Last 3 exams SAQs Flashcards
5 mechanisms for pathogenesis of PET and clinical sequalae
Failure of trophoblastic invasion into maternal spiral arteries prior to 20 weeks causing ischemia IUGR
Damaged placenta releases inflammatory factors into maternal circulation which causes endothelial dysfunction and loss of water into intravascular space OEDEMA
Vasoconstriction of blood vessels due to damaged endothelial cells does not accommodate extra cardiac output HYPERTENSION
Endothelial damage at the kidney causes protein to escape at the glomerular capillaries PROTEINURIA
Maternal plasma volume contraction due to loss of water from intravascular space and activation of clotting factors due to endothelial damage VTE
6 points to pre-conception counselling for previous PET
Educate the woman at an increased risk in pregnancy: Recurrence 30% <32weeks 15% >32weeks Increased IUGR and GHTN Review for any ongoing issues: Hypertension (stop ace-i) Diabetes Should have been screened for APLS Baseline U&Es and uPCR Management to reduce recurrence: Aspirin & calcium Antenatal care model: Uterine artery doppler Growth scans (from 24 weeks if notching on uterine) Regular BP urine checks Discuss long term sequalae of PET: Cardiovascular disease, hypertension, T2DM & VTE. Improve other risk factors such as weight and alcohol consumption. General pre-conception: Folic acid, iodine, vaccinations, smear tests & contracpetion
Name CLASP research design
Double blind RCT
Name intervention in CLASP
Low dose aspirin 60mg daily from 12-32 weeks vs placebo
State level the level of significance for the findings of CLASP
Reduction in proteinuric PET by 12% overall 22% <20weeks. Not statistically significant.
1 reason for smaller effect of aspirin found in CLASP
Heterogenous participant including those high risk and low risk for PET and using aspirin for treatment and prevention purposes. This may have diluted effect of aspirin in high risk women.
What is sequential genetic carrier testing and advantages and disadvantages
One member of a couple is tested for heritible conditions first and then if positive the other partner is screened.
Advantages:
Less screening, allows for cascade screening of effected partner’s family.
Disadvantages:
More referrals to genetic counsellors, time delay may cause anxiety while 2nd person’s screen is completed.
What is combined couple genetic carrier testing the advantages and disadvantages
Both members of the couple are tested simultaneously
Advantages:
Quick
Disadvantages:
Only gives assessment for them as a couple if changes partners no longer relevant.
Principles of informed consent
Information being provided to the couple in a form, language and manner that is acceptable to the couple and allows them to understand.
Given all options and the advantages and disadvantages for each.
Person competent to understand the information and weigh up pros and cons.
Options if a heritable genetic condition is discovered in a couple
Spontaneous conception and test neonate Spontaneous conception and invasive prenatal testing in pregnancy. IVF and preimplantation genetic testing IVF with donor sperm or egg Adoption or remaining childless
Carrier frequencies for 3 common conditions
Fragile X premutation 1:332
Spinal muscular dystrophy 1:50
Cystic fibrosis 1:25-35
Contraindications to VBAC
Previous classical c-section
Uterine rupture at last c-section
J or T incision
Previous surgery that breeched cavity e.g. myomectomy
Short interpregnancy interval <12 months.
1 benefit and 4 risks to neonate from VBAC
Benefit: Reduction in RDS Risks: Term stillbirth Hypoxia in labour Birth injury Meconium liquor and aspiration
Features suggestive of uterine rupture
Abnormal CTG Abdominal pain beyond contraction Acute onset of scar tenderness PV Bleeding Heamaturia Cessation of previously good uterine activity Maternal shock Loss of station of presenting part
3 most likely causes of primary PPH
Uterine atony
Genital tract trauma
Retained tissue
5 management principles for PPH
RECOGNITION e.g. Weigh loss
COMMUNICATION e.g. Call for help
RESUSCITATION e.g. ABCs
MONITORING AND INVESTIAGTIONS e.g. Observations
MANAGEMENT e.g. early transfer to OT if bleeding continues
2 surgical interventions appropriate for uncontrolled PPH
Bakri
B-Lynch or Hayman suture
Hysterectomy
MOA of tranexamic acid
Prevents conversion of plasminogen to plasmin. Plasmin is required to breakdown fibrin so it prevents the breakdown of clots.
