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OnG Active > James Bloomer O&G > Flashcards

James Bloomer O&G Flashcards

1
Q

Drugs to avoid in pregnancy

A

aspirin
sulphonylureas
carbimazole
ciprofloxacin
benzodiazepines
lithium
sulphonamides
tetracyclines
amiodarone
cytotoxic drugs

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2
Q

If not started on the first day of the menstrual cycle how long does an IUS take to work?

A

7 days

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3
Q

If not started on the first day of the menstrual cycle how long does an COCP take to work?

A

7 days

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4
Q

If not started on the first day of the menstrual cycle how long does an Nexplanon (implant) take to work?

A

7 days

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5
Q

If not started on the first day of the menstrual cycle how long does an Depo proverb (injection) take to work?

A

7 days

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6
Q

If not started on the first day of the menstrual cycle how long does an POP take to work?

A

2 days

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7
Q

If not started on the first day of the menstrual cycle how long does an IUD take to work?

A

Immediately

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8
Q

A 60-year-old woman presents lower abdominal discomfort, urinary frequency, bloating and abdominal distension

A

Ovarian cancer

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9
Q

A woman who is 10 weeks pregnant presents with vaginal bleeding. Ultrasound shows no fetus but a ‘snowstorm’ appearance. The B-hCG is markedly elevated

A

Hydatidiform mole

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10
Q

Complete hydatidiform mole

A

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism (hCG may mimic TSH) may be seen

Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months

Around 2-3% go on to develop choriocarcinoma

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11
Q

Partial hydatidiform mole

A

A normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

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12
Q

PPH

A

Post-partum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary

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13
Q

Primary PPH

A

occurs within 24 hours
affects around 5-7% of deliveries
most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors

Risk factors:
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia
macrosomia
ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

Management
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 mcg
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

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14
Q

Secondary PPH

A

occurs between 24 hours - 12 weeks**
due to retained placental tissue or endometritis

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15
Q

Cervical cancer

A

The incidence of cervical cancer peaks around the 6th decade. It may be divided into
squamous cell cancer (80%)
adenocarcinoma (20%)

Features
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge

Risk factors
human papilloma virus 16,18 & 33
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill*

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16
Q

PID

A

Caused by:
Chlamydia trachomatis - the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

Features
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation

Investigation
screen for Chlamydia and Gonorrhoea

Management
Low threshold for treatment
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in.

Complications
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy

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17
Q

Syntocinon

A

Syntocinon is a synthetic version of oxytocin that is used in the active management of third stage of labour. It stimulates the contraction of the uterus reducing the risk of postpartum haemorrhage. It is also used to induce labour.

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18
Q

Ergometrine

A

Ergometrine is an ergot alkaloid which is used as an alternative to oxytocin in the active management of third stage of labour. By constricting vascular smooth muscle of the uterus it can decrease blood loss.

Mechanism of action
stimulates alpha adrenergic, dopaminergic and serotonergic receptors

Adverse effects
coronary artery spasm

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19
Q

Mifepristone

A

Mifepristone is used in combination with misoprostol to terminate pregnancies. Misoprostol is a prostaglandin analog that causes uterine contractions.

Mechanism of action
competitive progesterone receptor antagonist

Adverse effects
menorrhagia

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20
Q

Placenta accreta

A

Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.

Risk factors
previous caesarean section
placenta praevia

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21
Q

Pre-eclampsia
Complications?

A

Maternal:
Eclampsia, cerebrovascular accidents, liver/renal failure, homeless, HELLP, pulmonary oedema

Fetal:
IUGR, abruption, morbidity and mortality

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22
Q

Pre-eclampsia
Management?

A

Admit if - BP 160/110+ and PCR>30 or 24hr collection >0.3g/24h
Antihypertensives if - BP 150/100mmHg
Steroids if - Moderate/severe at

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23
Q

Pre-eclampsia

A

Mild: proteinuria and mild hypertension
Moderate: proteinuria and severe hypertension (160/110mmHg)
Severe: proteinuria and any hypertension

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24
Q

Primary Dysmenorrhoea

A

Dysmenorrhoea is characterised by excessive pain during the menstrual period.

