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Obs and Gynae > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is hyperemesis gravidarum?

A

Prolonged vomiting and nausea, leading to dehydration, ketosis, electrolyte derangement and weight loss.

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2
Q

What are the risk factors for hyperemesis gravidarum?

A 
Young maternal age
Non-smoker
First pregnancy
Multiple pregnancy
Gestational trophoblastic disease
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3
Q

How should hyperemesis gravidarum be managed?

A

Exclude other causes of vomiting e.g. infection
Admit to hospital if dehydration is significant.
Fluid replacement and correction of electrolyte disturbances.
Thiamine supplementation
Antiemetis e.g. promethiazine and cyclizine. In intractable cases consider steroids.
Thromboprophylaxis.

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4
Q

What is the definition of a miscarriage?

A

When the fetus dies or delivers dead before 24 weeks.

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5
Q

What proportion of clinically recognised pregnancies end in miscarriage?

A

15%. The majority occur before 12 weeks and the rate increases with maternal age.

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6
Q

What are the different types of miscarriage?

A 
Threatened miscarriage - only 25% will go on to miscarry.
Inevitable miscarriage.
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Missed miscarriage
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7
Q

What are the causes of miscarriage?

A

Isolated non-recurring chromosomal abnormalities account for >60%.
If three or more occur, rarer recurrent causes are more likely e.g. anti-phospholipid antibodies, chromosomal defects (parental karyotyping), anatomical factors, infection

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8
Q

What investigations should be carried out in a suspected miscarriage?

A

USS to show if there is a fetus and if it is viable. If in doubt, the scan should be repeated a week later as non-viable pregnancies can be confused with very early pregnancies.
Blood test - HCG levels in the blood normally increase >66% in 48 hours in a viable intrauterine pregnancy.
Rhesus group and FBC

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9
Q

How can a non-viable intrauterine pregnancy be managed (missed miscarriage)?

A

Expectorant management - as long as the woman is willing and there is no infection

Medical management - prostaglandin sometimes preceded by mifepristone (anti-progestrogen)

Surgical - ERPC if the woman prefers it, if there is heavy bleeding or signs of infection

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10
Q

What are the complications of miscarriage?

A

Heavy and painful bleeding - requires 24 hour direct access to EPAU
Infection can lead to endotoxic shock
Surgical evacuation can partially remove the endometrium causing Asherman syndrome

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11
Q

What are the risk factors for ectopic pregnancy?

A 
PID
Assisted conception e.g. IVF
Previous ectopic pregnancy
Endometriosis
Copper IUD
Smoker
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12
Q

What are the clinical features of an ectopic pregnancy?

A

Lower abdominal pain followed by scanty, dark vaginal bleeding.
Syncopal episodes
Shoulder tip pain - intraperitoneal blood loss
Usually amenorrhoea, but patient may be unaware of pregnancy

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13
Q

What investigations should be carried out in a woman with suspected ectopic pregnancy?

A

Pregnancy test
USS
Blood tests - cross match and FBC
Quantitative serum hCG is useful if the uterus is empty. If the level is >1000 IU/ml, then any intrauterine pregnancy should be visible. A declining or slow rising hCG (slower than >66% increase per 48 hours) suggests an ectopic or non-viable pregnancy.
Laparoscopy - the most sensitive investigation.

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14
Q

How should an ectopic pregnancy be managed?

A

Surgical - laparoscopy and salpingectomy
Medical - if the ectopic is unruptured with no cardiac activity and an hCG level <3000 IU/dl, methatrexate may be used. Serial hCGs are then used to ensure that all trophoblastic tissue has gone.
Conservative - if small and unruptured, if location is unclear and hCG levels are low and declining

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15
Q

What is gestational trophoblastic disease?

A

These are unique tumours that develop from placental tissue (syncitiotrophoblast and cytotrophoblast) and express hCG. They result from an abnormality at fertilisation.

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16
Q

What are the risk factors for gestational trophoblastic disease?