Inclusion criteria from WOMAN trial
Any woman >16 years old having PPH defined as >500ml in vaginal birth and >1000ml in C-section
Primary outcome in WOMAN trial
The need for hysterectomy
1 limitation of WOMAN trial
Decision for TXA often happened simultaneously with hysterectomy especially in low resource settings meaning the primary outcome is likely less statistically significant than it should be.
1 strength of WOMAN trial
large numbers 20,000, randomised placebo controlled, double blind study
Differentials of acute abdomen in pregnancy
Gynae: torsion, PID Obstetric: uterine rupture, abruption GI tract: Appendix, cholecystitis Genitourinary: Pyleonephritis, kidney stones Vascular: ruptured aortic aneurysm.
What is risk of loss in appendicitis
Generally 1.5%
Peritionitis 6%
Perforated 35%
What is a LANZ incision
Open incision for appendicitis gives more accurate to base of appendix than McBurney’s
2/3rds from ASIS towards umbilicus then incise along Langerhs lines over point of maximal tenderness
Principles of labour management for woman with abdominal wound
Aim for vaginal birth c-section for obstetric indications only
Antenatal review by obs team to review location, date, indication and operation note
If c-section be conscious of adhesions
Physiology of DCDA twins
Monozygtic 1 egg splits <3 days
Dizygotic twining.
Evaluate MSS1 in twins
Combines maternal age, NT can (11-13+6), BHCG and PAPP-A (9-13+6).
Risk for each twin high risk result 1:300
Sensitivity 72-80% in twins vs 85% singleton
Pharmacology of mifepristone
A progesterone antagonist which encourages degeneration of decidua leading to trophoblastic seperation.
Pharmacology of Misoprostol
Prostaglandin E1 Analogue which acts on PG receptors in myometrium to cause uterine contractions and soften and dilates the cervix.
Mife:Miso trial
A randomised double blinded placebo controlled trial.
Looking at Mifepristone or placebo 48 hours prior to misoprostol.
Primary outcome - failure to spontaneously pass gestational sac within 7 days.
Results:
17% mifepristone vs 24% of placebo did not complete miscarriage RR 0.73
17% Mifepristone vs 25% of placebo required ERPOC RR 0.71
List primary outcomes of MIST trial
Gynaecological infection at 14 days and 8 weeks following expectant, medical and surgical management - no difference between groups.
Unscheduled surgery highest expectant.
Unscheduled hospital admission highest expectant.
2 most common causes for PMB
Atrophy of vulvovagina
Use of HRT
Advantages and disadvantages of using USS to investigate PMB
Advantages:
TVUSS <4mm 99% negative predictive value about endometrial cancer.
Avoids risk of instrumentation to the uterus
Readily accessible by primary care
Disadvantages
ET > 5mm 61% specificity for cancer so 39% of women going on to have uneeded surgery
Image quality reduced in high BMI
No histological diagnosis
Advantages and disadvantages of using endometrial pipelle to investigate PMB
Advantages:
Can be done in outpatient setting without anesthetic
IF cancer present on its histology the woman proceeds to hysterectomy.
99% sensitivity in postmenopausal women 91% sensitivity in premenopausal women.
Disadvantages:
Samples <50% of endometrium could miss focal lesions
Does not allow concurrent management of pathology
Mirena vs oral progesterone as second line management of typical hyperplasia
Mirena 52mg Levongesterol 90% regression rates
Medroxyprogesterone acetate up to 600mg daily in divided doses regression rate 70%
Atypical hyperplasia progression to cancer
8% over 4 years
Hyperplasia no atypia progression to cancer
<5% over 20 years
Describe 3 aspects of clinical governance and how they are fulfilled by a GONC MDM
AUDIT thorough collection of data related to cancer patients.
TEACHING AND PROFESSIONAL DEVLOPMENT sharing knowledge remaining up to date with best practice
CLINICAL EFFECTIVENESS Improves clinical outcomes for patients as their treatment is guided by regional experts following best practice.
What is the difference between AUB and HMB
HMB is subjective any amount that has an impact on a woman’s quality of life.
