Gynaecology 2 Flashcards
Ectopic Pregnancy
- What is it?
- Clinical features
a) symptoms
b) exam findings - What is the investigation of choice?
- implantation of fertilised egg somewhere other than the uterus
- a)
- vaginal Bleeding: less than period, may be dark brown
- Abdominal pain (constant, unilateral)
- Amenorrhoea: 6-8 weeks (more than consider miscarriage)
- Dizziness / fainting
+/- peritoneal bleeding causing shoulder tip pain or pain on urination / defacation
mnemonic: ectopic pregnancy is BAAD (as in an emergency)
b)
- abdominal tenderness
- cervical excitation
(AKA cervical motion tenderness)
NOTE: palpation of adnexae mass not indicated due to risk of rupturing ectopic
- TVUS
- What are the risk factors for ectopic pregnancy?
- Where is an ectopic pregnancy
a) most likely to be
b) most dangerous
- previous ectopic
- IVF (3% of pregnancies ectopic)
- damage to tubes: previous surgery, PID
- endometriosis
- POP
- IUCD
mnemonic: vague pairs of:
- common sense
- anatomical tube deformity
- contraception
- a) ampulla
b) isthmus
(make sure you know management via the disease profile you made in 3rd year and check this matches passmed)
Endometrial Cancer
- a) What are the RFs?
b) What factors are protective? - What clinical feature is seen?
- What investigations are done?
1.
- early menarche
- nulliparity
- tamoxifen
- late menopause
- unopposed oestrogen (I.e. given without progesterone)
- obesity
- diabetes
- PCOS
- HNPCC
mnemonic: longer exposure to oestrogen (Endometrial = Estrogen) , overweight, you know HNPCC causes it
2. intermenstrual / postmenopausal bleeding
- TVUS: >4mm endometrial thickness
- hysteroscopy + biopsy
Endometrial hyperplasia
- What clinical feature is seen?
- How is it managed?
- intermenstrual / postmenopausal bleeding
- simple: high-dose progesterone with
follow up sample in 3-4 months
complex: hysterectomy
Endometriosis
- What clinical features are seen?
- What investigation is gold-standard?
- How is it managed?
- chronic pelvic pain
- dysmenorrhoea (pain often starts before appearance of blood)
- dyspareunia / dyschezia
- sub fertility (for sake of mnemonic dysfertility)
mnemonic: DYS disease “endometriodys”
2. laparoscopy
- 1st line: NSAIDs / paracetamol
2nd line: COCP / progestogens e.g. medroxyprogesterone acetate
3rd line: GnRH analogues
NOTE: pharmacological management does not effect fertility
Fibroid degeneration
- What is it?
- What clinical features are seen?
- How is it managed?
- fibroids are sensitive to oestrogen and can therefore grow during pregnancy and can sometimes outgrow their blood supply
- pain
- vomiting
- low grade fever
- conservatively: symptoms should resolve in 4-7 days
What should you suspect in mid-cycle abdominal pain which settles over 24-48hrs?
+/- US shows small quantity of free fluid
Mittelschmerz
Heavy Menstrual Bleeding
- What can cause it?
- What is the treatment if
a) patient does not require contraception
b) patient requires contraception
c) require a short term option to rapidly stop menstrual bleeding - What must be performed?
- bleeding disorders
- anovulatory cycles (more common at extremes of reproductive age)
- uterine fibroids
- pelvic inflammatory disease
- hypothyroidism
- intrauterine devices (IUD)
mnemonic: heavy periods are BAUPHIn
NOTE: if no cause then known as DUB (50% of patients)
- a)
mefenamic acid (NSAID) or tranexamic acid
- start on first day of period
- if does not work try another drug while waiting for referral
b)
first line: IUS
alternatively COCP or long-acting progestogens (e.g. depo provera)
c) norethisterone
3. FBC
Hormone Replacement Therapy
- What does it involve?
- What are the SEs?
- What is a woman at increased risk of if they take it?
- What are the contraindications?
- oestrogen + progesterone in a woman with a uterus
- breast tenderness
- nausea and vomiting
- fluid retention and weight gain
THINK: same as someone who is pregnant
- breast cancer -> increases with time taken and adding progestogen
- endometrial cancer -> absolutely cannot give oestrogen only in any woman with uterus, progestogen decreases risk massively but risk still present
- VTE (but not if transdermal)
- stroke
- CV disease (if 10 years postmenopausal)
- breast cancer (past or present)
- oestrogen receptor positive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
Hyperemesis Gravidarum
- What makes the risk
a) increased
b) decreased - How is the vomiting managed?
- When can it occur?
CHECK: admission guidance is on the disease profile sheet with symptom mnemonic
1. a) - molar pregnancy - multiple pregnancy - hyperthyroidism - nulliparity - obesity
b) smoking
- first line: antihistamines (e.g. cyclizine, promethazine)
2nd line: ondansetron or metoclopramide
metoclopramide: can be used for maximum 5 days due to possibility of extra-pyramidal SEs
ondansetron: slightly elevated risk of cleft lip/palate -> woman must be counselled on this
3. often 8-12 weeks, very rarely past 20 weeks
What are the complications of hysterectomy
- acutely
- long term
- urinary retention
- enterocoele
- vaginal vault prolapse
Infertility
- What investigation is done for
a) men
b) woman - When should one refer to a specialist for the woman’s test?
- What advice should be given?
- a) semen analysis
b) progesterone level 7 days prior to expected period
2. if repeatedly below 16
if get result below 30: repeat
> 30 indicated ovulation
- folic acid
- aim for BMI 20-25
- regular intercourse every 2-3 days
- alcohol / smoking counselling
How long should women around menopause keep taking contraception?
<50 24 months after last period
> 50 12 months after last period
