ILAs

Question 1

how to diagnose PCOS?

whats the name of the criteria?

Answer 1

A diagnosis is made when you have any two of the following:

• oligo/amenorrheoa: irregular, infrequent periods or no periods at all
• hyperandrogenism: an increase in facial or body hair and/or blood tests that show higher testosterone levels than normal
• an ultrasound scan that shows polycystic ovaries.

rotterdam criteria

Question 2

symptoms of PCOS

Answer 2

…

Question 3

what is miscarriage?

when does it become a stillbirth?

Answer 3

An involuntary, spontaneous loss of a pregnancy before 24 completed weeks

After these differing cut-offs, the loss would be defined as a stillbirth.

Question 4

Diagnostic factors indicating miscarriage?

Answer 4

VAGINAL BLEED WITH OUR WITHOUT CLOT

+/- suprapubic pain, low back pain, recent post-coital bleed

Presence of risk factors: Key risk factors include older parental age, uterine malformation, bacterial vaginosis, and thrombophilias, parental chromosomal abnormalities (+other weaker associations: smoking, caffeine, NSAIDs etc)

Question 5

what investigations would you order in expected miscarriage?

what results might you expect or what are you assessing for?

Answer 5

urine pregnancy test - to confirm pregnancy = postive

FBC - degree of blood loss = low-normal

rhesus blood group - identifies Rh-negative blood group, if present, in mother (therefore need for anti-D immunoglobulin)

!!serum beta hCG titres - falling titres indicate a failing pregnancy

!!!trans-vaginal ultrasound scan -differentiates between different stages and types of miscarriage + would exclude other differential diagnoses of miscarriage.

Question 6

what are your differentials for miscarriage (vaginal bleeding in early pregnancy)

(hint: 2 types of pregnancy likely to miscarry and 2 non-pregnancy related diagnoses)

Answer 6

Ectopic pregnancy/heterotopic pregnancy: can rupture the fallopian tube BUT NB: Vaginal bleeding in ectopic pregnancy is the result of decidual breakdown in the uterine cavity due to suboptimal β-HCG levels. Bleeding from a ruptured ectopic pregnancy is usually intra-abdominal, not vaginal.

Partial/full Hydatidiform mole: type of chromosomally abnormal pregnancy that have the potential to become malignant (gestational trophoblastic neoplasia/persistent trophoblastic disease)

Cystitis: haematuria (suprapubic pain, dysuria and frequency +/- fever)

Pregnancy co-existing with a bleeding cervical polyp/large ectropion

Question 7

what are the 5 types of miscarriage and briefly describe them

Answer 7

TICIM

threatened - haven’t actually miscarried yet, signs of possible miscarriage: some bleeding from CLOSED cervix, lower abdo pain. may miscarry or continue the pregnancy, nothing can be done to prevent

inevitable - occurs after threatened or without warning, miscarry and cervix OPENS and the fetal matter will come away in the bleeding.

complete - all fetal tissues are no longer in the uterus

incomplete - some tissue is still retained in the uterus

missed - baby dies but remains in utero - cervix is open. poss asymptomatic miscarriage other than some brownish discharge, might only find out on scanning

Question 8

name and describe the 3 types of pregnancies which will often end in miscarriage

Answer 8

Ectopic pregnancy - implants outside the uterus, likely in the fallopian tube, most often will miscarry

Molar pregnancy aka hydatidiform mole: : type of chromosomally abnormal pregnancy meaning the baby doesn’t develop (either at all or properly). Leftover cells have the potential to become malignant (gestational trophoblastic neoplasia/persistant trophoblastic disease)

Blighted ovum aka anembryonic pregnancy. Sac develops but no embryo develops inside.

Question 9

what is the difference between a biochemical, early or late pregnancy loss?

comment on gestation, metal activity, what you might find on USS and what beta hCG might show?

Answer 9

Biochemical pregnancy loss:

Typical gestation <6 weeks
No fetal activity ever detected
Pregnancy not located on ultrasound
Beta hCG levels are low and then fall.

Early pregnancy loss:

Gestation typically 6 to 8 weeks (up to 12)
No fetal activity ever detected
Empty sac or large sac with minimal structures without fetal heart activity
Beta hCG levels show an initial rise and then fall.

Late pregnancy loss:

Typical gestation >12 weeks
Loss of fetal heart activity
Crown to rump length and fetal heart activity previously identified.