AUB is more objective e.g. intermenstrual bleeding, post-coital bleeding cycle length etc
What does PALM COIEN stand for
Polyp Adenomyosis Leiomyoma Malignancy Coagulopathy Ovulation Iatrogenic Endometrium Not yet classified
Principles of a POPQ assessment
Standardised way of recording findings of an exam for pelvic organ prolapse. Proven inter-observer and intra-observer reliability. Relies on documenting 6 different points in relation to a fixed point the hymenal ring on full valsalva as well as 3 different length measurements total vaginal length, genital hiatus and perineal body.
Aa - proximal anterior wall 3cm from hymenl ring
Ba - Most distal point of anterior wall
C - cervix
D - posterior fornix
Ba - proximal part of posterior wall 3cm from hymenl ring
Bp - distal portion of remaining posterior wall
Describe your patient selection for mesh
Not for primary repair
Not for posterior or apical prolapse
Should have grad 3-4 prolapse
Avoid if <50 years old
Do not use if already have chronic pelvic pain
Should discuss women in an MDM
A skilled operator should perform the surgery
Make sure patient has no contraindications to ovestin (1st line tx for mesh erosion)
Not currently endorsed by governing bodies.
What is a sacrospinous fixation and the advantages and disadvantages of it
Vaginal vault is fixed to right sacrospinous ligament.
Advantages:
Earlier recovery than other surgical management
Cheaper and quicker to perform
Success 90% Recurrence 5-7%
Disadvantages
Not suitable for those with short vaginal length or dysparunia
High incidence of post op anterior prolapse
1:20 buttock pain
Pudendal nerve injury
What is a sacrocolpopexy and the advantages and disadvantages of it
Support vaginal vault by fixing it to sacral promantary using a piece of mesh.
Advantages
Gold standard in vault prolapse success ~95%
Can diagnose and treat abdominal pathology concurrently
Decreased dysparunia
Can be performed laparoscopically
Disadvantages
Risk of anterior wall prolapse
Risk of bowel complications e.g. ileus
Mesh complication erosion, pain, chronic infection
IVF cycle risk factors for OHSS
Use of GnRH agonist Exposure to HCG (as a trigger or luteal support) Multiple follicular response with stimulation Conception Large number of oocytes retrieved General risk factors: Young age PCOS Multiple pregnancy Previous OHSS
Why are FBC and USS important in work up for OHSS
USS - assess the size of the ovaries, presence of ascites and complications e.g. torsion
Mild <8ml
Moderate 8-12ml + ascites
Severe >12ml
WBC count:
HCT – HCT > 0.45 is severe
WCC – WCC > 15 is moderate, > 25 is severe
Principles of management of OHSS
MDT
OP vs IP (severe classification, oligouria, pain, vomiting)
FLUID BALANCE (avoid K as at risk of hyperkaliemia)
MONITORING (electrolytes, pulmonary oedema)
VTE PROPHYLAXIS
SYMPTOM RELIEF (nausea and pain +/- paracentesis of ascities)
MDT (may need ICU if HCT >0.55, anuria, VTE, acute RDS & tense ascities), feritility.
Majority of OHSS is self limiting and resolves in 7-10 days
Define early onset GBS
Neonatal sepsis due to GBS with onset within 7 days following delivery
Reduction of GBS with intra-partum abx
83%
How to take GBS swab
Ano-rectal improves detection by 10%
Cultured in an enriched medium other false negative rates ~50%
Taken at 35-37 weeks as GBS carriage can fluctuate
Antibiotics for GBS with penicillin allergy
Cefazolin 2g loading then 1g 8 hourly
Erythromycin resistance in 30%
Clindamycin resistance in 20%
Vancomycin 1g 12 hourly
Management of PPROM if GBS +ve
<34 weeks and if clinically stable manage conservatively.
>34 weeks induce to reduce rates of EOGBS
What are the signs of late onset GBS in neonate
Lethargy, poor feeding, rash, seizures, jaundice, irritability. Should seek medical attention and baby get septic screen.
Outcomes for PGE2 vs Balloon for vaginal birth within 24 hours
Both are equally likely to result in vaginal birth within 24 hours.
