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DRCOG > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What are the Rotterdam criteria for diagnosing PCOS?

A

You need 2 of the 3 to diagnose PCOS:

1) Signs of infrequent or absent ovulation -> Oligomenorrhoea (menstrual cycles > 35 days) or Amenorrhea

2) Clinical (acne, hirsutism, male-pattern baldness)
or Biochemical indicators (raised Free Androgen Index [ total testosterone level / sex hormone binding globulin x 100]
of hyperandrogenism

3) USS showing polycystic ovary (>12 follicles in one or both ovaries) or increased ovarian volume (>10mls)

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2
Q

What are the recommended baseline investigations if PCOS suspected as per NICE CKS?

A

LH
FSH
Testosterone
Sex Hormone Binding Globulin
Prolactin
Thyroid Stimulating Hormone
HbA1C / FBG to assess for impaired glucose tolerance

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3
Q

What are the classical biochemical changes seen in bloods in PCOS?

A

The only blood marker that is involved in official diagnosis as per the Rotterdam criteria is the Free Androgen Index (total testosterone / SHBG x 100) - this is raised in PCOS as testosterone is usually normal or high and SHBG is usually normal or low)

Other blood markers that may support the diagnosis though are:
Total testosterone - normal to slightly raised (if markedly elevated consider other diagnosis)
Sex Hormone Binding Globulin (SHBG) - normal to low
Prolactin - normal to slightly raised
LH: FSH ratio - may be elevated - in PCOS LH is elevated more continuously and so you don’t get the same LH surge effect to prompt ovulation

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4
Q

What is the normal postmenopausal endometrial thickness?

A

<4mm

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5
Q

Under what circumstances is Anti-D required / not required in ectopic pregnancy in rhesus negative woman?

A

If medical management - anti- D not required
if surgical management of ectopic - anti-D immunoglobulin required (250 IU)

Do not offer anti-D rhesus prophylaxis to women who:
receive solely medical management for an ectopic pregnancy or miscarriage or
have a threatened miscarriage or
have a complete miscarriage or
have a pregnancy of unknown location.

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6
Q

What are the reporting / recording obligations in cases of suspected or confirmed FGM?

A

ALL cases of known FGM must be recorded with the FGM Enhanced Dataset - details are NOT annonymous but the women should be assured it is secure.

Confirmed/reported FGM in girl <18 - must report to the police within 1 month of disclosure

Suspected or at-risk of FGM in girl < 18 - refer to social services or police depending on severity of risk

Non-pregnant women > 18 - no obligation to report to police / social services UNLESS a child is thought to be at risk

Pregnant women - FGM safeguarding risk assessment tool, if risk to unborn child or other child then refer to social services or police

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7
Q

Classic presentation of ovarian torsion?

A

Severe localised pain in RIF or LIF
Associated N+V
Onset may coincide with exercise
May have low-grade fever if ovarian necrosis set in
May have unilateral tender addnexal mass on examination

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8
Q

What are contraindications to expectant management of miscarriage as per NICE guidelines?

A

1st line miscarriage mx is expectant (Await 7-14 days before then offering medical or surgical)
Exceptions to this are if:
1) Evidence of infection
2) Increased risk of haemorrhage (in late first trimester, coagulopathy or pt unable to have a blood transfusion)
3) prev adverse / traumatic experience in pregnancy (stillbirth etc)

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9
Q

What is the most common cause of postcoital bleeding?

A

Cervical ectropion

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10
Q

Which medications are contraindicated in combination with Tamoxifen due to interactions?

A

The SSRIs fluoxetine and paroxetine
(they inhibit CYP450 which reduces the effectiveness of tamoxifen)

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11
Q

What is the general management approach for a lady presenting with menorrhagia?

A

FBC and Hx/exam in all.
If symptoms/signs suggestive of underlying pathology do further Ix including Pelvic USS
If not:
-> if does NOT require contraception, 1st line = Tranexamic Acid 1g TDS OR Mefanamic Acid 500mg TDS (or other NSAID) both started on first day of period
-> if DOES require contraception, 1st line = Mirena coil (if acceptable to the woman) 2nd line = COCP 3rd line = Depot provera

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12
Q

What is the upper limit of termination of pregnancy in the UK?