A

Extremes of reproductive age
Previous GTD
Diets deficient in protein, folic acid and carotene
Women of blood group A with blood group O partners
Women with blood group AB have a worse prognosis if diagnosed with GTD

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17
Q

What different types of gestational trophoblastic disease are there?

A

Complete moles - euploid and of paternal origin caused by an empty ovum fertilised by 2 haploid sperm.
Partial mole - triploid and arises with an ovum is fertilised by a duplicated or 2 haploid sperm.
Gestational trophoblastic neoplasia - invasive mole or choriocarcinoma.

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18
Q

How does GTD present?

A

Irregular vaginal bleeding in the first trimester or suspicious findings at routine US
14-32% have hyperemesis gravidarum
Large for dates uterus
15-30% of women have theca lutein cysts in the ovary which may cause accidents.
10% have biochemical hyperthyroidism
10-12% have first or second trimester pre-eclampsia

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19
Q

What investigations should be done for GTD?

A

USS - snowstorm appearance. Can be cystic or invasive.

Blood test for serum hCG - useful diagnostically and also for monitoring.

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20
Q

How should GTD be managed?

A

Surgical evacuation by suction curettage with subsequent hCG monitoring for malignancy.
In the UK, women with a molar pregnancy should be registered with a supraregional centre.

Pregnancy and COCP should be avoided until hCG levels are normal because they may increase the need for chemotherapy.

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21
Q

How would a malignant mole present, and how would it be treated?

A

Gestational trophoblastic neoplasia present with persistently elevated or rising hCG levels, persistent vaginal bleeding or evidence of metastases, most commonly in the lungs.

Usually very sensitive to chemotherapy. 5 year survival rates are 100%.

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22
Q

What are the causes of PID?

A

Sexual factors account for 80%
Uterine instrumentation e.g. ERCP, TOP, laparoscopy and dye, IUDs
Complications of childbirth and miscarriage
Descending infections e.g. appendicitis

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23
Q

What investigations should be done for suspected PID?

A

Triple swabs (endocervix, high vaginal and urethral/urine) and microscopy
Bloods - FBC, CRP, ESR, blood cultures if pyrexial
Laparoscopy can support diagnosis and exclude others
USS with Doppler to identify tubal masses and dilation

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24
Q

How should PID be managed?

A

Analgesia
Antibiotics - parenteral cephalosporins e.g. IM ceftriaxone followed by doxycycline and metronidazole.
Admit febrile patients.
Surgery may be required to drain abscesses, divide adhesions or drainage of pelvic fluid collections by USS guidance.
Patients should be referred to GUM clinic for a full sexual health screen.

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25
Q

What are the complications of PID?

A

Fitz-Hugh-Curtis syndrome - RUQ abdo pain and perihepatitis
Chronic pelvic pain, deep dyspareunia and sexual dysfunction
Increased risk of ectopic pregnancy
Subfertility

26
Q

What is cervical intraepithelial neoplasia?

A

The presence of atypical cells within the squamous epithelium. These atypical cells are dyskaryotic, exhibiting larger nuclei and frequent mitoses.

27
Q

Which strains of HPV are associated with cervical cancer?

A

16, 18, 31 and 33.

28
Q

When should cervical screening be done?

A

All women from age 25 upwards or after first sexual intercourse if later, and then repeated every 3 years until the age of 49.
Between the age of 50 and 64 years - 5 yearly
From age 65, only those who have not been screened since age 50 or have had recent abnormal tests are screened.

29
Q

When is subfertility diagnosed?

A

When conception has not occurred after a year of regular protected intercourse. Primary subfertility is if the female partner has never conceived. Secondary is if she has previously conceived.

30
Q

In what ways can ovulation be detected?

A

History - regular cycles, vaginal spotting, vaginal discharge or mittelschmertz
Examination - cervical mucus will fern on a slide and form elastic-like strings. Body temperature normally drops 0.2 degrees preovulation then rises 0.5 degrees in the luteal phase.
Investigation - mid luteal phase serum progesterone will generally be elevated. LH based urine predictor kits can be used.

