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RNH > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is fragile X syndrome

A

fragile area on the FMR1 gene on the X chromosome

causes a problem with brain development

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2
Q

What is being tested in the 3 gene prenatal screening panel

A

cystic fibrosis
spinal muscular atrophy
fragile x syndrome

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3
Q

Pros and cons of adding in pre conception screening to pre conception care

A

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

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4
Q

What is cystic fibrosis

A

mutation in CFTR gene

autosomal recessive

affects secretions in lungs and GIT

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5
Q

What is spinal muscular atrophy

  • recessive or dominant
  • lower or upper motor neurone
  • what part of the spinal cord
A

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

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6
Q

Vaccinations recommended for pregnant women (prior to pregnancy)

A

MMRV
DTPa
Hep B

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7
Q

When should folic acid be taken in terms of pregnancy and what dose

A

1 month prior to conception
first 3 months of pregnancy
0.4mg daily

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8
Q

What is the nuchal translucency scan and what information does it provide

A

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

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9
Q

Boundaries of the pelvic inlet

A

anterior - superior surface of pubic bones

poster - superior sacrum

Lateral - arcuate line of inner surface of the ilium

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10
Q

Boundaries of the pelvic outlet

A

anterior - pubic symphysis

posterior - tip of coccyx

lateral - ischial tuberosity

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11
Q

Layers of the urogenital triangle (anterior perineum)

A
  1. skin
  2. perineal fascia
  3. superior perineal pouch
  4. perineal membrane
  5. deep perineal pouch

simplified:

  • urogenital triangle muscles
  • urogenital diaphragm / triangular ligament
  • levator ani
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12
Q

Contents of the anal triangle (posterior perineum)

A

anus, external anal sphincter, ischioanal fossa

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13
Q

Levator ani muscles

A

puborectalis
pubococcygeus
iliococcygeus

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14
Q

Superficial perineal muscles

A

bulbospongiosus
superficial transverse perineal muscle
ischiocavernosus

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15
Q

Blood supply for perineum, vagina, uterus and ovaries

A

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

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16
Q

Nerve supply to perineum, posterior vulva and anterior vulva

A

perineum - pudendal nerve (S2-4)

anterior vulva - ilioinguinal and genitofemoral

posterior vulva - pudendal

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17
Q

Location of Bartholin’s and Skene’s glands

A

Skene’s - periurethral

Bartholin’s - either side of vaginal opening

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18
Q

Ligaments supporting the uterus and their location

A

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

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19
Q

Contents of the broad ligament

A 
fallopian tube
round ligaments 
ovarian ligaments 
nerves 
BV
lymphatics
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20
Q

Ligaments of the ovary

A

suspensory - attaches to lateral pelvic wall, contains ovarian artery and vein, ovarian nerve plexus, lymphatics

ovarian ligament - connects to body of uterus

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21
Q

Location ovarian veins drain into

A

L ovarian vein –> L renal vein

R ovarian vein –> IVC

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22
Q

Describe hormonal control of ovulation

A
  • 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
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23
Q

4 stages of endometrial cycle

A

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
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24
Q

Stages of cervical cycle

A

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

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25
Q

Points to mention to patient post CST

A

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

26
Q

Ddx AUB

A

PALM - structural
Polyps, adenomyosis, leiomyosis, malignancy

COINE - non structural
Coagulopathy, ovulatory dysfunction, iatrogenic, not yet classified, endometrial (endometriosis, hyperplasia)

27
Q

Causes of 1st and 2nd trimester bleeding

A 
Implantation of placenta 
Ectopic
Spontaneous abortion 
Molar
Genital lesion (fibroid, polyp, cancer)
28
Q

Gynae ddx for acute pelvic pain

A

Adnexal: ectopic, torsion, ruptured ovarian cyst

Uterine: PID, torsion of pedunculate fibroid

Pregnancy related: ectopic, labour, spontaneous abortion, placental abruption

29
Q

Gynae ddx for chronic pelvic pain

A 
primary dysmenorrhoea 
endometriosis and adenomyosis
ovarian neoplasms
fibroid 
chronic PID
uterine prolapse 
ovarian remnant syndrome
30
Q