A

23+6 weeks (ie <24 weeks

(legal beyond 24 weeks only if mother’s life is at risk or child at risk of severe disability)

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13
Q

Beyond which gestation do rhesus negative women require anti D?

A

Rhesus neg women need anti D during TOP from 10+0 weeks onwards

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14
Q

What criteria are stipulated for expectant management of an ectopic pregnancy?

A

Size < 35mm
Beta HCG < 1,000 and declining
Asymptomatic
Nil heartbeat
Unruptured

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15
Q

How should cervical bleeding during cervical smear procedure be managed?

A

Contact bleeding in otherwise healthy-looking cervix - reassure, explain sample may be insufficient -> if repeated problem of contact bleeding, refer to gynae

Contact bleeding + suspicion of malignancy - DO NOT send off the smear -> refer with 2WW to gynae

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16
Q

Under what circumstances should the cervical smear be delayed?

A

Pregnant
<12 weeks postpartum or post-miscarriage or TOP
Currently menstruating
Active infection / abnormal discharge

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17
Q

Which other QTc prolonging medications should be avoided being given in combination wih fluconazole?

A

Erythromycin
Quinodine
Pimozide
Cisapride

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18
Q

Which route of taking Misoprostol (2nd step) in medical TOP is better tolerated?

A

Vaginal misoprostol carries a lower risk of side-effects (N+V) than buccal or sublingual

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19
Q

What is the typical presentation of partial v complete molar pregnancy?

A

Partial molar pregnancy -> may mimic a miscarriage [may have intrauterine sac +/- fetal pole] but with a disproportionally high beta HCG

Complete mole - snowstorm appearance on USS, large-for-dates uterus, symptoms of thyrotoxicosis (hcg has common alpha unit as TSH so in large amounts can stimulate thyroid gland), hyperemesis

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20
Q

What is Nageles Rule to predict EDD?

A

LMP + 9 months + 7 days

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21
Q

What is the only intervention which is shown to reduce the rate of further miscarriage in couples with recurrent unexplained miscarriage?

A

Psychological support & regular scans

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22
Q

What is the recurrence risk of a further ectopic pregnancy after a previous ectopic?

A

Recurrence = ~ 10%

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23
Q

How long after management of a hydatiform mole should the woman wait until TTC again?

A

If had chemo (with MTX) -> wait 1 year

If surgical evacuation, wait for 6 months post-evacuation or post-HCG levels normalising whichever is later

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24
Q

Which investigation is now considered the most accurate / gold-standard investigation for diagnosing ectopic pregnancy?

A

Transvaginal USS

  • laparoscopy is no longer considered gold standard as false negative rate may be upto 5% if undertaken too early in the pregnancy*
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25
Q

What is the classical USS finding in ovarian torsion?

A

Enlarged ovary in the midline with free pelvic fluid
& WHIRLPOOL SIGN = as a result of the ovary twisting on itself

26
Q

Risk factors for ovarian torsion?

A

Ovarian Mass
Reproductive Age
Pregnancy (^ ligament laxity & corpus luteum cyst)
Ovarian stimulation for fertility tx
High-intensity exercise

R cyst more likely to tort than left cyst as ligament longer and L cyst held in place more by sigmoid colon

27
Q

Potential causes of paralytic ileus post-operatively?

A

HYPOkalaemia - important to check U&Es as replacing the potassium helps resolve the ileus

Urine in the abdomen 2ndary to ureteric or bladder injury can also cause ileus.

28
Q

What is the rate of progression to endometrial cancer in women found to have endometrial hyperplasia WITHOUT atypia?

A

< 5% over 20 years
Most cases of endometrial hyperplasia without atypia resolve spontaneously

29
Q

Differentials for post-hysterectomy PV bleeding?

A

Early - vault dehiscence (rare) presents w/ haematoma running down vagina
Days - weeks - infection - 2ndary haemorrhage
Late (several weeks+) granulation tissue - can cause sudden onset bleeding, apply silver nitrate topically locally.