No difference in rates of c-section
Increased risk of hyperstimulation with PGE2
PGE2: MOA, contraindication and side effects
Stimulates PGE2 receptors in the myometrium, decidua and cervix to encourage cervical softening, dilatation and uterine contractions. Contraindications: Previous c-section Previous uterine procedure were cavity was breeched e.g. myomectomy IUGR with abnormal dopplers Severe IUGR <3rd centile Grandmultips >para 4 Side effects: Vaginal irritation Uterine hyperstimulation Nausea, vomiting Fever
Transcervical balloon: MOA, contraindication and side effects
Catheter through the cervix into extra-amniotic space with balloon seperation of the membranes from the lower decidua to increase release of endogenous prostaglandins. Contraindications: Ruptured membranes Low lying placenta Maternal infection Unstable lie Side effects: APH Maternal discomfort Maternal or neonatal infection Ruptured membranes Urinary retention
Describe McRoberts
Hyperflex the knees towards nipples
Apply routine axial traction
Widens anterior/posterior diameter of the pelvic outlet
90% success rate
Describe Suprapubic pressure
Assistant apply suprapubic pressure from the side of the fetal back. Downward and lateral just above pubic symphasis.
Continuous or rocking for 30 seconds
Reduces the fetal bisacromial diameter and rotate the shoulder into the wider oblique diameter of pelvis.
Non invasive.
Describe the delivery of the posterior arm
3rd in order of shoulder dystocia maneuvers
Reduces bisacromial diameter.
Find the elbow and encourage it to bend then grasp the wrist and gently remove arm by sweeping hand over baby’s face.
Describe rotational maneouvres - Woodscreww
Pressure placed on posterior aspect of posterior shoulder. Encourages rotation and adduction of shoulder.
Most common cardiac complication to occur in mitral stenosis in pregnancy
Pulmonary oedema
List 2 medications that are used in mitral stenosis that may need to be changed & why
Warfarin - <12 weeks nasal hypoplasia and limb contractures
>12 weeks IUGR, low IQ and impaired neurodevelopment.
Ace-i associated with renal failure causing oligohydramnios and premature ductus arteriosus closure.
2 medications commonly used in mitral stenosis that can be continued
B-blockers
Calcium channel blockers
How do you manage delivery in mitral stenosis
Needs referral to tertiary centre and telemetry in labour
MAINTAIN EUVOLEAMIA - hypervoleamia cannot be accommodated and puts her in increased risk of pulmonary oedema. IDC, IV fluids monitored +/- Frusemide.
AVOID HYPOTENSION - due to risk of heart failure due to fixed low output state. Active management of PPH avoiding syntometrine.
AVOID TACHYCARDIA - Further reduces diastolic filling precipitating thrombus and pulmonary oedema. Early epidural, short second stage +/- forceps.
Chance of miscarraige after 3+ miscarriages
40%
Affects 1% of couples
Justify APLS screening in recurrent miscarriage (lupus anticoagulant, anticardiolipin and anti-B2 glycoprotein)
Present in 10-20% of recurrent miscarriages population vs 2% in general.
Appropriate treatment with LMWH and low dose aspirin can improve live birth rate.
Justify Karyotype in recurrent miscarriage
If products abnormal genetically perform peripheral blood karyotype on the couple
Unbalanced translocation found in 2-5% of couples.
If found this can be addressed with pre-implantation genetic screening, adoption or donor gametes IVF.
If not found less likely to have further miscarriage.
Progesterones for preventing miscarriage - Cochrane review 2021
Little or no difference in live birth rate for women with threatened or recurrent miscarriage.
PV progesterone may be useful in early pregnancy bleeding if woman has had 1 or more miscarriages previously to increase live birth rate.
No difference in adverse events with PV progesterone
Pathogenesis of molar pregnancy
Only paternal chromosomes. p57 -ve.
Fertility after molar pregnancy
No affect on fertility
Increased risk of recurrence 1:70 vs 1:200-1000
Avoid pregnancy in follow up (3 weekly levels negative then 6 monthly levels negative)
Contraption COCP, POP fine
Criteria for referral for GTN
plateau in HCG +/- 10% that lasts for 4 measurements Risk in HCG on 3 measurements HCG >20000 4 weeks after ERPOC Still +ve after 6 months Evidence of metastes
Treatment of GTN
2nd ERPOC 40% chance of no chemo FIGO score 0-4 with no mets Single agent chemo - Methotrexate FIGO score 0-6 99% cure Triple agent chemo Methotrexate, etoposide, actinomycin FIGO score 6+ 85% cure rate
What is FIGO scoring system for GTN
Score 0, 1, 2 or 4 in 8 categories Age Antecedent pregnancy outcome Time since index pregnancy HCG Largest tumour size Location of mets Size of mets Previous failed chemo
WHO recommends spacing of pregnancy 24-36 months why?
