Gynaecology Flashcards
Follicular phase = FSH stimulates follicular development
Oestrogen and inhibin produced by dominant follicle inhibits FSH production
Due to declining FSH levels, only the dominant follicle survives
LH surge occurs 36 hours before ovulation
Dominant follicle ruptures, releasing oocyte
In the luteal phase the corpus luteum is formed and progesterone is released
Luteolysis occurs 14 days post-ovulation
What is metrorrhagia?
Regular IMB
Duration of a normal menstrual cycle
21 - 35 days
What is oligomenorrhoea?
Menses at duration >35 days
What is adenomyosis?
A cause of painful/ heavy periods
It is similar to endometriosis but the endometrium breaks through the normal myometrium
An important cause of chronic pelvic pain
List some causes of menorrgahia?
Local:
- fibroids
- polyps (endometrial )
- endometriosis
- adenomyosis
- endometrial hyperplasia
- PID
Systemic;
- DM
- Thyroid
- Clotting disorder e.g. VWD
Dysfunctional uterine bleeding is a diagnosis of exclusion. It is more common in obese women and at the extremes of reproductive age. What investigations should be done prior to this diagnosis?
- FBC
- smear
- Clotting
- TFT
- TVUS
- Endometrial biopsy
Define menorrhagia?
Menstrual loss >80ml/ cycle
1st line for a lady wanting contraception who has menorrhagia?
Mirena
What is androgen insensitivity syndrome?
Also call testicular feminisation
X-linked recessive - patients have male karyoptype (46XY)
Testes develop but do not descend - androgen response does not occur so patients have undescended testes with female genitalia
Presents at puberty with amenorrhoea and lack of pubic hair
An adult is found to have an undescended testes. What should be considered?
Orchidopexy = cancer risk is x6
What secretes testosterone?
Leydig cells
What do Sertoli cells do?
Loads of actions:
- blood-testes barrier
- provide nutrients
- phagocytosis
- release androgen binding globulin
- secrete seminiferous tubule fluid
LH acts on Leydig cells to regulate testosterone secretion
FSH acts on Sertoli cells to enhance spermatogenesis
Don’t forget to ask about steroid abuse in male patients with infertility
Don’t forget to ask about steroid abuse in male patients with infertility
What is the normal scrotal volume?
12-25ml
In male ?infertility what examinations would you perform?
1) Look for secondary sexual characteristics e.g. body hair, gynaecomastia
2) Scrotal and penile exam e.g. vas deferense, urethral orifice
What investigations would you like to do for ?male infertility
1) Bloods: LH, FSH, TSH, PRL, testosterone
2) Chromosomal analysis
3) semen analysis - 6 weeks apart
4) ? Biopsy/ US
What are the endocrine features of Klinefelters?
Low testosterone
High LH and FSH
In a standard 28 day cycle - which are the most fertile days?
Days 8 to 18
Lactational amenorrhoea is 98% effective. What are the 3 criteria?
1) Exclusive breastfeeding
2) Less the 6/12 post-natal
3) Amenorrhoea
What is the mode of action of combined hormonal contraception?
1) Mainly inhibits ovulation
What is the mode of action of the POP?
Primarily inhibits ovulation
E.g. desogestrel
What is the mode of action of the implant?
Primary inhibits ovulation
What is the mode of action of the depo provera?
Primarily inhibit ovulation for 14 weeks (given every 12)
What is the mode of action of the mirena?
It effects implantation by making the endometrium unfavourable
(failure rate is 1 in 500)
What is the mode of action of the IUD?
Prevents fertilisation due to inflammatory response
BP and BMI measures before giving depo, CHC or POP
Do a PV to check uterine position/ size before IUD
Don’t forget to ask about FH of breast cancer if you are prescribing the pill
If yes, enquire about BRACA gene - this may make it too high risk
Which cancers does the pil protect against?
1) Protect = ovarian and endometrial
2) Increase risk = cervical and breast
What is the main risk factor of the depo provera?
Low bone mineral density e.g. smoking, very low BMI etc
Give some absolute CI to using the COC?
- Smoking >15/day if >35
- migraine with aura
- personal history of VTE
- BP > 160/95 etc
When does the pill become effective
1) Day 1-5 of cycle/ day of TOP = immediately
2) After day 5 = condoms for 1 week
What are missed pills rules/
1) 2 or more pills missed = take next pill and use condoms for 7 days
2) 2 pills of 1st 7 days missed = emergency contraception
POP missed pills rule
If 1 or more pill missed or late (>12 hours if cerazette) then need emergency contraception if UPSI has occurred in 2 days after this
If someone is anxious about having an STI screen done. What could you say to reassure them about the confidentiality?
GP does not have to be told
Samples are given a number not a name
What STIs are partner notification not required?
BV
Thrush
Herpes
Warts
Which vaccines are given to protect people against STIs?
Hep B
HPV
A MSM is at risk of contracting HIV after UPSI with a high risk partner. What can you tell him about PEPSE?
1) has to be taken within 72 hours
2) 28 days total
3) reduces risk of hIV by 80%
Could also consider the Hep B vaccine, must be given within 72 hours
What are the 2 situations in which an emergency abortion can be performed?