30
Q

Which tumour markers should be performed in women <40 with an ovarian mass?

A

CA-125 & hCG & alpha fetoprotein (due to risk of germ cell tumours in younger women) & LDH

31
Q

What is the baseline risk of endometrial cancer in a woman presenting with postmenopausal bleeding?

A

5-10%

32
Q

What is the typical presentation of lichen sclerosus et atrophicus and which complication should you be wary of?

A

Painful white skin on the vuva with cracks

^ risk of SCC developing in the area so ensure any ulceration / new lesions are biopsied

33
Q

Typical presentation of imperforate hymen?

A

Primary amenorrhoea
Cyclical lower suprapubic pain
Palpable mass due to extended vagina filled with bloods (haematocolpos)

Surgical intervention pre-pubertal only if symptomatic as pubertal oestrogen normally causes the hymen to open

34
Q

NICE recommendations for endometriosis management?

A

1st line symptomatic relief: paracetamol + NSAID (ibuprofen or mefenamic acid) for cyclical pain

2nd line; COCP or Depot provera injection

3rd line or if fertility a priority: refer to gynae for consideration of GnRH analogues or laparoscopic excision or ablation + adhesionolysis +/- endometrioma removal

Surgical Mx improves fertility outcomes, not drug Tx

35
Q

Cervical screening programme for HIV positive women?

A

ANNUAL cervical HPV testing AND liquid-based cytology

36
Q

Typical presentation of and risk factors for vulval squamous carcinoma?

A

Presents as non-healing lump / ulcer on the vulva, may have associated itch or irritation.

Risk factors:
Age > 65
Lichen sclerosus
Immunocompromise
HPV infection
VIN (vulval intraepithelial neoplasm)

37
Q

What are the main long-term sequelae of PCOS?

A

^ risk endometrial hyperplasia & cancer (due to amenorrhoea or oligmenorrheoa while being exposed to pre-menopausal oestrogen levels) - highest risk in people not getting periods for > 3 months - can reduce this risk by inducing a bleed every 1-3 months with COCP or Lg-IUS

Subfertility
diabetes
obstructive sleep apnoea
Coronary artery disease
Stroke / TIA

38
Q

How to diagnose premature ovarian insufficiency

A

Suspect in women < 40 with menopausal symptoms.

Confirm with 2x FSH levels > 30 IU taken 4-6 weeks apart & oligo/amenorrhoea for > 3 months

39
Q

Clinical features of adenomyosis?

A

= endometrial tissue growing in myometrium

Tends to present towards END of reproductive years
Dysmenorrhoea, menorrhagia & enlarged boggy uterus of TV USS.

Mx:
TXA and mefanamic acid
COCP or IUS
Uterine artery embolisation

40
Q

Why is ullipristal acetate no longer recommended for fibroid drug treatment?

A

Concerns re risk of it causing severe liver deficiency

41
Q

What endometrial thickness is considered abnormal on TV USS in post-menopausal woman and would merit a referral for hysteroscopy and biopsy?

A

> 4mm in post menopausal woman = need to refer for hysteroscopy & biopsy

If < 4mm endometrial Ca excluded

42
Q

What are the 4x types of FGM?

A

Type I - clitoridectomy
Type 2 - excision of the clitoris & labia minora +/- excision of the labia majora
Type 3 - narrowing of the vaginal orifice by apposition of the labia minora/majora
Type 4 - other non-medical procedures to the female genitalia eg piercing, cauterisation

43
Q

Stress versus urge incontinence and their recommended management?

A

Stress Incontinence:
coughing/sneezing/laughing
1st line = pelvic floor exercises (8 exercises TDS for min 3 months)
-> then consider surgical referal for retropubic mid-urethral taping
If declines surgical referral = Duloxetine = increases contractility of urethral sphincter

Urge incontinence / Detrusor overactivity:
sudden urge to urinate followed by uncontrolled leakage
1st line = bladder retraining for min 6 weeks (^ time between voids)
-> Antimuscarinic agent
- Oxybutynin IR (caution in elderly), Tolteridone, Darifenacin
In elderly consider Mirabegron (beta 3 agonist) instead to avoid anticholinergic side effects

44
Q

What is the single greatest risk factor for ovarian torsion?