Reduction in congential anomalies Reduction in SGA Reduction in pre-term birth Reduction in postnatal depression Reduction in stillbirth
Why is CA125 not a good screening tool
Numerous benign conditions cause it to rise giving false positives
Only risen in 50% of early high grade epithelial cancer
Only risen in serous epithelial cancers so you won’t identify mucinous, endometriod, germ cell, sex cord stromal.
What percentage of stage 3 ovarian cancer responds to chemo
80%
Paclitaxel chemo agent used for ovarian cancer unique side effect
Peripheral neuropathy causing parathesia
Cisplatin chemo agent used for ovarian cancer unique side effect
Hearing loss and tinnitus
Methods to ensure optimal quality of semen sample
Avoid intercourse and masturbation for 3 days prior
Do not use lube
Keep sample at body temp
Send to lab within 1 hour
Major components of semen analysis and normal values
Volume >1.5ml pH >7.2 Concentration 15 million/ml Total sperm count >39 million Normal morphology 4% Total motility 40% Progressive forward motility 32%
Modifiable risk factors affecting semen quality
Stop smoking including marijuana Alcohol <6 units per week Avoid tight underwear or shorts Increased BMI Medications e.g. fluoxetine, anabolic steroids, lamotrigine
Initial advice on borderline semen sample
Repeat 50% of time it will then be normal
Wait 12 weeks
Outline investigations
KARYOTYPE e.g. fragile X, kleinfelters
SCROTAL USS for obstruction 25% have variocele
FSH + TESTOSTERONE to classify cause
SPERM ANTIBODIES >40% coated signifcant
PROLACTIN +/- MRI micro/macro prolactinoma
POST EJACULATORY URINE SAMPLE retrograde ejaculation
Investigation of dyspareunia and infertility
Fertility work up Day 2-4 LH, FSHH Mid luteal progesterone day 21 AMH Further imaging MRI has symptoms of DIE
Why would you do a manual rotation at fully
The average fetal head diameter with a deflexed OP position is 11.5cm, which is significantly bigger than that for OA (9.5cm).
High success rate ( ~93%) increase likelihood of vaginal birth, may shorten the second stage, and has a low risk of maternal and fetal complications (eg, cervical laceration, fetal distress necessitating expeditious delivery).
Reasons to consider trial of instrumental in OT
- 1/5 palpable
- Likely to be a difficult rotational delivery
- The woman does not have appropriate analgesia
- LGA
- Maternal BMI >30
When to re-attempt ventouse after cup pop off
Rapid decompression with a pop off can cause vessel damage which may increase the risk of a subgaleal haematoma
Consider possible contributing factors for pop off
- Ensure correct application
- Minimal caput
- Good maternal effort
- No maternal tissues involved
Ensure these prerequisites are meet, otherwise consider forceps
Unless delivery imminent, consider alerting theatre staff to possibility to transfer
Cephaloheamatoma
Collection of blood underneath the periosteum - limited to that specific bone by the periosteal attachments (i.e. does not cross suture line)
Caused by rupture of vessels beneath the periosteum
Subgaleal heamatoma
Potentially life-threatening
Blood accumulates in the loose areolar tissue in the space between the periosteum of the skull and the aponeurosis
No boundaries to contain the blood crosses suture lines
Emissary veins are sheared or severed
Potential for massive blood loss (20-40% of blood volume)
Subgaleal haematoma presents as a diffuse, fluctuant swelling of the head that may shift with movement.
Define placenta Accreta
Partial or complete absence of decidua with adherence of placenta directly to superficial myometrium
Define placenta increta
Villi invade into but not through the myometrium
Define placenta percreta
villi invade through the full thickness of the myometrium and serosa.