In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.

Features:
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh

Management:
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line

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25
Q

Secondary Dysmenorrhoea

A

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.

Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids

Recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.

*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea

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26
Q

Levonorgestrel

A

Should be taken as soon as possible - efficacy decreases with time
Must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
Single dose of levonorgestrel 1.5mg (a progesterone)
Mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
Levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
If vomiting occurs within 2 hours then the dose should be repeated
Can be used more than once in a menstrual cycle if clinically indicated

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27
Q

Ulipristal

A

Progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
Concomitant use with levonorgestrel is not recommended
May reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
Caution should be exercised in patients with severe asthma
Repeated dosing within the same menstrual cycle is not recommended
Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

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28
Q

Urinary incontinence - treatment

Urge incontinence

A

1st line - Bladder retraining

Antimuscarinic drugs
Surgical - sacral nerve stimulation

29
Q

Urinary incontinence - treatment

Stress incontinence

A

1st line - pelvic floor muscle training
Surgical - retropubic mid-urethral tape procedures

30
Q

Urinary incontinence

Initial Ix

A

Bladder diaries should be completed for a minimum of 3 days
Vaginal examination to exclude cystocele
Urine dipstick and culture

31
Q

Vaginal infection:

Candida

A

‘cottage cheese’ discharge
vulvitis
itch

32
Q

Vaginal infection:

Trichomonas vaginalis

A

Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix

33
Q

Vaginal infection:

Bacterial vaginosis

A

Offensive
Thin, white/grey, ‘fishy’ discharge

34
Q

Risk factors for gestational diabetes?

A

BMI of > 30 kg/m^2
Previous macrosomic baby weighing 4.5 kg or above.
Previous gestational diabetes
First-degree relative with diabetes
Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

35
Q

Management of gestational diabetes?

A

Responds to changes in diet and exercise in around 80% of women
Oral hypoglycaemic agents (metformin) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia)
There is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin
Hypoglycaemic medication should be stopped following delivery
A fasting glucose should be checked at the 6 week postnatal check

36
Q

Fetal varicella syndrome

A

Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
Studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
Features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

37
Q

Management of chickenpox exposure in pregnancy

A

If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
If the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
Consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

38
Q

Pre-existing hypertension

A

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

Occurs in 3-5% of pregnancies and is more common in older women

39
Q

Pregnancy induced hypertension

A

Hypertension (Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic) occurring in the second half of pregnancy (i.e. after 20 weeks)

No proteinuria, no oedema

Occurs in around 5-7% of pregnancies

Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

40
Q

Physiological cysts (functional cysts)

Follicular cysts

A

Commonest type of ovarian cyst
Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles

41
Q

Physiological cysts (functional cysts)

Corpus luteum cyst

A

During the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst

More likely to present with intraperitoneal bleeding than follicular cysts

42
Q

Benign germ cell tumours

Dermoid cyst

A

Also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
Most common benign ovarian tumour in woman under the age of 30 years
Median age of diagnosis is 30 years old
Bilateral in 10-20%
Usually asymptomatic. Torsion is more likely than with other ovarian tumours

43
Q

Benign epithelial tumours (Arise from the ovarian surface epithelium)

Serous cystadenoma

A

The most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
Bilateral in around 20%

44
Q

Benign epithelial tumours (Arise from the ovarian surface epithelium)

Mucinous cystadenoma

A

Second most common benign epithelial tumour
They are typically large and may become massive
If ruptures may cause pseudomyxoma peritonei

45
Q

Causes of PID

A

Chlamydia trachomatis - the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

46
Q

Emergency contraception:

Levonorgestrel

A

Should be taken as soon as possible - efficacy decreases with time
Must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
Single dose of levonorgestrel 1.5mg (a progesterone)
Mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
Levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
If vomiting occurs within 2 hours then the dose should be repeated
Can be used more than once in a menstrual cycle if clinically indicated