A

Having an ovarian mass

45
Q

Is there an association between presence of cervical ectropion and cervical cancer risk?

A

NO
COCP slightly increases the risk of cervical cancer but the presence of a cervical ectropion even if symptomatic does not increase the risk of cervical Ca.

46
Q

What category of drug is clonidine for the menopause?

A

Alpha 2 agonist

47
Q

What medication can be prescribed to help delay a period in the short term eg when going on holiday?

A

Norethisterone 5mg TDS taken 3 days prior next expected period
Menses will resume 2-3 days after stopping the tablets
Caution in using norethisterone in those with lots of CVD risk factors or VTE risk factors

48
Q

Definition of primary amenorrhoea?

A

Failure to develop menses by 15 in someone WITH secondary sexual characteristics or by 13 in someone WITH NO secondary sexual characteristics.

49
Q

Definition of secondary amenorrhoea?

A

Absence of menses for 3-6 months in someone with previous normal regular cycles or 6-12 months in someone with prev irregular cycles

50
Q

Definition of oligmenorrhoea?

A

Menses occurring less frequently than every 35 days

51
Q

How long after a breast exam must you wait to take a prolactin level?

A

48 hrs

(prolactin may be falsely elevated for 48 hrs post breast exam)

52
Q

What are indications for referral to urologist in context of woman presenting with urinary continence issues?

A
  • Associated faecal incontinence
  • Palpable bladder on bimanual or abdo exam post-voiding
  • Suspected neurological disease
  • Suspected fistula
  • Prev continence or pelvic cancer surgery
  • Prev pelvic radiotherapy
  • Persisting bladder or urethral pain
  • Symptoms of voiding difficulty
53
Q

What is the only surgical management option for uterine prolapse that protects future fertility?

A

Vaginal sacro-hysteroplexy with sutures

54
Q

Where is the most common location for an ectopic pregnancy?

A

AMPULLA (~ 97%)

More dangerous if in the isthmus

55
Q

Indications for surgical Mx in ectopic pregnancy?

A

HCG > 5,000
Visible fetal heartbeat
Significant pain
Ruptured
Size > 35 mm

56
Q

Indications for methotrexate Mx in ectopic pregnancy?

A

HCG < 1,500
Unruptured
No fetal heartbeat
Size < 35mm
Nil significant pain

57
Q

Indications for expectant Mx in ectopic pregnancy?

A

HCG < 1,000
Pain-free, unruptured and nil heartbeat
Size < 35 mm

58
Q

Management of ovarian mass / cyst in pre-menopausal women?

A

DO NOT need to do a CA-125 in all premenopausal women if USS shows a simple cyst. Simple cysts < 50mm nil follow-up needed, almost always resolve within 3 cycles, simple cysts 50-70 mm consider annual USS, simple cysts > 70 mm should be referred for further Ix

LDH, AFP, HCG should be done in all women < 40 with a COMPLEX ovarian mass:
Elevated in the following malignant germ cell tumours
- Dysgerminoma (associated w/ Turner’s syndrome) - release HCG & LDH
- Yolk sac tumour - releases AFP
- Choriocarcinoma - release high levels of HCG

Ca-125 less reliable in pre-menopausal women (^ fibroids, endometriosis, adenomyosis and pelvic infection) - if < 200 investigate for one of these other differentials and consider serial levels (Static levels unlikely in malignancy), if > 200 then discuss w/ gynae oncology

If USS shows any of these red flags (‘M rules’) refer to gynae oncology:
- Strong blood flow
- 4+ papillary structures
- Irregular multiloculated solic tumour > 100mm
- Ascites

Calculate RMI I if suspect ovarian malignancy (although will be less reliable in pre-menopausal women):
- USS (1x score for bilateral, solid areas, multi-loculated, ascites, metastases U = 0 if 0 points, U = 1 if 1 point U = 3 if 2-5 points)
x
Pre-menopausal (1 point) Post-menopausal (3 points)
x
Ca-125

RMI 200+ = high malignancy risk

59
Q

How should ovarian cysts / masses be managed in postmenopausal women?