Risk factors for morbidly adherent placenta
Previous C-section
- 2 previous sections with praevia 40% risk of placenta accreta
Placenta praevia on anatomy scan
Anterior placenta praevia
Advanced maternal age
History of painless APH
Indication was breech - that implies that they were elective rather than in labour, and that increases the risk of accreta
When to deliver placenta acreta
Admit from 34 weeks consider delivery from 34+0 - 35+6
Gold standard delivery option for placenta acreta
Uterine incision distant from placenta, trim cord and then perform a hysterectomy
2015 Cochrane review looked at outcomes for surgical approach of hysterectomy performed for benign disease
Found that vaginal hysterectomy appears to be superior when compared to abdominal or laparoscopic hysterectomy
- Associated with faster return to normal activities
Laparoscopic approach had some advantages over abdominal approach
- More rapid recovery
- Fewer febrile episodes
- Fewer wound or abdominal wall infections
Compared to vaginal hysterectomy, laparoscopic hysterectomy is associated with longer operating time and a higher rate of urinary tract injuries
Vaginal history approach
- Perform standard three pedicle hysterectomy
o Use 1 vicryl suture - 1st pedicle – uterosacral and cardinal ligaments – clamp, divide and ligature bilaterally
o Clip pedicle to drapes - 2nd pedicle – uterine vessels
- 3rd pedicle – tubo-ovarian and round ligaments pedicle (includes utero-ovarian vessels)
Unilateral flank pain day 3 post vaginal hysterectomy you suspect uteric injury what investigations do you order
Bloods, including FBC, urea and electrolytes, creatinine, CRP, blood cultures, lactate
Want to check kidney function
Infection in differential therefore want to look for potential source
Imaging of renal tract
- CT urogram
- Renal ultrasound
Used to image the renal tract
Contrast allows for identification of injury site
MSU for culture and sensitivity
Differential diagnosis of pyelonephritis from the history provided
Delancey levels of support
Level 1 - utero-sacral and cardinal ligaments
Level 2 - Endopelvic fascia
Level 3 - The perineal membrane and urogenital diaphragm
Level 1 is the most relevance when performing a vaginal hysterectomy as they provide elevation of uterus which needs to be dissected in order to allow sufficient descent and access to the other pedicles.
Places of injury to ureter
Distal ureter at level of uterines when taking pedicle
IP ligament particularly when taking tubes and ovaries
Vaginal cuff closure at the point where ureters enter bladder
When reflecting the anterior leaf of broad ligament as ureter passes deep in posterior leaf (laparoscopic)
Justify two (2) tests that will enable you to distinguish between CAIS and MRKH
Karyotye 46XY in CAIS, 46 XX MRKH
LH - levels very high CAIS
Testosterone - high CAIS
Medical issues associated with CAIS
Germ cell tumours Gender dysmorphia Infertility Short vaginal length CVD and reduced bone density once gonads removed
Explain adaptive immune system
Adaptive immunity occurs after exposure to an antigen either from a pathogen or vaccination. On first exposure antigens are presented to the cells and memory forms on next exposure the cells are reactivated when presented with the same antigen.
Two types of adaptive response:
1. Cell mediated response = T cells are activated by the specific antigen and cytokines are released, they also identify infected cells and kill them.
2. Humoral immune response = B cells are activated by the antigen to produce antibodies which bind to the virus or antigen and prevent it from replicating or spreading.
Outline immune system response to HPV
HPV enters genital tract and infects parabasal cells (keratinocytes).
These cells act as antigen presenting cells to stimulate the immune mediated response.
This induces the response of T helper cells to produce cytokines and CD4 and CD8 T cells to produce a cytotoxic response resulting in the killing of infected cells and the clearance of the virus.
Describe 3 ways HPV evades the immune system
- HPV infects and multiplies in keratinocytes which have a short half life. This means that the virus does not need to kill the cell to spread preventing inflammation and there is no presentation of viral antigens.
- HPV does not replicate in the blood and the infection is not spread systemically. This means the immune system is less likely to be triggered.
- HPV downregulates expression of interferon genes which down regulates the cytokine and inflammatory response.
IF someone is still sexually active would you still give Gardasil vaccine
Would still recommend having the vaccine.
- Unable to protect against strains of HPV the woman already has but can prevent her from being infected with any other strains of HPV.
- Also some evidence increases number of antibodies which helps to prevent reinfection.
Gardisil 4 vs Gardisil 9
Gardasil 4 contains virus like particles that protect against 4 strains of HPV 6, 11, 16 and 18. These are the two strains that cause 70% of cervical cancer and the two strains that cause genital warts.
Gardasil 9 contains HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58. It protects against 5 other oncogenic strains of HPV and prevents 90% of cervical cancers. Increased potential for cancer prevention not only cervix but vulva, vagina, anal, oropharynx and penile.
