Gynaecology Part 2 Flashcards
(77 cards)
1
Q
Type 1 female genital mutilation:
A
partial or total removal of clitoris and/or prepuce
2
Q
Type 2 female genital mutilation:
A
partial or total removal of clitoris and labia minora, with or without excision of labia majora
3
Q
Type 3 female genital mutilation:
A
narrowing of vaginal orifice with creation of covering seal by cutting and positioning labia minora or majora, with or without excision of clitoris (infibulation)
4
Q
Type 4 female genital mutilation:
A
all other harmful procedures to female genitalia: pricking, piercing, incising, scraping and cauterisation
5
Q
How can fibroid degeneration come about and how does it present and treatment?
A
- sensitive to oestrogen so grows during pregnancy
- growth outstrips blood supply - red/carneous degeneration
- low grade fever, pain and vomiting
- manage conservatively with rest and analgesia (resolves within 4-7 days)
6
Q
Features of Mittelschmerz:
A
- mid cycle pain
- sharp onset
- little systemic
- recurrent
- settles over 24-48 hours
7
Q
Investigation and treatment of mittelschmerz:
A
- FBC normal
- US may show small quantity free fluid
- conservative management
8
Q
Features of endometriosis pain:
A
- 25% asymptomatic
- menstrual irregularity, infertility, pain and deep dyspareunia
- intermittent small bowel obstruction
- intra abdominal bleeding - localised peritoneal inflammation
- recurrent episodes
9
Q
Investigations endometriosis:
A
- US - free fluid
- laparoscopy - lesions
10
Q
Features of ovarian torsion pain:
A
- suden onset
- deep seated colicky abdominal pain
- vomiting and distress
- adnexial tenderness
11
Q
Investigation of ovarian torsion:
A
- US - free fluid
- laparoscopy diagnostic and therapeutic
12
Q
Features of ectopic gestation pain:
A
- symptoms of pregnancy without evidence of intrauterine gestation
- emergency with evidence of rupture or impending rupture
- small amount of vaginal discharge
- adnexial tenderness
13
Q
Investigation and management of ectopic gestation:
A
- US - no intrauterine pregnancy
- beta hCG elevated
- intra abdominal free fluid
- laparoscopy or laparotomy if harm-dynamically unstable
- salpingectomy usually
14
Q
Features of PID pain:
A
- bilateral lower abdominal pain
- associated with vaginal discharge
- may also have dysuria
- peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis)
- may have RUQ discomfort
- fever >38 degrees
15
Q
Investigation and management of PID:
A
- FBC: leucocytosis
- pregnancy test negative
- amylase - normal or slightly raised
- high vaginal and urethral swabs
- medical management
16
Q
Investigations carried out if menorrhagia:
A
- FBC
- routine transvaginal US if symptoms suggest structural or histological abnormality
17
Q
If a patient with menorrhagia does not require contraception, use:
A
mefenamic acid 500mg tds (especially if also dysmenorrhoea) or tranexamic acid 1g tds
18
Q
If a patient with menorrhagia does require contraception, use:
A
- intrauterine (mirena) first line
- COCP
- long acting progestogens
19
Q
What can be used as a short term option to rapidly stop heavy menstrual bleeding?
A
norethisterone 5mg tds
20
Q
What is HRT typically used for in women?
A
small dose of oestrogen to help alleviate menopausal symptoms (also progestogen if uterus)
21
Q
Side effects of HRT:
A
- nausea
- breast tenderness
- fluid retention and weight gain
22
Q
Complications of HRT:
A
- increased risk breast cancer
- increased risk endometrial cancer
- increased risk of VTE
- increased risk of stroke
- increased risk of ischaemic heart disease if more than 10 years after menopause
23
Q
In what way does HRT increase risk of breast cancer:
A
- increased by addition of progestogen
- increased risk with duration of use
- risk of breast cancer begins to decline when HRT stopped and reaches previous level after 5 years
24
Q
How does HRT increase risk of endometrial cancer?
A
- oestrogen on its own should not be given as HRT to women with a womb
- reduced by the addition of progestogen but not eliminated
25
How does HRT increase risk of VTE?
- increased by addition of progestogen
- transdermal HRT does not increase risk
- refer to haematology before starting treatment if high risk
26
What is hyperemesis gravidarum thought to be due to?
raised beta hCG levels
27
Associations with hyperemesis gravidarum:
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
- smoking DECREASES incidence
28
Referral criteria for n&v in pregnancy:
- continued n&v and unable to keep down liquids or oral antiemetics
- continued n&v with ketonuria and/or weight loss, despite treatment with oral antiemetics
- confirmed or suspected comorbidity
29
What triad must be present before diagnosis of hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
30
What scoring system can be used to classify severity of NVP:
Pregnancy-Unique Quanitification of Emesis PUQE
31
Management of hyperemesis gravidarum:
- antihistamines first line
- cyclizine
- ondansetron and metoclopramide second line
- ginger and P6 (wrist) acupressure
- admission for IV hydration
32
Complications of hyperemesis gravidarum:
- Wernicke's encephalopathy
- Mallory Weiss tear
- central pontine myelinolysis
- acute tubular necrosis
- foetal: small for gestational age, pre-term birth
33
Long term complications of hysterectomy:
- enterocoele
| - vaginal vault prolapse
34
Acute complication of hysterectomy:
urinary retention
35
Causes of infertility:
- male factor 30%
- unexplained
- ovulation failure
- tubal damage
- other causes
36
Basic investigations of infertility:
- semen analysis
| - serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, done on day 21
37
Interpretation of serum progestogen in infertility investigations:
- <16nmol/L - repeat if consistently low, refer to specialist
- 16-30nmol/L - repeat
- >30nmol/L - ovulation
38
Average age for menopause:
51yo
39
Recommended time to use effective contraception until:
- 12 months after last period in women >50yo
| - 24 months after last period in women <50yo
40
When can the clinical diagnosis of menopause be made?