31
Q

What investigations should be done for suspected PCOS?

A

TVUS
Bloods - FSH, LH, testosterone, prolactin, TSH
Fasting lipids and glucose

32
Q

What are the complications of PCOS?

A

Up to 50% of women with PCOS develop type 2 diabetes and 30% develop gestational diabetes.
Endometrial cancer is more common after many years of amenorrhoea due to unopposed oestrogen action.

33
Q

What are the treatments for PCOS?

A

Conservative - diet and exercise
COCP will regulate menstruation and treat hirsutism if fertility is not required
Antiandrogens e.g. spironolactone or cyprotenone acetate can be used to treat hirsutism
Metformin

To induce ovulation, can use comifene, metformin, gonadotrophins, ovarian diathermy or IVF

34
Q

What factors predispose to prolapse?

A

Pregnancy and vaginal delivery (especially with big babies, prolonged second stage and instrumental delivery)
Congenital factors e.g. Ehlers-Danlos syndrome
menopause
Chronic predisposing factors causing an increase in intra-abdominal pressure e.g. obesity, chronic cough, constipation, pelvic mass, heavy lifting
Iatrogenic factors e.g. hysterectomy and continence procedures.

35
Q

What is prolapse?

A

Protrusion of the uterus and/or vagina beyond normal anatomical confines. The bladder, urethra, rectum and bowel are often involved.

36
Q

How can prolapse be managed?

A

Physiotherapy with pelvic floor muscle exercises, biofeedback and vaginal cones.
Vaginal pessaries - ring pessary and shelf pessary
Surgery

37
Q

What is urinary stress incontinence?

A

Involuntary leakage of urine on effort or on exertion, or on sneezing or coughing.

38
Q

How should urinary stress incontinence be assessed?

A

History - the degree to which the patient’s life is affected.
Examination - with a Sims speculum to look for a cystocoele or urethrocoele, and leakage with coughing. The abdomen is palpated to exclude a distended bladder.
Ix - urine dipstick to exclude infection, cystometry to exclude overactive bladder

39
Q

How can urinary stress incontinence be managed?

A

Conservative - weight loss, treat chronic cough, reduce fluid intake and strengthen pelvic floor
Medical - duloxetine to enhance urethral striated sphincter activity.
Surgery.

40
Q

What is urge incontinence?

A

Overactive bladder with urgency, characterised by involuntary contractions of the detrusor during the filling phase which may be provoked by, for instance, coughing.

41
Q

What are the causes of urge incontinence?

A

Mostly idiopathic
May follow operations for stress incontinence
Can be due to the presence of underlying neuropathy such as MS or spinal cord injury.

42
Q

How can urge incontinence be treated?

A

Conservative - reduce fluid intake, review drugs e.g. diuretics and antipsychotics and bladder training.

Medical - anticholinergics, oestrogen and botox

43
Q

A woman has had her smear, which came back as borderline abnormal and HPV positive. What is the next step?

A

Colposcopy and possibly punch biopsy. Borderline with no HPV gets sent back to routine recall.

44
Q

How is CIN II or III treated?

A

Excision of transformation zone with cutting diathermy under local anaesthetic - LLETZ

45
Q

What are the clinical features of cervical cancer?

A

Hx - PCB, offensive vaginal discharge, IMB and PMB. In later stages of the disease, involvement of bladder, ureters, rectum and nerves causes uraemia, haematuria, rectal bleeding and pain. Smears have usually been missed.
Ex - an ulcer or mass may be visible or palpable.

46
Q

Broadly speaking, what are the stages of cervical cancer?

A

1 - confined to cervix
2 - invasion into vagina but not pelvic wall
3 - invasion of lower vaginal wall or pelvic wall, or causing ureteric obstruction
4 - invasion of bladder, rectal mucosa or beyond

47
Q

What is the epidemiology of endometrial cancer?

