Gynaecology teach amk day Flashcards
Inter-menstrual bleeding
bleeding between periods
Post-coital bleeding
bleeding after sexual intercourse
Dysmenorrhoea – Pain during period
Dyspareunia – Pain during sexual intercourse
Pruritus vulvae
Itching of the vulva and vagina
A 35-year-old woman attends your GP practice, she is known to you as she is having trouble conceiving and has been trying for a baby for the past 8 months. She comes today as she has noticed her periods have been getting heavier over the past year or so. She thought it was due to her getting older, but now her periods have become unmanageable and she has had episodes of flooding. After taking a full history you examine her abdomen, which is soft, non-tender, but you can palpate a supra-pubic mass.
What is the mostly likely diagnosis?
fibroids
foudn intra mural - myometrium pedunculate - a stalk submucosal - below endometrium subserosal - below perimetrium
Pregnant women with history of fibroid presenting with severe abdominal pain + low grade fever
Rapid growth of fibroids during pregnancy and it outgrows its blood supply
Ischaemic & necrosis of fibroid
Most likely to occur during 2nd and 3rd trimester of pregnancy
Tx: Supportive management
ectopic pregnancy risk factors
PID (e.g. chlamydia)
Endometriosis
IUS/IUD
Tubal damage
hCG normally doubles after 48 hours
if it rises over 63% after 48 hours what could be happening
intrauterine pregnancy
if rise of under 63% ectopic and if fall of more than 50% miscarriage
symptoms of ectopic pregnancy
shoulder pain, unilateral pelvic pain, vaginal bleeding and cervical tenderness - blob sign in test
A 6-month-old child is brought to the surgical clinic because of non descended testes. What is the main structure that determines the descent path of the testicle?
The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.
menopause characterised by what hormone changes
The menopause can either be a natural or iatrogenic process that results in the cessation of oestradiol and progesterone production in the ovaries. Due to this decrease, FSH and LH levels will often increase.
Rose is a 34-year-old female who has been in a relationship for 4 years. Rose and her partner have been trying to conceive regularly for over a year without success. They have visited their GP to organise some investigations into a possible cause. Which hormone is released after ovulation occurs and can be used as a marker of fertility?
progesterone
Presence of fetal squamous cells in the maternal blood vessels of a woman who died during or just after labor points towards
amniotic fluid embolism rather than pulmonary thromboembolism
What is the normal type of epithelium lining the ectocervix
stratified squamous non-keratinized epithelium
endocerix lining
mucus-secreting simple columnar epithelium
Anteversion refers to the position of the uterus in the coronal plane being tipped forward anteriorly towards the bladder. Conversely, retroversion of the uterus describes the body and fundus leaning posteriorly towards the rectum.
Anteflexion refers to the position of the main body of the uterus relative to the long axis of the cervix. This is easiest to view in the sagittal plane where the fundus of the uterus is anterior relative to the cervix.
normal uterus
in relation to the ovarian artery
common iliac artery and uterine artery where does the ureters go
water under the bridge
At the renal pelvis, the ureters are located most posteriorly. As the ureters course inferiorly, they pass posteriorly to the ovarian artery. The ureters cross the pelvic brim anteriorly at the bifurcation of the common iliac arteries. Ureters pass underneath the uterine artery (AKA ‘water under a bridge’). Therefore when ligating the uterine artery, care should be taken to avoid the ureters.
most common cause of ovarian cancer
rf
iX
round 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
CA125
Extraction of fluid from the rectouterine pouch or the pouch of Douglas is via the
Extraction of fluid from the rectouterine pouch or the pouch of Douglas is via the posterior fornix of the vagina.
In terms of the anatomical position, the anterior fornix of the vagina is located closer to the bladder than the rectouterine pouch.
A menopausal woman is started on Hormone Replacement Therapy, which includes oestrogen and progesterone. What are the functions of these hormones in HRT?
Oestrogen is for symptomatic relief and progesterone is protective against oestrogenic adverse effects
Many of the menopausal symptoms are due to low oestrogen; therefore the oestrogen in HRT aims for symptomatic relief. However, oestrogen causes endometrial thickening which is a risk for neoplasia, so progesterone is added to HRT to prevent endometrial thickening and any associated risk of malignancy.
Rhesus disease is classically associated
hydrops fetalis
when do you use anti-oestrogen drugs
Hormone therapy is often used after surgery (as adjuvant therapy) to help reduce the risk of the cancer coming back. Sometimes it is started before surgery (as neoadjuvant therapy). It is usually taken for at least 5 year
What is the mechanism leading to anaemia during pregnancy?
haemodilation due to increased plasma volume
ncrease in plasma volume disproportionate to the increase in haemoglobin, causing an overall decrease in haemoglobin concentration.
what do you treat anaemia in pregnancy
oral ferrous sulfate or ferrous fumarate
treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
difference between broad and round ligament
The broad ligament contains the ovaries and the fallopian tubes
This ligament runs from the uterine fundus to the labia majora. It is found within the broad ligament.