1) Save the life of the women
2) Prevent grave permanent harm to the physical or mental health of the women
Remember conscientious objection is not allowed if it is an emergency
Would have to abort if it was to save ladies life
In GP, patient wants a TOP. What actions do you take?
Refer to TOP clinic
Nurse led
Chat, scan and options
Blood taken - FBC, G+S
? STI screen
What are the time cut offs for TOP in Tayside?
Surgical = up to 12 weeks Medical = up to 18 weeks, 6 days
(Elsewhere it is 24 weeks max and any if fetal abnormal)
An early medical abortion is at <9 weeks. How is it done?
1) Oral mifepristone 200mg (anti-progesterone)
2) vaginal or oral misoprostol (prostaglandin) - can be taken at home
For later abortions, multiple doses of misoprostol will be needed
Surgical TOP is Scotland?
Vacuum aspiration from 6-12 weeks
Done under GA as day case
Vaginal prostaglandin used to ‘prime’
LARC fitted
Levonorgestrel and ulipristal acetate are emergency contraeption. How do they work?
Delay ovulation
Ulipristal acetate is more effective and can be taken up to 120 hours after UPSI. What is a major CI?
Severe asthma controlled by steroids
IUD is best EC as has pre- and post- implantation effects e.g. toxic to ovum
All women must be screened (+ treated) prior to insertion
When does an embryo implant?
Dat 8-10 post fertilisation
What is the incubation period for common STI?
Chlamydia/ Gonorrhoea = up to 1 weeks
Hep B = 6 weeks
HIV/ Hep C = up to 3 months
HIV targets CD4 cells. What is the normal level? What puts patients at risk of opportunistic infection?
Normal = 500-1600 cells/mm
At risk = <200
What is the treatment for PCP?
High dose co-trimoxazole
Remember is anyone has HIV think - do they have TB too?
Remember is anyone has HIV think - do they have TB too?
CMV presents in HIV with reduced visual acuity and floaters
What CD4 level puts people at risk?
CD4 <50
Opthalmoplegia screening is offered to all patients with this CD4 level
Kaposi sarcoma is a vascular tumour seen in HIV. What causes it?
Human herpes virus 8
EBV will also predispose to Burkitt’s lymphoma
What is the risk of mother to child transmission if viral load is undetectable?
<0.1%
Wha examination and investigations are done at the booking scan?
Height and weight BP, CVS and abdo exam US FBC - Hb, ABP, rhesus HIV, HBV, HCV, syphillus US Urinalysis - MSSU, C&S
What investigations/ examinations do you do in ALL pregnant women at every visit?
BP Urinalysis Symphysis-fundal heigh Lie Auscultation for heart
Ask about mood and anxiety
When you do an ultrasound at the booking scan - what are you looking for?
Intravascular-uterine pregnancy
Obvious anomalies
Placental site
When is the nuchal thickness measured?
Between 11 and 13+6 weeks (e.g. in the first trimester)
Combined with HCG and PAPP-A (pregnancy associated plasma protein A) and maternal age
In the 2nd trimester, a blood sample can be taken at 15-20 weeks which measures HCG and AFP. UE3 and inhibin A What is the cut off for ‘high risk’ downs and therefore requires further investigation?
> 1 in 250
When is CVS performed?
After 12 weeks
Miscarriage rate = 2%
When is amniocentesis performed?
After 15 weeks
Miscarriage rate = 1%
What are the 2 main haematological disorders to be aware of in pregnancy?
Sickle cell
Thalassaemia
60% of all women are anaemia in pregnancy
RF for gestational DM?
BMI >30 Previous macrosomic baby (>4.5 kg) Previous GDM FH of DM (1st degree) High risk ethnicity
Where should the bump be at what stage?
Pubic symphysis = 12 weeks
Umbilicus = 20 weeks
Xiphoid pricess = 36 weeks
If SFH measurement is <10th centile or growth is static/ slowing then…
Refer for US do fetal size
RF for ‘high risk’ pre-eclampsia
Chronic HT or previous gestational HT
CKD
Lupus or similar
Type 1 or 2 DM
How do you treat primary, secondary and tertiary syphilis of duration <12 months?
Benzylpenicillin 2.4 mega units IM
doxycycline is used as the alternative in penicillin allergic
How do you treat latent syphilis e.g. 3 years previously?
Benzylpenicillin 2.4 units IM weekly for 3 weeks
Common cause of diarrhoea in HIV positive person?
Cryptosporidium
Patient with profuse watery diarrhoea +blood/ mucus and hypokalaemia?
Rectal villous adenoma
they secrete large amounts of mucus which can cause hypokalaemia - also risk of malignant transformation
Anchovy sauce pus in a liver abscess?
Infecting organism is most likely to be ameoibic causing an abscess
Papillary thyroid cancer derived from iodine rich cells
Medullary thryoid derived from C cells in the thyroid
Patient with small papule ulcer on genital region. This breaks down to form a painless ulcer. Lymph node involvement with matted inguinal lymph nodes, abscess and sinus formation
Lymphogranuloma venerum
L1 -L3
Severe bleeding from placenta praevia necessitates resusucation and C-section
Vaginal delivery is CI if there has been major bleeding
Normally placenta praevia is managed with a section from 38 weeks
Sudden onset SOB and pleuritic pain after amniocentesis?
Amniotic fluid embolism
this can be complicated by DIC as shown by development of a rash