Pathophysiology of mennorhagia and dysmennorhoea in Adenomyosis
Heavy bleeding
Enlarged surface area.
Ectopic endometrial glands stops the myometrium from contracting to stop bleeding.
Increases menstrual volume.
Pain
Ectopic endometrial glands react to oestrogen swelling around menses. Creating an inflammatory response and increasing pain.
Why endometrial ablation is not suitable in adenomyosis
Endometrial ablation works by using radiofrequency or thermal energy to remove the endometrium – it will not obliterate/remove the glands within the myometrium itself. Reducing bleeding but not pain.
If she wishes to preserve her fertility - Pregnancy after ablation is contraindicated as the risk of placenta accrete spectrum disorders is much higher, miscarriage and ectopic pregnancy.
Mirena MOA and clinical benefit in adhenomyosis
– downregulates endometrial (and adneomyotic tissue’s) oestrogen receptors –> makes them less susceptible to oestrogen action
Reduction in menstrual blood loss (including amenorrhoea in some women)
May result in a reduction in pain
GnRH analogue MOA and clinical benefit in adhenomyosis
Suppress the hypothalamic-pituitary-ovarian axis, leading to suppression of ovulation and thus oestrogenic stimulation of the adenomyotic tissue leading to their regression
Reduction in menstrual blood loss or amenorrhoea
Reduction in pelvic pain
May enable hysterectomy by minimally invasive method by reducing the size of the uterus
In a mixed picture urge vs stress what symptoms can help diagnosis
- Volume of urine lost each time urge>stress
- Can she predict when it will happen stress when increasing abdominal pressure, urge more random
- Nocturia more likely with urge
Examination features to distinguish between stress and urge incontinence
Cough stress test – will leak urine and have stress
Co-existing POP – more likely to have stress incontinence
Palpable bladder more likely in chronic retention which can then worsen urge
Pelvic floor contraction likely to be weaker in stress
Weight and BMI more likely in stress
First line investigations for incontinence
MSU and urine dip
Post-void residual
Role of urodynamics to assess mixed incontinence
Unclear diagnosis - choice of procedure is influenced by urodynamic results
Coexisting pathologies to determine which should be treated first, such as obstruction and detrusor overactivity or stress incontinence and detrusor overactivity
Help with to measure treatment response
1st line conservative management in overactive bladder
Bladder diary: 3 day duration. Four parameters Frequency and voided volumes, leakage episdoes, pad changes and type and volume of fluid intake. Helps to direct bladder training and confirm diagnosis.
Bladder training the aim is to gradually increase the amount of time you can wait before emptying your bladder.
Topical oestrogen - Most of the available evidence regarding proven benefit deals with the symptom of UUI, showing improvement in urgency and bladder capacity.
2nd line medical management in overactive bladder
Antimuscarinic therapy e.g. Oxybutynin or Vesicare can significantly reduce incontinence episodes per day, reduction in number of micturitions per day and reduction of urgency episodes per day.
Many women find side effects which are common of dry mouth, constipation, blurred vision and somulence intolerable.
Caution in prescribing in elderly due to link with dementia and Alzheimer’s.
3rd line other management in overactive bladder
Botox interferes with neural transmission by blocking the calcium-dependent release of neurotransmitter, acetylcholine, causing the affected muscle, the detrusor, to become weak and atrophic. Many women find helpful for around 6-9 months. Common side effects are UTI and retention 6.9%.
The tibial nerve is a mixed nerve containing L4–S3 fibres and originates from the same spinal cord segments as the innervation to the bladder and pelvic floor. Can have weekly sessions of nerve stimulation.
Peripheral neuromodulation may offer an alternative therapeutic option for those patients with intractable OAB who have failed to respond to medical therapy. Success rates 32-87%. In trials has shown to be as effective as medical therapy and better than placebo.