With antiretroviral medication for the mother and baby, delivery by caesarean section and discouragement of breastfeeding, the risk of HIV transmission is reduced to less than 2%
what are the factors that reduce transmission
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)\
Screening
NICE guidelines recommend offering HIV screening to all pregnant women
Antiretroviral therapy
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
Infant feeding
in the UK all women should be advised not to breast feed
is old paternal age associated with miscarriage
yes
HRT increases the risk of
thrombotic events, such as stroke. This mechanism involves platelet aggregation and is different to atheroma formation, which largely involves cholesterol accumulation. HRT does not increase the risk of thrombocytopaenia or vulval cancer, and the presence of progesterone in the HRT also minimises the risk of developing endometrial cancer.
risk factors fro perianal tears
primigravida large babies precipitant labour shoulder dystocia forceps delivery
how do you screen of gestational diabetes
the oral glucose tolerance test (OGTT) is the test of choice
diagnosis of gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
the doctors decide to preform a culdocentesis, extracting fluid from the rectouterine pouch, to assess if Hannah has a hemoperitoneum.
Where will a needle be passed to aspirate some fluid from the rectouterine pouch, via the culdocentesis route?
posterior vaginal fornix
A pregnant woman comes in to see the doctor as her husband is concerned about her breathing becoming deeper. Chest examination is unremarkable. Her respiratory rate is 16/min. Which explanation should be provided to this couple?
normal cause by progesterone
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Negative hrHPV
return to normal recall, unless
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Positive hrHPV
samples are examined cytologically
if the cytology is abnormal → colposcopy
this includes the following results:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
If the sample is ‘inadequate’
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
does smoking prevent a cancer
yes endometrial and COCP
Which change marks the transformation of the primordial follicle to a primary follicle?
devlopemtn of zona pellucida
layers of the scortum
Skin
- Dartos fascia and muscle
- External spermatic fascia
- Cremasteric muscle and fascia
- Internal spermatic fascia
- Parietal layer of the tunica vaginalis
The risk factors for endometrial cancer are as follows*:
obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma
postmenopausal bleeding is the classic symptom
premenopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
symptoms of endometrial cancer
what is an normal endometrial thickness and over what should it be investigated further and indicative
under 4
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive va
ocalised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surger
mamagaemtn of endometrial cancer
Bloating and abdominal cramps in females over the age of 50 should raise suspicion of ovarian cancer. The most appropriate investigation is to
test for serum Ca125
layers of the spermatic cord
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
first line for urge and stress icnontince
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
main contributor to increase CO in pregnancy
stroke volume
During pregnancy, increased stroke volume is the main contributor to the increased cardiac output. This is due to increased plasma volume, secondary to activation of the renin-angiotensin system. The heart rate increases slightly too but this is not as major a contributor. Remember the equation: cardiac output= stroke volume x heart rate. As the stroke volume will increase more in number than the heart rate, it is the major contributor to the increased cardiac output.
Which type of receptor is found on the theca?
LH
A 26-year-old woman presents to her GP with milky discharge from her breasts. Her periods have also become very irregular and she has not menstruated in the past 3 months. On further questioning, she reports not being sexually active since having a miscarriage 7 months ago which required surgical management. On examination, there are no palpable masses in her breasts bilaterally, she demonstrates a small amount of milky white discharge from her left nipple which is collected for microscopy, culture, and sensitivity. She has no focal neurological deficits, cardiac, and respiratory examination is unremarkable, and her abdominal examination is unremarkable.
What is the most likely diagnosis?
Prolactinoma causes amenorrhoea in females through inhibiting the secretion of GnRH which in turn results in low levels of oestrogen
This patient is presenting with symptoms consistent with a prolactinoma - she has amenorrhoea and galactorrhoea. Male also report gynaecomastia. further investigate she should have a urinary pregnancy test, blood tests to check for bHCG, prolactin, oestradiol, luteinising hormone, and follicle-stimulating hormone.
a microprolactinoma is the most likely diagnosis if results come back with nothing or no drug causes and should be confirmed by MRI or CT head.
Intraductal papilloma is a benign breast lesion that is a common cause of nipple discharge. The discharge is typically clear or yellow and there is often an underlying lump. It is not associated with changes in menses. As this patient is presenting with amenorrhoea and does not have a breast lump, this is not the most likely answer.
Sheehan’s syndrome is panhypopituitarism caused by ischaemic necrosis of the pituitary gland from post-partum blood loss/hypovolaemia. The typical scenario for this presentation is a woman presenting following a large post-partum haemorrhage with no galactorrhoea (lack of expected post-partum milk-letdown due to reduced prolactin secretion), amenorrhoea (due to reduced GnRH which causes low levels of oestrogen), hypothyroid symptoms, and hypoadrenalism. The patient in this scenario is reporting galactorrhoea and there is no evidence of a post-partum haemorrhage which should steer the student away from this option.
what is ashermnans sydnoem
Asherman’s syndrome is a cause of amenorrhoea but does not lead to galactorrhoea.
It is caused by intrauterine adhesions, which may occur following dilation and curettage. While this may lead the endometrium to not respond to oestrogen as it normally would (causing the amenorrhoea), it would not cause prolactin secretion leading to lactation.