Question 10

what produces beta hCG?

Answer 10

trophoblast

Question 11

what other risk factors/problems can cause miscarriage?

Answer 11

chromosomal abnormalities (aneuploidy (missing or extra chromosome), or polyploidy)

failure to implant

implanting elsewhere in the uterus (ectopic) = reduced space and blood supply

corpus leutem not producing enough progesterone to keep up the pregnancy

placenta not producing enough hormones or blood supply to keep up the pregnancy

environmental teratogens - heavy metals (mercury), smoke, drugs, alcohol

trauma: falls, RTAs, CVS/amniocentesis

uterine abnormalities: septate uterus/fibroids

fetal infections: toxoplasma, cytomegaly virus, herpes simplex virus

maternal disorders: SLE, antiphosolipid syndrome, DM

increasing parental age

Question 12

what is CVS?

when is it done?

Answer 12

chorionic villus sampling - sample is taken from the placenta for genetic sampling

10-14 weeks

Question 13

when would you use amniocentesis over CVS?

Answer 13

after 15 weeks

Question 14

3 different management modalities in women with confirmed diagnosis of miscarriage?

Answer 14

Use expectant management for 7–14 days as the “first-line” management strategy for women with a confirmed diagnosis of miscarriage.

next line:
medical: misoprostol (vaginally, can do oral) (may need mifepristone before)

next line:
surgical: manual vacuum aspiration under local anaesthetic or surgical management under GA (+anti D rhesus if women = rhesus neg)

BUT always give them a choice

Question 15

when offering treatment for miscarriage, in which type might you require potential anti D rhesus immunoglobulins and why?

Answer 15

all rhesus negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.

increased risk of fetal blood/maternal blood mixing, and if the mum is rhesus negative but the baby is rhesus positive she will produce antibodies against it which may threaten the next pregnancy

Question 16

in what women who have had a miscarriage should you tell to take a pregnancy test?

how long after should they do it? and what should they do if positive?

Answer 16

take a urine pregnancy test 3 weeks after medical management or expectant management of miscarriage

return for possible treatment to ensure all fetal tissue passed

Question 17

symptoms of ectopic pregnancy

Answer 17

• amenorrhoea or missed period history
• abdominal or pelvic pain - esp one sided
• vaginal bleeding with or without clots.
• shoulder tip pain

other reported symptoms: breast tenderness gastrointestinal symptoms dizziness, fainting or syncope, urinary symptoms, passage of tissue, rectal pressure or pain on defecation.

Question 18

why can you get shoulder tip pain in ectopic pregnancy?

Answer 18

the irritation of the diaphragm by blood in the peritoneal cavity leads to referred shoulder tip pain. This is because the diaphragm and the supraclavicular nerves (which innervate the shoulder tip) share the C3-C5 dermatomes.

Question 19

name and describe 3 possible treatment modalities for ectopic pregnancy

Answer 19

based on symptoms, hemodynamic stability, risk of tubal rupture, if they can attend for follow up etc

if asymptomatic:
expectant management - allow it to pass alone, use paracetamol and pads for management of pain and bleeding: requires follow up
or
medical management - with methotrexate: requires follow up

symptomatic:
surgical management - salpingectomy or salpingotomy, (part of full removal of fallopian tube) is performed laparoscopically or by open laparotomy under GA - ANTI RHESUS D PROPHYLAXIS IF RH NEG

Question 20

what drug is used in the medical management of ectopic pregnancy and what is its mechanism of action?

Answer 20

methotrexate

folate antagonist - prevents DNA replication so stops the pregnancy from growing

Question 21

first steps of diagnosis of ectopic pregnancy from vaginal bleeding episode

Answer 21

1. assess hemodynamic stability of woman
2. urine pregnancy test (Beta hCG) - if positive assess for signs of ectopic (consider urinalysis if suspect UTI)
3. abdo exam and GENTLE pelvic exam - if there is abdo, pelvic or cervical motion tenderness, suspect ectopic
4. transvaginal ultrasound scan: identify the location of the pregnancy and whether there is a fetal pole and heartbeat. (trans abdo and then MRI are second and third line) - if not identified it’s a pregnancy of unknown location = could be ectopic (or miscarriage or very early uterine pregnancy)
5. do serum beta hCG to narrow this down
   - >1500 iU = ectopic until proven otherwise: DIAGNOSTIC LAPAROSCOPY
   - <1500 iU = repeat 48 hours later

viable pregnancy = would have doubled
miscarriage = would have halved
anything in-between = possible ectopic

