Gynaecology student presentations Flashcards
What is the definition of a miscarriage?
Loss of the pregnancy before viability (23weeks)
- Usually due to chromosomal abnormalities
What are the 4 types of miscarriage?
- Threatened miscarriage: vaginal bleeding but a confirmed viable pregnancy
- Incomplete miscarriage: history of vaginal bleeding with previously confirmed viable pregnancy. Now not viable but some products of conception remain inside the uterus
- Complete miscarriage: history of vaginal bleeding, with previously confirmed pregnancy but now there are no products of conception in uterus
- Missed miscarriage: no symptoms of miscarriage but confirmation on ultrasound. Entire gestational sac may still be within the uterus
What is the management of a threatened pregnancy?
- If bleeding gets worse, or persists beyond 14 days, return for further assessment and an ultrasound
- If the bleeding stops, she should start or continue routine antenatal care
If she has had a previous miscarriage offer vaginal progesterone until 16weeks
What is the management of an incomplete miscarriage?
Tissue may pass out of the womb naturally
Medication can help
Surgery is available
What is a chemical pregnancy?
When the pregnancy test is briefly positive but becomes negative
How is a miscarriage diagnosed?
Transvaginal or abdominal ultrasound is done and repeated 7 days later to confirm
What are the features of an intrauterine pregnancy on an ultrasound scan?
Gestation sac seen (once HCG >1500)
yolk sac (at 4+ weeks)
Fetal pole ( at 5 weeks)
Fetal heart beat (at 6 weeks)
What is the drug misoprostol used for in gynaecology?
A synthetic prostaglandin used for medical management of miscarriage
Also used for medication abortion, induction of labour, and cervical ripening before labour
When is a woman offered further investigations for misscarriage?
After 3 or more consecutive first trimester miscarriages or one+ second trimester miscarriages
What investigations for miscarriage are offered?
- Tests for Antiphospholipid Antibodies are offered 6 weeks after a pregnancy
- Karyotype of the fetal tissue is offered
- For a second trimester loss a complete thrombophilia screen is offered
What is the management of pregnancy when women has Antiphospholipid Antibodies?
Treatment with LMWH and aspirin
What is the presentation of an ectopic pregnancy?
Abdominal/pelvic pain (often unilateral)
PV bleeding
Dizziness
Shoulder-tip pain
What are the risk factors for an ectopic pregnancy?
Previous pelvic surgery
Pelvic infection (PID)
Smoking
IVF pregnancy
Subfertility
Contraception failure
Previous ectopic pregnancy
How is an ectopic pregnancy managed?
- Monitor HCG, should be decreasing
- Methotrexate is given to stop grow of pregnancy
- Surgery to remove pregnancy and affected fallopian tube
What is antepartum haemorrhage?
Bleeding from genital tract, from 24+0 weeks of pregnancy
Important causes: placenta previa and placental abruption
How is the severity of antepartum haemorrhage monitored?
By the volume of blood bled
Eg.
- Spotting
- Minor haemorrhage- blood loss <50ml that has settled
- Major haemorrhage- blood loss of 50-100ml, with no signs of clinical shock
- Massive haemorrhage- blood loss >1000ml and/or signs of clinical shock
- Recurrent APH- episodes of APH more than one occasion
What is placenta previa?
When the placenta partially or completely covers the opening of the uterus
What is placental abruption?
When the placenta partially or completely separates from the inner wall of the uterus
What is the difference in presentation of placenta previa vs placental abruption?
Previa:
- Painless vaginal bleeding
- Unprovoked bleeding
- Abdomen: soft, non-tender
Abruption:
- constant abdominal pain
- Associated with trauma
- Abdomen: tense and tender
What is the management of antepartum haemorrhage?
A-E approach
- Establish cause
- May require delivery of baby
What is endometriosis?
The presence of endometrial-like tissue outside the uterus, inducing a chronic, inflammatory state
What are the risk factors for endometriosis?
- Nulliparity
- Early menarche
- Short menstrual cycle
- Being white or Asian
What are the reasons for misdiagnosis of endometriosis?
- Intermittent contraception causing hormonal suppression of symptoms
- Misdiagnosis eg. IBS
- Attitude towards menstruation
What are the symptoms of endometriosis?
- Subfertility
- Gi: bloating, diarrhoea, constipation, cycling PR bleeding
- Fatigue/tiredness
- Bladder pain
- Haematuria
What is dyschezia?
Difficult pooing
Eg. pain, straining, obstructed defecation
How is endometriosis diagnosed?
Transvaginal ultrasound and laparotomy
What is an endometrioma?
Cystic lesions that stem from the disease process of endometriosis
- Treated with a laparoscopic excision
What is adenomyosis?
When endometrial tissue grows into the muscular wall of the uterus causing and enlarged uterus and very heavy menstrual bleeding
Not the same as endometriosis
What is a fibroid?
A non-cancerous growth in the wall of the uterus
What are the symptoms of a fibroid?
-A symptomatic sometimes
- Menorrhagia
- Subfertility
- Pressure symptoms depending on the size and site
How are GnRH analogues used to treat fibroids?
They can help shrink the fibroid prior to resection
What is the treatment for fibroids?
Only treated if causing symptoms
- Bleeding treated as other heaving menstrual bleeding: tranexamic acid and mefenamic acid or contraception
- Can be surgically resected
What is gestational trophoblastic disease?
