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ICCP: Reproductive Health > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

what is a missed miscarriage?

A

the fetus is no longer alive but no symptoms have occurred

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2
Q

what is an inevitable miscarriage?

A

vaginal bleeding with an open cervix

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3
Q

what is an incomplete miscarriage?

A

retained products of conception remain in the uterus after the miscarriage

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4
Q

what is a threatened miscarriage?

A

vaginal bleeding with a closed cervix and the fetus remains alive

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5
Q

how is a miscarriage diagnosed?

A

transvaginal ultrasound

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6
Q

what are the 3 features used for assessing the viability of a pregnancy?

A

mean gestational sac diameter
fetal pole and crown rump length
fetal heartbeat

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7
Q

what do you do when the mean gestational sac diameter is over 25mm and there is no fetal pole?

A

repeat the scan a week later, if there is still no fetal pole an anembryonic pregnancy can be confirmed

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8
Q

what do you do if the crown rump length is over 7mm without a fetal heartbeat?

A

repeat the scan a week later, if there is still no fetal heartbeat a non viable pregnancy can be confirmed

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9
Q

management of miscarriage in a pregnancy <6 weeks

A

women with pregnancy<6 weeks presenting with bleeding can be managed expectantly provided they haven pain, complications or risk factors (previous ectopic).
expectant management involved awaiting the miscarriage without investigations or treatment (ultrasound is unhelpful)
a repeat urine pregnancy test is performed after 7-10 days, if negative miscarriage can be confirmed

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10
Q

options for management of miscarriage if >6 weeks gestation

A

ultrasound to confirm the location and viability of the pregnancy and to exclude ectopic
expectant management: 1-2 weeks given to allow miscarriage to occur. repeat pregnancy test after 3 weeks to confirm miscarriage is complete
medical management: misoprostol- can be given orally or vaginally
surgical management: manual vacuum aspiration with local anaesthetic or electric vacuum aspiration under general anaesthetic

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11
Q

what is misoprostol?

A

prostaglandin analogue. it softens the cervix and stimulates uterine contraction. used in medical management of miscarriage

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12
Q

what are risk factors for ectopic pregnancy?

A 
previous ectopic pregnancy 
previous PID
previous surgery to the Fallopian tube 
intrauterine devices 
older age 
smoking
tubal tying 
endometriosis 
IVF
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13
Q

how does ectopic pregnancy typically present?

A

typically presents around 6-8 weeks gestation
missed period
constant lower abdominal pain in the iliac fossa
vaginal bleeding
lower abdominal or pelvic tenderness
cervical motion tenderness
may also have dizziness or syncope, shoulder tip pain (peritonitis)

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14
Q

how to distinguish a tubal ectopic pregnancy from a corpus luteum?

A

a tubal ectopic pregnancy will move separately to the ovary

a corpus luteum will move with the ovary

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15
Q

what does a rise of less than 63% in serum hCG in 48 hours indicate?

A

ectopic pregnancy

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16
Q

what is the criteria for expectant management of ectopic pregnancy?

A 
follow up must be possible to ensure successful termination
unruptured ectopic 
adnexal mass <35mm 
no visible heart beat 
no significant pain 
hCG level <1500IU/L
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17
Q

what is used for medical management of ectopic pregnancy?

A

methotrexate, given as IM injection into the buttock

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18
Q

what are the options for surgical management of ectopic pregnancy

A

laparoscopic salpingectomy- 1st line. involves removal of affected Fallopian tube
laparoscopic salpingoctomy- used in women at increased risk of infertility due to damage to the other tube. the ectopic pregnancy is removed and tube is preserved

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19
Q

what is a molar pregnancy?

A

a type of tumour that grows like a pregnancy in the uterus. either forms when 2 sperm cells fertilise an ovum which contains no genetic material (complete mole) or 2 sperm cells fertilise a normal ovum at the same time (partial mole)

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20
Q

what does a snowstorm appearance on an ultrasound indicate?

A

molar pregnancy

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21
Q

how is molar pregnancy managed?

A

evacuation of the uterus to remove the mole- send products for histological examination
refer to gestational trophoblastic disease centre for management and follow up
monitor hCG levels until they normalise

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22
Q

what are the types of fibroids?

A

intramural- within the myometrium- most common
subserosal- just below the outer layer of the uterus. can grow outwards and fill the abdominal cavity
submucosal- just below the endometrium
pendunculated- on a stalk

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23
Q

how do fibroids present?