Vulval pruritus ddx

A

infectious: candidiasis, BV
dermatological: dermatitis, psoriasis, lichen sclerosis, lichen planus
neoplastic: skin cancer
inflammatory: irritants, atrophic vaginitis

31
Q

Ddx for superficial and deep dyspareunia

A

superficial: inadequate lubrication, STI, lichen sclerosis, bartholin gland abscess
deep: endometriosis and adenomyosis, PID, tubo-ovarian abscesses, ovarian cyst, fibroids and polyps

32
Q

Diagnostic criteria for PCOS

A

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)

33
Q

Complications of PCOS

A 
infertility 
T2DM
CVD
endometrial hyperplasia and cancer 
miscarriage 
GDM 
anxiety and depression
34
Q

Ddx PCOS

A 
cushing's syndrome 
hyper or hypothyroid
hyperprolactinaemia 
congenital adrenal hyperplasia
androgen secreting tumours 
pituitary adenomas and adrenal tumours
35
Q

Infertility definition

A

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

36
Q

Female causes of infertility

A

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
37
Q

Ddx for primary amenorrhoea

A

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)

38
Q

Ddx for secondary amenorrhoea

A

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)

39
Q

Colposcopy - types of staining and what each colour change means

A

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
40
Q

Two main treatment options for CIN2 and 3

A

Large loop excision of the transformation zone (LLETZ) - loop electrosurgical excision procedure (LEEP)

Cone biopsy - larger chunk of the tissue using a scalpel

41
Q

Indications for colposcopy

A

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)

42
Q

LSIL vs HSIL

A

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

43
Q

HSIL and affect on fertility / pregnancy

A

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

44
Q

Stages of cervical cancer

A 
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)
45
Q

Management of cervical cancer

A

1A - cervical excision for women wanting to preserve fertility

Beyond 1A - radical hysterectomy with resection of pelvic LN, ovaries can be preserved

46
Q

Causes of cervical ectropion

A

normal response to high oestrogen - OCP, pregnancy, adolescence

early cervical cancer

47
Q

Male causes of infertility

A

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
48
Q

Types of molar pregnancies

A

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

49
Q

Level 1 prolapse - organ and support failure

A

uterus and cervix, vault

uterosacral ligament and cardinal ligament

50
Q

Level 2 prolapse - organ and support failure

A

bladder and rectum

arcus tendineous fasciae pelvis (ATFP)
arcus tendinous rectovaginalis
levator ani fascia

51
Q

Level 3 prolapse - organ and support failure

A

urethra and anus

pubourethral ligaments, perineal body, urogenital diaphragm

52
Q

Grading of pelvic organ prolapse

A

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

53
Q

Medical management of ectopic, miscarriage and abortion

A

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

54
Q

5 types of miscarriage

A

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

55
Q

Criteria for non viable IUP aka USS findings of a missed miscarriage

A

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

56
Q

Benefits and limitations of female vs male sterilisation

A

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

57
Q

Risk factors for endometrial cancer

A

Unopposed oestrogen

  • late menopause, early menarche
  • nulliparous
  • HRT
  • tamoxifen

lifestyles - obesity, DM, PCOS

Fam Hx

58
Q

Post menopausal bleeding work up

A

Labs - routine bloods and coagulation
TVUS - post menopausal >/=5mm is abnormal
Endometrial sampling - pipelle biopsy or diagnostic hysteroscopy with biopsy

59
Q

Clinical features of ovarian mass

  • when they are symptomatic
  • complications
A

asymptomatic until large (>10cm) or complication

mass effect - distension, bloating, nausea, constipation
complications - cyst rupture, adnexal torsion, haemorrhage

60
Q

Ddx pelvic mass

A

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

61
Q

Workup for ovarian mass

A

Bloods - FBC, UEC, CA125, bHCG

Imaging - TVUS and abdominal USS

62
Q

When to excise ovarian cyst

A 
suspicious on USS
>7cm
symptomatic
complex cyst
risk of malignancy index (RMI) >25

RNH (9 decks)

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