When abnormal trophoblast cells grow inside the uterus after conception inside the uterus from tissue that forms after conception
Happens when the sperm fertilises and empty egg or 2 sperms fertilise a normal egg
What is the most common type of gestational trophoblastic disease?
A hydatidiform mole (benign)
- Originates from the placenta and become invasive as it spreads
What is the difference between a complete and partial molar pregnancy?
Complete: no sign of baby, cord, or amniotic membranes (2 sets of DNA)
Partial: early sign of baby, cord, and amniotic membrane but it cannot survive or develop (3 sets of DNA)
What are some types of malignant gestational trophoblastic disease?
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour
Epithelioid trophoblastic tumour
What are the risk factors for a molar pregnancy?
- Extremes of age: <15 or >40
- Previous molar pregnancy
- Previous spontaneous miscarriage
- Blood group AB or A
- High gamma globulin in absence of hepatic disease
What is the clinical presentation of a molar pregnancy?
- Abnormal PV bleeding in early pregnancy
- Lower abdominal pain
- Early onset pre-eclampsia (25%)
- Hyperemesis gravidarum (25%)
- Large for dates uterus in complete mole (50%)
- Missed miscarriage, small for dates uterus in partial mole(90%)
- Hyperthyroidism (1-7%)
- Enlarged ovaries with theca lutein cyst (25-50%
How is a molar pregnancy diagnosed?
Ultrasound: ‘bunch of grapes’ appearance, no fetus, enlarged ovaries
Bloods: abnormally high HCG (>100,000)
- Confirmed by histology -
How is a molar pregnancy managed?
- Surgical evacuation
- Registration of the patient at the Gestational Trophoblastic Disease Service ( Charing Cross)
- Advise patient to avoid pregnancy by using reliable contraception ( barrier) until the HCG levels have dropped
- Early scan in future pregnancies
What is Rotterdam criteria for?
Diagnosis of PCOS
- Oligo- or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
-Polycystic ovaries
(Diagnosis with 2 of those and exclusion of related disorders)
What is the pathophysiology of PCOS?
- Chronically elevated LH (hyperandrogenism) and insulin resistance
- There is increased conversion of testosterone into more potent dihydrotestosterone
What is the clinical presentations of PCOS?
- Hirsutism/ acne/ alopecia
- Oligo/amenorrhoea
- Infertility
- Obesity
- Acanthosis nigricans
What is acanthosis nigracans?
Dark, thick, velvety skin in the folds and creases of the body
Eg, armpits, groin, and neck
How is PCOS diagnosed?
Clinical presentation, biochemical, and ultrasound
What are some causes of premature ovarian insufficiency?
- Idiopathic
- Chromosomal abnormalities – e.g Turners syndrome (gonadal dysgenesis)
- Previous chemotherapy and radiotherapy
- Pelvic surgery involving ovaries or interruption of blood supply to ovaries (can occur in hysterectomy)
- Autoimmune disease
Why is FSH used to diagnoses premature ovarian insifficiency?
Because when oestrogen is no longer being produced, there is a feedback loop of that to the hypothalamus and pituitary gland that stimulates production of GnRH and FSH
What are the different types of ovarian masses?
- Epithelial cell – cells covering the outer surface of the ovaries (most common)
- Germ Cells – cells that are destined to form eggs
- Stromal Cells – cells that release hormones (rare)
What are the different types of endometrial cancers?
Adenosarcoma
- Most common
- Begins from glandular tissue
- Usually postmenopausal
Myometrial cancer
- From uterine muscle
- Associated with Lynch syndrome
Uterine sarcoma
- Very rare
How does obesity contribute to onset of endometrial cancer?
Fatty tissue produces oestrogen that increases risk of uterine cancer
70% of uterine cancers are linked to obesity
What is the clinical presentation of uterine cancer?
- Abnormal menstrual bleeding
- Postmenopausal bleeding
- Intermenstrual bleeding
- Pain during sex
What is the aetiology of cervical cancer?
HPV and smoking
What is the clinical presentation of cervical cancer?
- Usually detected through screening
- Abnormal vaginal bleeding: post-coital bleeding, intermenstrual bleeding, postmenopausal bleeding
What is Lichen sclerosis?
A skin condition that causes itchy white patches on the genitals and body, there is no cure
Untreated, it can change the look of the genitals and narrow the opening of the vulva
What is the aetiology of vulval cancer?
HPV and Lichen sclerosis
What are some differentials for pelvic pain?
- Endometriosis
- Pelvic infection
- Pelvic adhesions
- Ectopic pregnancy
- Ovarian cyst accident
- Torsion, haemorrhage
- Non-gynaecological cause of pain: eg, appendicitis and UTI
What is hydrosalpinx?
Fluid blockage in your fallopian tubes that may make it difficult for you to become pregnant
Can be caused by thing like UTI’s
Treatment: draining, repairing, or removing the fallopian tubes
What is a colposcopy?
Taking a closer look at the cervix
What is the first line medication given for long and heavy periods with no red flags?
Tranexamic acid
Which medication is used to treat anovulatory infertility like in PCOS?
Clomifene citrate
What is the preferred contraceptive in PCOS?
Ethinyloestradiol and cyproterone acetate
As is helps with the hirsutism and acne