47
Q

Emergency contraception:

Ullipristal

A

A progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
Concomitant use with levonorgestrel is not recommended
May reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
Caution should be exercised in patients with severe asthma
Repeated dosing within the same menstrual cycle is not recommended
Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

48
Q

Emergency contraception:

IUD

A

Must be inserted within 5 days of UPSI, or
If a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
May inhibit fertilisation or implantation
Prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
Is 99% effective regardless of where it is used in the cycle
May be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

49
Q

Puerperal pyrexia

A

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.

Causes:
endometritis: most common cause
urinary tract infection
wound infections (perineal tears + caesarean section)
mastitis
venous thromboembolism

Management
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

50
Q

Miscarriage types

Threatened

A

Painless vaginal bleeding occurring before 24 weeks, but

Typically occurs at 6 - 9 weeks
cervical os is closed

Complicates up to 25% of all pregnancies

51
Q

Miscarriage types

Missed (delayed)

A

A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion

Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear

When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

52
Q

Miscarriage types

Inevitable

A

Cervical os is open
Heavy bleeding with clots and pain

53
Q

Miscarriage types

Incomplete

A

Not all products of conception have been expelled

54
Q

Affect on Fetus of Rhesus

A

Oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
Jaundice, anaemia, Hepatosplenomegaly
Heart failure
Kernicterus

Treatment: transfusions, UV phototherapy

55
Q

When should Anti-D Ig always be given?

A

Delivery of a Rh +ve infant, whether live or stillborn
Any termination of pregnancy
Miscarriage if gestation is > 12 weeks
Ectopic pregnancy
External cephalic version
Antepartum haemorrhage
Amniocentesis, chorionic villus sampling, fetal blood sampling

56
Q

Menopause management

A

Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women’s Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis.

Management options for hot flushes or night sweats:
lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing
hormone replacement therapy: most effective
tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
selective serotonin reuptake inhibitors: only small trials have been completed to date

Vaginal atrophy
topical oestrogens

57
Q

PCOS management: general

A

Weight reduction if appropriate
If a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)

58
Q

PCOS management: hirsuitism and acne

A

COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
If doesn’t respond to COC then topical eflornithine may be tried
Spironolactone, flutamide and finasteride may be used under specialist supervision

59
Q

PCOS management: infertility

A

Weight reduction if appropriate
The management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins

60
Q

Cervical ectropion

A

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

The term cervical erosion is used less commonly now

This may result in the following features
vaginal discharge
post-coital bleeding

Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms

61
Q

PCOS - features and Ix

A

Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.

Features
subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)

Investigations
Pelvic ultrasound: multiple cysts on the ovaries
FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
Check for impaired glucose tolerance

62
Q

Genital warts treatment

A

Topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
Imiquimod is a topical cream which is generally used second line
Genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

63
Q

Infertility

A

Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years

Causes
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%

Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period

If 30 nmol/l indicates ovulation

Key counselling points
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

64
Q

Alpha feto-protein

A

Increased:
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

Decreased:
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

65
Q

Pregnancy: thyroid problems
Thyrotoxicosis

A

Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour

Graves’ disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester

Management
Propylthiouracil has traditionally been the antithyroid drug of choice. This approach was supported by the 2007 Endocrine Society consensus guidelines
Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism
Thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine risk of neonatal thyroid problems
Block-and-replace regimes should not be used in pregnancy
Radioiodine therapy is contraindicated

66
Q

Pregnancy: thyroid problems
Hypothyroidism

A

Thyroxine is safe during pregnancy
Serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum
Some women require an increased dose of thyroxine during pregnancy
Breast feeding is safe whilst on thyroxine

67
Q

Antiretroviral treatment in pregnancy

A

All pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously

If women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation

68
Q

Neonatal antiretroviral therapy

A

Zidovudine is usually administered orally to the neonate if maternal viral load is

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