A 
menorrhagia 
prolonged menstruation- >7 days
abdo pain 
bloating 
urinary or bowel symptoms due to pelvic pressure 
deep dyspareunia 
reduced fertility
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24
Q

investigations in fibroids

A

hysteroscopy
pelvic ultrasound
MRI scan- may be considered before surgical options

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25
Q

medical management of fibroids

A

mirena coil- 1st line but fibroids must be less than 3cm with no distortion of the uterus
symptomatic management- NSAIDs and tranexamic acid
COCP, cyclical oral progesterones

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26
Q

surgical management of fibroids

A

endometrial ablation
resection of submucosal fibroids during hysteroscopy
uterine artery embolisation
myomectomy- surgical removal of the fibroid
hysterectomy
GnRH agonists (goserelin) may be used to reduce size of fibroids before surgery

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27
Q

what is red degeneration of a fibroid?

A

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
more likely to occur in larger fibroids during the 2nd and 3rd trimester of pregnancy.
presents with severe abdominal pain, low grade fever, tachycardia, and vomiting

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28
Q

management of red degeneration of the fibroid

A

supportive with rest fluids and analgesia

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29
Q

investigations for endometrial polyps

A

transvaginal ultrasound
hysteroscopy
endometrial biopsy

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30
Q

what are risk factors for endometrial hyperplasia?

A 
caused by excessive oestrogen without opposition with progesterone
obesity 
exogenous oestrogen use 
oestrogen secreting ovarian tumour 
tamoxifen use 
PCOS 
nulliparity
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31
Q

definitive diagnosis of endometrial hyperplasia

A

pipelle endometrial biopsy biopsy

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32
Q

how is endometrial hyperplasia managed?

A

progesterone treatment- mirena coil or continuous oral progesterone
hysterectomy- 1st line in atypical hyperplasia and not wanting children

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33
Q

pathophysiology of pain in endometrisis?

A

during menstruation the endometrial tissue sheds causing irritation and inflammation of the tissues around the sites of endometriosis resulting in cyclical pain during menstruation. localised inflammation can lead to adhesions which can lead to chronic non-cyclical pain

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34
Q

what do the symptoms of dysmenorrhea, deep dyspareunia, and haematuria together suggest?

A

endometriosis

haematuria due to endometrial tissue in the bladder

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35
Q

what is the gold standard investigation for endometriosis?

A

investigative laparoscopy

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36
Q

management of endometriosis

A

hormonal management- COCP, progesterone only pill, mirena coil, nexplanon implant
surgical management- laparoscopy, hysterectomy

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37
Q

how are cervical polyps usually treated?

A

usually found incidentally during a cervical smear
usually removed at the time using polyp forceps to twist the polyp off
may take a biopsy to make sure it is not cancerous

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38
Q

how is a problematic bleeding ectropion treated?

A

cauterisation with silver nitrite

39
Q

how is a bartholins abscess treated?

A

analgesia and a warm compress
antibiotics
surgical: word catheter, marsupialisation (incision stitched open to allow constant drainage

40
Q

how is chlamydia treated?

A

doxycycline 100mg BD 7 days or azithromycin 1g single dose

41
Q

how is gonorrhoea treated?

A

azithromycin 1g oral with 500mg IM ceftriaxone single dose

42
Q

what is the difference between the presentation of bacterial vaginosis and candidiasis

A

bacterial vaginosis- watery grey/white discharge with a fishy odour, not normally itchy
candidiasis- thick white lumpy discharge which does not usually smell. itchy

43
Q

how is candidiasis (thrush) treated?

A

anti fungal cream or pessary (clotrimazole)

oral anti fungal (fluconazole)

44
Q

how is bacterial vaginosis treated?

A

metronidazole 400mg BD for 5-7days

45
Q

what is the 1st line treatment for syphilis?

A

benzathine benzylpenicillin (8ml injection)- once for early stage, once a week for 3 weeks for late stage

46
Q

what are the symptoms of syphillis?

A

primary chancre followed by rash over palms and soles of feet and lumps
late stage- gummatous, cardiovascular and neurosyphillis

47
Q

what are the components of the Rotterdam criteria for the diagnosis of PCOS?

A

diagnosis requires at least 2 of 3 of:

  • oligoovulation or anovulation
  • hyperandronism- presents with hirsutism and acne
  • polycystic ovaries on ultrasound
48
Q

what is the investigation of choice in PCOS and what is the characteristic appearance?

A

transvaginal ultrasound

string of pearls appearance

49
Q

what is a tumour marker used in ovarian cancer?