A

90% >50 years, with only 15% of cases occurring pre-menopausally.

48
Q

What are the risk factors for endometrial cancer?

A 
High oestrogen to progesterone ratio, such as in the following:
Exogenous oestrogen
Obestiy
PCOS with prolonged amenorrhoea
Nulliparity
Early menarche, late menopause
Tamoxifen

Also associated with htn/diabetes and HNPCC.

COCP is protective.

49
Q

What is the staging for endometrial cancer?

A

1 - confined to uterus
2 - spread to cervix
3 - invasion through uterus to adnexae and pelvic/para-aortic nodes
4 - in bowel, bladder or distant

50
Q

How should PMB be investigated?

A

TVUS - if thicker than 4mm refer to biopsy
Endometrial biopsy to obtain histology - Pipelle or curettage
Hysteroscopy
MRI scan may be helpful in staging established carcinoma

Should also assess fitness for surgery

51
Q

What is the epidemiology of ovarian cancer?

A

80% of cases occur in women >50 years of age. Highest rates in women aged 80-84.

52
Q

What are the histological types of ovarian cancer and their distribution?

A 
Serous cystadenocarcinoma - 50%
Endometriod carcinoma - 20%
Mucinous cystoadenocarcinoma - 10%
Clear cell - 10%
Other - 10%

Germ cell tumours are most common in women <30 years

53
Q

What are the risk factors and protective factors for ovarian cancer?

A

Risks relate to the number of ovulations:
Early menarche
Late menopause
Nulliparity

Cancer genes: BRCA1 and 2, HNPCC

Protective factors:
Pregnancy
Lactation
Pill

54
Q

How does ovarian cancer spread?

A

Ovarian adenocarcinoma spreads directly within the pelvis and abdomen (transcoelomic spread). Lymphatic and blood borne spread may also occur

55
Q

How should symptoms of ovarian pathology be investigated?

A

Ca125 levels should be measured in women with many abdominal symptoms. If raised, USS abdomen and pelvis to look for ascites or masses.
AFP and hCG should be measured in women 250 should be referred to a specialist

Staging by CT and during surgery

56
Q

What is the management of ovarian cancer?

A

Assess fitness for surgery.

Surgery - midline laparotomy for assessment with BSO + TAH and partial omentectomy, aspiration of ascites. Biopsies should be taken of any peritoneal deposits, random biopsies of peritoneum and retropertioneal lymph nodes.

Chemo - cisplatin/carboplatin for stages 2-4

Radiotherapy used only for dysgerminomas.

57
Q

What is vulval cancer associated with?

A

VIN is a premalignant stage, but carcinoma often arises de novo.
It is associated with lichen sclerosis, immunosuppression, smoking and Paget’s disease of the vulva.

58
Q

What are the two types of VIN?

A

Usual type - most common, associated with HPV, CIN, smoking and chronic immunosuppression. May be multifocal with a varied appearance

Differentiated type - rarer, associated with lichen sclerosis and seen in older women. Usually unifocal in the form of an ulcer/plaque. Higher risk of progression

59
Q

How should endometrial hyperplasia be managed?

A

Simple endometrial hyperplasia without atypia responds to high dose progestogens e.g. Mirena coil. Repeat histology after 3 months. Long term follow up is advised especially in complex hyperplasia as relapse frequently occurs.

Surgical - transcervical resection of endometrium/ hysterectomy.

60
Q

What are the main anatomical supports for the vagina?

A

Level 1: the cervix and upper part of the vagina are supported by the cardinal and uterosacral ligaments. These are attached to the cerrvix and suspend the uterus from the pelvic sidewall and sacrum respectively.
Level 2: mid portion of the vagina is attached by endopelvic fascia to the pelvic side walls
Level 3: lower third of vagina supported by levator ani and the perineal body.
The horizontal axis of the vagina is also important.

Obs and Gynae (6 decks)

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