Question 22

risk factors for ectopic pregnancy

Answer 22

• Maternal age of 35-44 years.
• Previous ectopic pregnancy.
• Previous pelvic or abdominal surgery.
• Pelvic Inflammatory Disease (PID)
• Several induced abortions.
• Conceiving after having a tubal ligation or while an IUD is in place.
• Smoking.
• Endometriosis.
• Undergoing fertility treatments

Question 23

counsel a woman in what to expect in the first trimester of pregnancy

Answer 23

breast tenderness

25% experience normal bleeding - light and spotting - counsel for red flags
milky white discharge

fatigue
constipation 
heartburn 
frequent urination 
food cravings 
weight gain 
nausea - worse in morning 
mood swings

Question 24

what population is most prone to ovarian cysts?

Answer 24

women of reproductive age - BUT can happen in women of all age

Question 25

name some types of ovarian cysts and what they are categorised into?

Answer 25

functional cysts normally 2-3cm but can go up to 10cm, filled with clear serous fluid

• follicular cyst
• corpus leuteal cysts (hemorrhagic cysts)
  ^simple cysts
• theca luteal cysts (bilateral) = only occurs in pregnancy due to increase in hCG (esp in multiple foetuses/molar pregnancies

neoplastic cysts - normally complex: normally >10cm, irregular borders, septate, fluid = heterogeneous

• benign cysts
• endometriomas (chocolate cysts - old blood with each menstruation)- respond to hormones with each menstruation
• benign tumours
• -omas:
• malignant tumours
• • carcinomas

Question 26

how do follicular cysts form and in what condition might you see lots of them in?

Answer 26

dominant follicle doesn’t rupture (normally because the surge in LH from pituitary which is meant to make it rupture doesn’t occur) so it turns into a cyst

will see many of them in PCOS
(and because they secrete androgens you get hyperandrogenism = hirstuism)
(also amenorrhoea occurs because there is no ovulation - the follicle doesn’t leave the ovary)

Question 27

complications of ovarian cysts

Answer 27

hemorrhagic: esp corpus luteal cysts and follicular
rupture: into the peritoneal cavity - can happen spontanous or after sexual activity
torsion: (ovary twists around the suspensory ligament, containing the blood vessels and nerves gets twisted)

Question 28

symptoms of ovarian cysts

including if there are different types of cysts what extra symptoms might you find

Answer 28

many are asymptomatic

symptomatic:
- low, aching abdo pain
- dysparaneuia
- feeling of pressure in the pelvic cavity - can cause frequent urination

if rupture, torsion or hemorrhagic can be - SUDDEN ACUTE LOWER ABDO PAIN instead

• vomitting, nausea, low grade fever = torsion
• increase HR and decrease BP = rupture/hemorrhagic – can also get shoulder tip pain due to irritation of the diaphragm

if PCOS associated: amorrhoea, hirtuism

if endometriosis: dysmenorhoea - painful menstruation - cyclical pelvic pain

Question 29

diagnosis of ovarian cysts

Answer 29

USS pelvis

MRI if unsure

CA-125 (cancer antigen) - but very unspecific as can be raised in fibroids, endometriosis, and pregnancy - normally use in menopausal/post menopausal women - to indicate risk of it being an malignant ovarian tumour

histologic - cyst cells via US guided aspiration or following removal of the cyst

Question 30

treatment of cyst

Answer 30

watch and monitor
<5cm
or if ruptures and hemodynamically stable (NSAIDs for pain)

surgery for removal by laparoscopy 
if >5cm 
or benign tumours cases regular symptoms 
or hemodynamically unstable 
or torsion 
or appear malignant

Question 31

what is endometriosis?

where does it most commonly occur and why?

Answer 31

when endometrial cells migrate to ANYWHERE else in the body, and start growing there (in response to hormone changes each month)

• often in the pouch of Douglas due to retrograde menstruation

BUT we don’t know why it actually occurs

Question 32

what are the theories of why endometriosis occurs?