A

Any post-menopausal woman with an ovarian cyst > 10mm should get CA-125 and TV USS & calculate RMI.

If RMI < 200:
If asymptomatic, unilateral, unilocular, simple AND < 50mm with normal Ca-125 consider conservative Mx - repeat USS & Ca-125 in 4-6 months if unchanged repeat again in 4-6 months. Consider discharging if resolved by 1 year.
If any of the following: symptomatic, multi-locular, non-simple, > 50mm, bilateral -> bilateral laparoscopic salpingo-oopherectomy (using laparoscopic retrieval bag)

if RMI > 200:
Need CT Abdo & Pelvis
&
Refer to Gynae Oncology MDT review

If gynae onc MDT thinks high risk of malignancy = full staging procedure
If thinks low risk of malignancy = laparotomy & pelvic clearance (TAH & BSO & omenectomy & peritoneal cytology)

60
Q

NICE Guidelines on ectopic and miscarriage care?

A

If woman < 6 wks, nil risk factors for ectopic & PAINLESS PV bleeding
= conservative mx - advise to return if bleeding continues / worsens, advise UPT 7-10 days and that if negative = miscarriage

Refer to early pregnancy assessment unit or out-of-hours gynae if PV bleeding with;
- Pain
- Gestation > 6 weeks
- Pregnancy of uncertain gestation
for pregnancy viability scan

  • If CRL < 7mm & no heartbeat - repeat in 7 days
  • if CRL > 7mm & no heartbeat - either ask for 2nd opinion to confirm non-viability or repeat in 7 days

If no fetal pole, can measure gestational sac;
- if gestational sac < 25mm & no HB - repeat in 7 days
- if gestational sca > 25 mm & no HB either ask for 2nd opinion to confirm non-viability or repeat in 7 days

DO NOT DIAGNOSE COMPLETE MISCARRIAGE BASED ON USS IF NIL PREV USS TO CONFIRM INTRAUTERINE PREGNANCY - TREAT AS PUL AND HAVE F/U HCG OR USS

PUL: if stable
Measure HCG 48 hrs apart
- If ^ > 63% at 48 hrs - inform likely intrauterine pregnancy - offer USS at 7-14 days
- If > 50% drop in HCG at 48 hrs, inform likely non-viable pregnancy - urine PT at 14 days
- If between 50% drop to 63% increase refer for EPAU assessment within 24 hrs

Threatened miscarriage:
(Bleeding in woman with confirmed intrauterine pregnancy with fetal HB)
- If prev miscarriage - then give 400mg vaginal progesterone BD until 16 wks
- if nil prev miscarriage then don’t
- advise to re-contact if bleeding continues > 14 days

Confirmed miscarriage:
Expectant management for 7-14 days unless
* at risk of haemorrhage eg late first trimester or coagulopathy * signs of infection * prev traumatic experience

Medical management:
Missed miscarriage - 200mg oral mifepristone then 800 mcg misoprostol oral/sublingual/vaginal 48 hrs later
Incomplete miscarriage - 600mcg misoprostol oral/sublingual/vaginal

Expectant management ectopic:
repeat HCG day 2, 4, 7 then weekly until negative - should get at least 15% drop each time, if not refer for review
Fertility and safety outcomes similar between expectant and medical ectopic management

Post-MTX
HCG day 4 and 7 (should be > 15% drop)
then weekly until negative

Surgical ectopic mx:
Only offer salpingotomy if concern re the contralateral tube health
If offer salpingotomy advise 1 in 5 women will need either mTX or further surgical Mx
Repeat HCG 7 days post surgery then weekly until negative

If have salpingectomy then just need UPT at 3 weeks

Only need anti D if SURGICAL mx of ectopic or miscarriage (250IU, nil KH needed)

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