no period for 12 months
41
Contraindications of using HRT for menopause symptoms:
- current or past breast cancer
- oestrogen sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
42
Management of vasomotor symptoms in menopause: (hot flushes, night sweats)
- fluoxetine
- citalopram
- venlafaxine
43
Management of vaginal dryness in menopause:
- vaginal lubricant
| - moisturiser
44
How should HRT be stopped in menopause:
- gradually reducing HRT is effective at limiting recurrence in short term
- long term - no difference symptom control
45
Long term complications of menopause:
- osteoporosis
| - increased risk ischaemic heart disease
46
Causes of menorrhagia:
- dysfunctional uterine bleeding
- anovulatory cycles
- uterine fibroids
- hypothyroidism
- intrauterine devices
- PID
- bleeding disorders e.g. VW disease
47
Threatened miscarriage:
- painless vaginal bleeding before 24 weeks (typically at 6-9)
- bleeding less than menstruation
- cervical os closed
- complicates 25% pregnancies
48
Missed (delayed) miscarriage:
- gestational sac which contains dead foetus before 20 weeks without expulsion symptoms
- may have light bleeding/discharge
- not usually pain
- closed cervical os
- when sac >25mm and no embryonic part seen - blighted ovum or anembryonic pregnancy
49
Inevitable miscarriage:
- heavy bleeding with clots and pain
| - cervical os open
50
Incomplete miscarriage:
- not all products of conception expelled
- pain and bleeding
- open cervical os
51
What is abortion:
the expulsion of products of conception before 24 weeks
52
How many diagnosed pregnancies will miscarry in early stages?
15-20%
53
Miscarriages should be managed surgically or medically if:
- increased risk of haemorrhage (late first trimester, coagulopathies, unable to have blood transfusion)
- previous adverse experience
- evidence of infection
54
What kind of medical management can be used for miscarriages:
- vaginal misoprostol - prostaglandin analogue binds to myometrial cells to cause myometrial contractions
- oral mifepristone not added
- contact doctor if bleeding doesn't start in 24 hours
- antiemetics and pain relief
55
What surgical management can be used for miscarriages:
- vacuum aspiration
| - surgical in theatre
56
Risk factors of ovarian cancer:
- family history: mutations of BRCA1 or BRCA2 gene
| - many ovulations: early menarche, late menopause, nulliparity
57
Clinical features of ovarian cancer:
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms
- early satiety
- diarrhoea
58
Investigations ovarian cancer:
-CA125
(do not use in asymptomatic women)
-US
-diagnosis: laparotomy
59
What can also raised CA125 other than ovarian cancer?
- endometriosis
- mensturation
- benign ovarian cysts
60
A CA125 above what level requires urgent US scan of the abdomen and pelvis?
>=35 IU/mL
61
Management ovarian cancer:
surgery and platinum based chemotherapy
62
What kind of ovarian cysts should be biopsied?
complex (multi-loculated) to exclude malignancy
63
What are the physiological cysts (functional cysts):
- follicular
| - corpus luteum
64
What is a follicular ovarian cyst?
- most common
- non-rupture of dominant follicle or failure of atresia in non-dominant follicle
- commonly regress after several cycles
65
What is a corpus luteum cyst?
- during cycle if pregnancy does not occur, corpus luteum may fill with blood or fluid
- intraperitoneal bleeding more common than cyst
66
What is a benign germ cell ovarian tumour?
- dermoid cyst
- also mature cystic teratomas
- lined with epithelial tissue
- most common under 30yo
- bilateral in 10-20%
- usually asymptomatic (torsion more likely than with other tumours)
67
What are the benign epithelial tumours?
- serous cystadenoma
| - mucinous cystadenoma
68
What is a serous cystadenoma?
- most benign epithelial tumour
- looks like most common type of cancer (serous carcinoma)
- bilateral 20%
69
What is a mutinous cystadenoma?
- large
| - if rupture, may cause pseudomyxoma peritonei
70
What can initial imaging modality for suspected ovarian cysts/tumours reveal?
- ultrasound used
- simple: unilocular, more likely physiological or benign
- complex: multilocular, more likely to be malignant
71
Management of ovarian enlargement finding in premenopausal women:
- conservative if <35yo
- if cysts small <5cm and simple, likely to be benign
- repeat US for 8-12 weeks and referral if persistent
72
Management of ovarian enlargement finding in postmenopausal women:
- physiological cysts unlikely
| - all referred to gynaecology
73
What is ovarian hyper stimulation syndrome?
- complication of some infertility treatment e.g. IVF
- multiple luteinised cysts in ovaries causes high oestrogen and progesterone and vasoactive substances such as VEGF
- increased membrane permeability and loss of fluid from intravascular compartment
74
Classification of OHSS:
- mild: pain, bloating
- moderate: n&v, as above, US ascites
- severe: as above, ascites, oliguria, haematocrit >45%, hypoproteinaemia
- critical: as above, ARDS, thromboembolism, anuria, tense ascites
75
What is ovarian torsion?
- partial or complete torsion of ovary on supporting ligaments
- can compromise blood supply
- if fallopian tube as well - adnexal torsion
76
Risk factors ovarian torsion:
- ovarian mass
- reproductive age
- pregnancy
- OHSS
77
Features of ovarian torsion:
- sudden onset deep colicky pain
- vomiting and distress
- fever in minority
- vaginal examination - adnexial tenderness
- US: free fluid or whirlpool sign
- laparoscopy - diagnostic and therapeutic