A

CA125

50
Q

what factors form the risk malignancy index and what is it used for?

A

the RMI estimates the risk of an ovarian mass being malignant, taking into account 3 things:
menopausal status
ultrasound findings
CA125 level

51
Q

how does ovarian torsion present?

A

sudden onset severe unilateral pelvic pain. often constant, gets progressively worse and is associated with nausea and vomiting
occasionally can twist and untwist causing intermittent pain

52
Q

how is ovarian torsion diagnosed?

A

transvaginal ultrasound- gold standard initial investigation. may show whirlpool sign (free fluid in pelvis and oedema of the ovary)
definitive diagnosis is with laparoscopic surgery

53
Q

what are the surgical options for managing ovarian torsion?

A

laparoscopic surgery to un-twist the ovary and fix it in place (detorsion), remove the affected ovary (oopherectomy)

54
Q

how does ovarian cyst rupture present?

A

sudden severe pelvic pain (may be after strenuous exercise or intercourse)
nausea and vomiting
vaginal bleeding
fever

55
Q

management of ovarian cyst rupture

A

may only need conservative management (rest, observation and pain relief) depending on severity
medical- pain relief, fluid replacement, antibiotics if infection
surgical- laparoscopy

56
Q

what are the types of female genital mutilation?

A

type 1: removal of part or all of the clitoris
type 2: removal of part or all of the clitoris and labia minora, the labia major may also be removed
type 3: narrowing or closing the vaginal orifice (infibulation)

57
Q

what are the options for emergency contraception?

A

levonorgestrel- should be taken within 72 hours of UPSI, given as 1.5mg single dose
ulpristal- should be taken within 120 hours of UPSI, given as a single dose of 30mg, should be avoided in severe asthma
copper coil- if inserted within 5 days of UPSI

58
Q

until what gestation can an abortion be carried out?

A

24 weeks

59
Q

what are the medications used in a medical abortion?

A

meifepristone- halts pregnancy and relaxes cervix
misoprostol- taken 1-2 days after. softens cervix and stimulates contraction. from 10 weeks additional doses (every 3 hours) are required until expulsion

60
Q

how is a surgical abortion carried out/

A

performed under local anaesthetic or general anaesthetic depending on preference and gestation
prior the cervix is primed with misoprostol, mifepristone or osmotic dilators.
two options for surgical abortion:
- suction (up to 14 weeks)
-evacuation using forceps (between 14 and 24 weeks)

61
Q

what is Fitz-hugh-curtis syndrome?

A

a complication of pelvic inflammatory disease caused by inflammation and infection of the liver capsule leading to adhesions. results in RUQ pain which can radiate to the shoulder tip

62
Q

how is pelvic inflammatory disease managed?

A

STI testing and vaginal swabs for cause
start empirical antibiotics while waiting for results
contact tracing

63
Q

when can menopause be diagnosed?

A

a retrospective diagnosis made after a woman has had no periods for 12 months

64
Q

how is menopause diagnosed?

A

clinical diagnosis in women over 45
consider an FSH blood test in women under 40 with suspected premature menopause and women40-45 with menopausal symptoms or a change in menstrual cycle

65
Q

until what age can the COCP be used

A

50

66
Q

management of menopausal symptoms

A

hormone replacement therapy- systemic oestrogens, should be given with cyclical progesterone in women with a uterus (reduce risk of endometrial cancer)
tibolone- can only be given after 12 months of amenorrhoea
clonidine- used to treat vasomotor symptoms
SSRIs
testosterone- used for reduced libidio
vaginal oestrogen- helps with dryness and atrophy

67
Q

how does lichen sclerosus present?

A

woman ages 45-60 complaining of vulval itching, skin changes, superficial dyspareunia
skin appears porcelain white shiny, tight

68
Q

how is lichen sclerosus managed?

A

symptom control using potent topical steroids (dermovate) and emollients

69
Q

what is lichen sclerosus?

A

chronic inflammatory skin condition affecting the labia, perineum and perianal skin. cause by an autoimmune condition.
carries a 5% risk of developing squamous cell carcinoma of the vulva

70
Q

what are dermoid cysts?

A

benign ovarian tumours. they are teratomas meaning they come from germ cells. they can contain various tissue types.

71
Q

what tumour markers are associated with germ cell tumours?

A

alpha fetoprotein

hCG

72
Q

what are the initial investigations and further investigations used in ovarian cancer?