A pregnant woman has her kidney function measured during a routine appointment. Her plasma urea and creatinine are found to be lower than before she was pregnant. Why is this?
increased renal perfusion
Plasma urea and creatinine fall during pregnancy due to increased renal perfusion allowing the clearing of these substances from the circulation more, as well as increased plasma volume diluting these substances
Physiological changes in pregnancy
Genital changes: increased uterine size (from muscle hypertrophy until 20 weeks, then stretching), cervical ectropion, reduced cervical collagen late in pregnancy (to allow cervical effacement), increased vaginal discharge (due to increased mucus production from vasocongested vagina)
Cardiovascular/haemodynamic changes: increased plasma volume disproportionate to increased red cell volume, causing net effect of increased stroke volume and anaemia; increased white cell count, platelets, ESR, cholesterol, fibrinogen; decreased albumin, urea and creatinine
Progesterone-related effects (due to muscle relaxation): decreased blood pressure, constipation, ureteral dilation, bladder relaxation, biliary stasis, increased tidal volume
hCG levels usually consistently rise until around week 10–12 of your pregnancy, when the levels plateau or even decrease.
difference with ectopic
Abnormal elevations in b-hCG, including an increase of less than 53% over 48 hours, is suggestive of a nonviable pregnancy, including ectopic.
what is congenital darnel hyperplasia
Congenital adrenal hyperplasia (CAH) refers to a group of genetic disorders that affect the adrenal glands,
what are Fraser guidelines
The Fraser guidelines apply specifically to advice and treatment about contraception and sexual health. They may be used by a range of healthcare professionals working with under 16-year-olds, including doctors and nurse practitioners.
Gillick competence is used to assess a child’s capability to make and understand their decisions in a wider context. Fraser guidelines are applied specifically to advice and treatment that focuses on a young person’s sexual health and contraception
What does the POP AND COCP DO
Pop thickens cervicla mucus
Cocp inhibrs ovultion
Steongest risk facotr for endometrial cancer
PCOS
COCP Incresase risk of what cancer
Cervical and breast
Injectable contraceptive (medroxyprogesterone acetate) does what
Inhbit ovulation and thicken cervical mcuous
Intrauterine contraceptive device MOA
Decrese speem motility and survival
Intrauterine system (levonorgestrel)
Pevents endometrial prolfieration and promoties ceevrical mcuous
Implantable contraceptive (etonogestrel) inhibts ovulation and thickens cervical mcuous last hwo long
3 years
Injectable is 12 weeks
High parity is associated with cervicla canver what canvers are associated with nulliparity
Ovarian
Breast
Endometrial
COCP 8NCREASE# RISK OF
Breast and cervical cancer
Tamofexin increases risk of
Endometrial
Does smoking a rf for cervcial cancer
Yes
Hormone replca ent therpay and COCP risk for what camver
Breast
Having diabetes mellitus risk for what cancer
Diabetes mellitud
HIV RISKF FOR WHAT CANCer
Cervical
High parity is risk for cervical cancer what is unposeee oestorgne
Endometrial
Late menopause risk facotr for what cancer
Brwat, ovairan and endometrial
Obesity riskf faoctr for
Brest and andometrial cancer
HRT risk facotr for
Breast cancer
Causes of folic acid defiecny
phenytoin
methotrexate
pregnancy
alcohol excess
Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
Megaloblastic anameia
Flocia aicd and b12. Dericiency
Sideroblastic anemai
B6 deficiency
Isonizad therpay
Bitamin B6
Cevrical camver what disease
HIV MSOT ASSOCIATE DWITH
P53 gene mutatuitons what cancer risk
P53 gene mutations what cancer risk breast
Smoking
Cervical camcer
Diabetes mellitus
Endometrial caNCER
Many sexual partner and hih parity
Cervcial canver
Low socioecon9mic status
Cervical cancer
Hereditary non-polyposis colorectal carcinoma
Endometiral cancer
Smoking
Cervical cancer
A woman who has had two previous caesarean sections develops massive bleeding shortly after giving birth is a stereotypical history of:
Placenta accreta
a woman who has had two previous caesarean sections develops massive bleeding shortly after giving birth
a 30-year-old woman develops a massive post-partum haemorrhage. An emergency hysterectomy is performed. Pathological examination demonstrates that the placenta is attached to the myometriu
Just given brith and everythign explodes
Differnce between endometiral can ee and MEN
Quick comparison: Stereotypical histories (endocrine disorders)
Endometrial cancer
a 60-year-old obese, nulliparous woman presents with vaginal bleeding
Multiple endocrine neoplasia (type 1)
a 30-year-old woman with a history of recurrent peptic ulcer disease is found to have hypercalcaemia on routine bloods.differnc ebt
IVF criteria
These guidelines recommend that IVF should be offered to women under the age of 43 who have been trying to get pregnant through regular unprotected sex for 2 years. Or who have had 12 cycles of artificial insemination, with at least 6 of these cycles using a method called intrauterine insemination (IUI).
what screen do you perform when you have a clinical suspicion
TORCH toxoplasmosis other such as varicella zoster rubella cytomeglovirus hopers