Answer 32

• retrograde menstruation - but lots of people have this and not everyone has endometriosis
• dysfunction of the immune system
• metaplastic theory: cells of the peritoneum can transform spontaneously into endometrial cells
• benign metastasis theory - travels to via lymph and blood
• extrauterine stem cell theory - stem cells differentiate into endometrial tissue

Question 33

endometriosis risk factors

Answer 33

FH of endometriosis

never having been pregnant

early menarche

late menopause

Question 34

how is infertility diagnosed?

Answer 34

failure to become pregnant after 1 year of regular sexual intercourse (2-3x a week)

Question 35

what initial investigations should you do for a couple who present with failure to become pregnant after 1 year of regular sexual intercourse?

Answer 35

Basic investigations

semen analysis

serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21. (add/minus number of days above a 28 day cycle to get the day you should do the test in a woman with a cycle not 28 days long)

Question 36

which form of contraceptive gives the longest length of time to return to normal fertility?

Answer 36

depo-provera injective (progesterone injection)

Question 37

can you get pregnant from having unprotected sex post partum?

Answer 37

they can get pregnant from day 21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first being giving contraceptive

UNLESS using lactational amenorrhea method (LAM) but the baby has to be getting at least 85% of its feeds as breast milk for this to work

Question 38

can you give breast feeding women the COCP?

Answer 38

The COCP is absolutely contraindicated (UKMEC 4) for women who are breastfeeding less than 6 weeks post-partum.

Question 39

when can the IUD (copper coil) be inserted?

Answer 39

The copper IUD can be fitted at any point during the menstrual cycle.

It can also be fitted immediately after first or second-trimester abortion,

and from 4 weeks postpartum.

Question 40

methods of emergency contraception?

Answer 40

IUD - best option - up to 5 days post USI

if declined

stat dose of levonorgestrel 1.5mg (up to 72 hours post USI)

or stat dose ulipristal 30mg (up to 120 hours post USI

Question 41

what act legalised abortion in the UK?

Answer 41

1967 ‘abortion’ act

Question 42

define hyperemesis gravidarum

Answer 42

when you start getting biochemical imbalances from excessive vomiting in early pregnancy (including becoming ketotic)

Question 43

how do you manage a woman with hyperemesis in pregnancy?

Answer 43

conservative measures if very mild - reassure, regular small fluids, ORT (diarolyte)

anti-emetics: (basically all are ok in pregnancy)

• cyclazine
• metaclopramide

-ondansetron - in refractory cases

extreme cases
IV fluids and replace electrolytes
can give steroids (unknown use)

Question 44

what day does implantation occur?

Answer 44

average 10 days after ovulation

Question 45

when does the pregnancy test become positive?

what is it testing for?

Answer 45

at the point of implantation (so around day 24 aka 10 days after ovulation/just before the next period)

b-hCG

Question 46

what produces the b-hCH?

Answer 46

trophoblast - the fetal part of the placenta

Question 47

what condition produces excessive b-hCG do?

Answer 47

molar pregnancy

Question 48

what causes constipation and heart burn in pregnancy?

Answer 48

progesterone - relaxes smooth muscle (keeping the uterus quiescent) but then also causes other smooth muscle to relax (so get constipation and heart burn even before larger increase in abdominal

Question 49

what produces progesterone in pregnancy? and what is its function?

Answer 49

corpus luteum of pregnancy until the placenta can make enough of its own

function: keep the uterus quiescent

Question 50

what percentage of all pregnancies will remain viable? how many will miscarry?

post miscarriage what is the

Answer 50

80%

20% miscarry

Question 51

what is recurrent miscarriage defined as?

Answer 51

3 or more

Question 52

what investigations do you do in recurrent miscarriages?

Answer 52

examination

looking for uterine abnormalities like a uterine septum:
scan - ultrasound
if suspect:
hysteroscopy - to confirm (+resect septum)

karyotyping - but is really expensive so we discourage from doing it
- sample miscarriage in 3rd/4th time and send for karyotyping

test for: antiphospholipid syndrome (aspirin/heparin to treat) and thombophillias which can be associated with recurrent miscarriage

Question 53

changes of having ectopic pregnancy again after first ectopic?

Answer 53

20% - advise get an early scan to locate

Question 54

what form of contraception can cause ectopic pregnancy?

Answer 54

IUD - prevents uterine pregnancies but not tubal!

Question 55

what is post menopausal bleeding until proven otherwise?

Answer 55

endometrial cancer