovaries on USS (>12 each side)
Complications of PCOS
infertility T2DM CVD endometrial hyperplasia and cancer miscarriage GDM anxiety and depression
Ddx PCOS
cushing's syndrome hyper or hypothyroid hyperprolactinaemia congenital adrenal hyperplasia androgen secreting tumours pituitary adenomas and adrenal tumours
Infertility definition
inability to conceive after frequent unprotected intercourse over a 12 month period and less than 35yo
or 6 months if 35+
primary - never been pregnant
secondary - been pregnant before, regardless of outcome
Female causes of infertility
Age
Pre-ovarian failure:
- hypothalamus - anorexia, Kallman syndrome, tumour, surgery
- pituitary - adenoma, Sheehan’s
- high prolactin
- systemic - thyroid, cushing’s, CKD, liver failure
Ovarian:
- PCOS
- POI
Post ovarian:
- tubal obstruction - PID, adhesions, ligation
- uterine - endometriosis, adenomyosis, fibroids, congenital abnormalities, Asherman’s
- cervix - cervicitis, thick or acidic mucus, stenosis
Ddx for primary amenorrhoea
no sexual characteristics:
- high FSH and LH –> USS gonads –> streak gonads (Turner’s, Fragile X)
- low FSH and LH –> MRI brain –> hypothalamic and pituitary causes
sexual characteristics:
- bHCG, TSH, USS uterus (mullarian abnormality)
Ddx for secondary amenorrhoea
Test: bHCG, TSH, PRL
- pregnant
- hypothyroid
- prolactinoma, adenoma, apoplexy, Sheehan’s
All negative –> FSH, LH, oestrogen
high FSH and LH –> ovarian USS (POI, menopause, resistant ovaries, ?PCOS)
low FSH and LH –> MRI, test HPO axis hormones
(physiological stress, Cushing’s, increased exercise, decreased caloric intake)
All normal –> uterine issue (IUD, ablation, hysterectomy, pregnant, Asherman’s)
Colposcopy - types of staining and what each colour change means
Acetic acid
- white = abnormal
- more nuclear activity = whiter
note: normal ectropion (simple columnar) stains white
Iodine
- dark brown = normal
- stains glycogen rich tissue dark brown (normal mature squamous epithelium)
- columnar, immature squamous epithelium and dysplastic tissue do not stain
Two main treatment options for CIN2 and 3
Large loop excision of the transformation zone (LLETZ) - loop electrosurgical excision procedure (LEEP)
Cone biopsy - larger chunk of the tissue using a scalpel
Indications for colposcopy
HPV 16 or 18
HSIL
LSIL <30yo & still present at 12 month re-test OR >30yo with no history of negative test in past 2 years
Typical cervical cancer sx (AUB, discharge, dyspareunia)
LSIL vs HSIL
LSIL - upper 1/3 of epithelium is dysplastic, most spontaneously clear
HSIL (CIN II or III) - majority or full thickness of epithelium is dysplastic, needs treatment
HSIL and affect on fertility / pregnancy
Need treatment prior to becoming pregnant
LLETZ and ablation - slightly increased risk of miscarriage and PTL in future
Cone biopsy - higher risk due to cervical incompetency or stenosis
Stages of cervical cancer
0 - CIN 1 - limited to cervix 2 - upper 1/3 of vagina involved 3 - pelvic wall or lower 1/3 of vagina 4 - beyond pelvis (bladder, rectum, distant)
Management of cervical cancer
1A - cervical excision for women wanting to preserve fertility
Beyond 1A - radical hysterectomy with resection of pelvic LN, ovaries can be preserved
Causes of cervical ectropion
normal response to high oestrogen - OCP, pregnancy, adolescence
early cervical cancer
Male causes of infertility
Congenital - Kallman, Klinefelter, CF, Kartagener’s
Pre testicular:
- hypothalamus - Kallmann
- pituitary - tumours, hyperprolactinaemia (prolactinoma, antiDA drugs)
Testicular:
- teratospermia, asthenospermia, oligospermia, azoospermia
- varicocele
- cryptorchidism
- past torsion, epididymo-orchitis, trauma
- tumour
Post testicular:
- congenital - absence of vas deferent, CF, kartagener’s
- post surgery - vasectomy, retrograde ejaculation
Types of molar pregnancies
complete: no foetal parts, benign and non invasive, diploid, no female genetic material, 46XX
partial: +/- foetal parts, triploid, 69XXY
invasive/persistent: malignant, locally destructive, +/- haemorrhage
choriocarcinoma: malignant
Level 1 prolapse - organ and support failure
uterus and cervix, vault
uterosacral ligament and cardinal ligament
Level 2 prolapse - organ and support failure
bladder and rectum
arcus tendineous fasciae pelvis (ATFP)
arcus tendinous rectovaginalis
levator ani fascia
Level 3 prolapse - organ and support failure
urethra and anus
pubourethral ligaments, perineal body, urogenital diaphragm
Grading of pelvic organ prolapse
0 - no descent during straining
1 - distal portion of prolapse >1cm above hymen
2 - <1cm above hymen
3 - >1cm below hymen
4 - complete eversion of total length of genital tract
Medical management of ectopic, miscarriage and abortion
ectopic - methotrexate (inhibit DNA synthesis)
miscarriage - misoprostol (vaginal)
medical termination of pregnancy (MToP) - mifepristone (anti progesterone) then misoprostol (myometrial contractions and cervical ripening) 36-48hrs later
5 types of miscarriage
Threatened - bleeding, +/- pain, closed cervical os, viable IUP on USS
Incomplete/inevitable - bleeding, pain, open cervical os, products have passed through but not all, USS shows foetal parts
Complete - bleeding and pain subsided, USS shows no products of conception
Septic - pain, bleeding (+/- purulent), fever, malaise, needs surgical evacuation
Missed - no symptoms, picked up on routine USS
Criteria for non viable IUP aka USS findings of a missed miscarriage
MSD >/=25mm but no foetal pole or yolk sac
CRL >/=7mm but no foetal heart beat
Gestational sac present but 2 weeks later there is no yolk sac or heart beat
Yolk sac and heart beat present but 11 days later there is no heart beat
Benefits and limitations of female vs male sterilisation
Both: don’t need to worry about contraception, but difficult to reverse
Female
Benefits - easier to reverse than male
Risks - permanent, ectopic, higher failure rate
Male
Benefits - lower failure rate, more simple, less risks associated (LA not GA)
Risks - difficult to reverse, contraception required a few weeks post surgery until ejaculate shows no sperm
Risk factors for endometrial cancer
Unopposed oestrogen
- late menopause, early menarche
- nulliparous
- HRT
- tamoxifen
lifestyles - obesity, DM, PCOS
Fam Hx
Post menopausal bleeding work up
Labs - routine bloods and coagulation
TVUS - post menopausal >/=5mm is abnormal
Endometrial sampling - pipelle biopsy or diagnostic hysteroscopy with biopsy
Clinical features of ovarian mass
- when they are symptomatic
- complications
asymptomatic until large (>10cm) or complication
mass effect - distension, bloating, nausea, constipation
complications - cyst rupture, adnexal torsion, haemorrhage
Ddx pelvic mass
6Fs - fat, foetus, fluid, faeces, flatus, filthy big tumour
uterine - pregnancy, fibroids, adenomyosis
ovarian - cyst, neoplasm
bowel - constipation, tumour
bladder - retention, tumour
fallopian - PID causing pyosalpinx
Workup for ovarian mass
Bloods - FBC, UEC, CA125, bHCG
Imaging - TVUS and abdominal USS
When to excise ovarian cyst
suspicious on USS >7cm symptomatic complex cyst risk of malignancy index (RMI) >25