A

initial: CA125 (>35 IU/ml is significant) and pelvic ultrasound to calculate risk malignancy index
further:
- CT scan- establish diagnosis and staging
-histology- CT guided biopsy, laparoscopy or laparotomy
- paracentesis- test ascitic fluid for cancer cells

73
Q

causes of raised CA125

A 
ovarian cancer 
endometriosis 
fibroids
adenomyosis
pelvic infection 
liver disease 
pregnancy
74
Q

what are protective factors for endometrial cancer?

A

COCP/ mirena coil
increased pregnancies
smoking- anti-oestrogenic

75
Q

what are the main symptoms in endometrial cancer?

A 
postmenopausal bleeding- main symptom 
postcoital/intermenstrual bleeding 
menorrhagia 
abnormal discharge 
haematuria 
raised platelet count
76
Q

what is the referral criteria in endometrial cancer?

A

2WW referral for anyone with postmenopausal bleeding
referral for transvaginal ultrasound in women over 55 with:
-unexplained vaginal discharge
-visible haematuriaplus raised platelets, anaemia or elevated glucose levels

77
Q

what investigations are used in endometrial cancer?

A

transvaginal ultrasound- assess endometrial thickness (<4mm postmenopause is normal)
pipelle biopsy- useful for excluding cancer in lower risk women
hysteroscopy with biopsy

78
Q

what HPV types are associated with cervical cancer and what proteins do they produce?

A

16 and 18

produces the proteins E6 and E7 which inhibit the tumour suppressor genes P53 and pRb

79
Q

how often are cervical smears performed?

A

every 3 years aged 25-49

every 5 years aged 50-64

80
Q

what happens if someone is HPV positive with normal cytology?

A

repeat HPV test in 12 months

81
Q

what are the CIN grades?

A

CIN is a grading system for the level of premalignant change in the cells of the cervix. diagnosed at colposcopy
CIN I: mild dysplasia, likely to return to normal without treatment
CIN II: moderate dysplasia, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer. sometimes called carcinoma in situ

82
Q

what are the liquids used during colposcopy to identify abnormal areas?

A

acetic acid- abnormal cells appear white

iodine- stains healthy cells brown, normal cells do not stain

83
Q

how is cervical cancer managed?

A

CIN or early stage 1A: LLETZ or cone biopsy
stage 1B-2A: radical hysterectomy and removal of local lymph nodes with chemo and radio therapy
stage 2B-4A: surgery, chemotherapy and radiotherapy
stage 4B: plus palliative care
pelvic exenteration- removal of most/ all of the pelvic organs. may be used in advanced cancer

84
Q

what is bevacizumab?

A

monoclonal antibody can be used with other chemotherapies in the treatment of metastatic or recurrent ovarian cancer

85
Q

how does vulval cancer present?

A 
vulval lump 
ulceration 
bleeding 
pain 
itching 
lymphadenopathy in the groin
86
Q

what is high grade squamous intraepithelial lesion?

A

a type of vulval intraepithelial neoplasia associated with HPV infection that typically occurs in younger women aged 35-50

87
Q

what is differentiated VIN?

A

a type of VIN associated with lichen sclerosus that typically occurs in older women 50-60

88
Q

what are the management options for anovulation in sub fertility?

A

weight loss- for overweight patients with PCOS
clomifene- used to stimulate ovulation
gonadotropins/letrozole- used if resistant to clomifene
ovarian drilling- laparoscopic surgery used in PCOS

89
Q

what is vault prolapse?

A

occurs in women who have had a hysterectomy. the top of the vagina (vault) descends down

90
Q

how is prolapse managed?

A

conservative- physiotherapy, weight loss, lifestyle changes, treatment of related symptoms, vaginal oestrogen
pessaries
surgery

91
Q

what causes urge incontinence and what is the typical description?

A

overactivity of the detrusor muscle.

suddenly feeling the urge to pass urine, having to rush to the bathroom

92
Q

what causes stress incontinence and what is the typical description?

A

weakness of the pelvic floor and sphincter muscles, allowing urine to leak at times of increased pressure on the bladder.
urinary leakage when laughing, coughing or surprised

93
Q

management of urge incontinence?

A

bladder retraining
anticholinergic medication- oxybutynin, tolterodin
mireabegron- alternative to anticholinergic
invasive procedures- botulinum toxin type A injection into the bladder, percutaneous sacral nerve stimulation, augmentation cystoplasty (enlarge the bladder)

94
Q

what are the antibiotic choices in lower UTI?

A

trimethoprim or nitrofurantoin (avoided if eGFR<45)

alternatives: pivmecillin, amoxicillin

ICCP: Reproductive Health (2 decks)

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