USS findings in adenomyosis
Venetian blind Nodules which extend from endometrium to myometrium Irregular myometrial junction Tiny echoic myometrial cysts Increased vascularity on doppler Sensitive 53-89% Specific 50-99%
How PCOS causes endometrial hyperplasia
PCOS → dysregulated hypothalamic pituitary and ovarian axis → amenorrhoea and irregular bleeding → endometrial proliferation and build up and increase risks of endometrial dysplasia
How high BMI causes endometrial hyperplasia
Elevated BMI → increase adipose tissue → increase aromatisation and increase levels of estrogen → stimulating endometrial proliferation and therefore increase risks of endometrial dysplasia
Prognostic factors for endometrial cancer
- Significant co-morbidities preventing adequate treatment
- High stage of cancer >1b
- Increasing myometrial invasion
- Vascular infiltration
- Tumour extension beyond fundus
- Tumour >2cm
- Distant metastases
- High grade
- DNA aneuploidy
- Serous or clear cell histology
- High Ca125
- Increasing age
What is NIPT extended genome panel
Genome wide testing for very rare conditions therefore positive predictive value falls.
This means more babies end up with diagnostic with risk of miscarriage to rule out conditions which are very unlikely.
Women have increased anxiety until delivery of their baby
Pre-test counselling for NIPT
Still a screening test and not diagnostic. Abnormal results require diagnostic testing e.g. CVS or amnio.
Not currently funded in NZ
High negative predictive value ~99% for T21, T18 + T13 but not perfect can miss affected babies
Does not replace 12-14 weekand 20 week scans for structural anaomalies
A NIPT shows 45XO write down reasons why with chromosomal pattern
Maternal mosaicism 46XX Turner's 45X0 Confined placental mosaicism 46XX or 46XY Co-twin demise - 46XX False positive - 46 XX or 46XY
What to do with a no result in NIPT
1-3% no result
Most women have sufficient fetal fraction on redraw.
Can offer conventional combined or quadruple screening
Could proceed to invasive testing especially if has a 2nd no result as can be associated with T18 and T13.
causes of a no result in NIPT
High BMI Test done <9 weeks Vanishing demised twin Mosaicism of placenta or mum Can be linked to T18 + T13
Define perinatal death
Fetal death after 20 weeks and/or birthweight >400g and early neonatal death within first 7 days
5 elements of safer baby bundle
Reduced fetal movements Smoking cessation Side sleeping Fetal growth restriction Timing of birth
How do you send placenta for histology
Written consent and document wishes for return of tissue
If lab is onsite and will process immediately send fresh.
If there will be a delay to processing send in formulin AFTER you have taken microbiology swabs, taken samples for cytogenetics of cord and membranes.
Why is threshold 140/90 used to diagnose hypertension in pregnancy
Perinatal mortality rises with diastolic blood pressures >90mmHg
Readings above this level are 2 standard deviations of mean blood pressure above an NZ cohort of normal pregnant women
Chosen levels are in line with international recommendations and hypertension diagnosis outside of pregnancy
Risk factors for PET
Nulliparity 2.9 Multiple pregnancy 2.9 Hx PET 7.2 Family hx 2.9 Obesity 2.7 APLS 9.7 Diabetes 3.6 HTN 2.4
MOA, contraindication and side effect of methyldopa
Centrally acting
depression
Dry mouth and sedation
MOA, contraindication and side effect of Nifedipine
Calcium channel blocker
Aortic stenosis
Tachycardia and headache
MOA, contraindication and side effect of Hydralazine
Cerebral vasodilator
Mitral valve rheumatic heart disease
Flushing and headache
MOA, contraindication and side effect of Labetalol
B-blocker with vasodilator effect
Asthma
Bradycardia and nausea
How to acutely lower severe hypertension
Labetalol 20mg every 10mins max 80mgs
Hydralazine 10mg every 20minsmax 30mg
Nifedipine fast acting PO if no IVL
Don’t forget MgSO4
What defines domestic violence
The abuse of an individual over 16 by a current or former partner or family member regardless of gender or sexuality
Types of domestic violence
Physical Emotional Psychological Financial Sexual
What effect does pregnancy have on domestic violence
30% begins in pregnancy
More likely to disclose as continually exposed to healthcare professionals
Can be a motivating time for women to leave
IS a time of financial reliance on partner so may make it more difficult to leave
How do you formulate questions about domestic violence
Build rapport and trust Get the woman alone Discuss confidentiality Frame questions non judgmental If she discloses praise her strength Provide information on support groups and womens refuge Have a safety plan for her Follow up appointment in person Social work referral Cultural support
High risk findings on colposcopy that warrents biopsy
increased uptake of acetic acid
Margins sharp and even difference in surface level such as cutting
Vessels are coarse or atypical
Lesion size >15mm and over all 4 quadrants
Iodine staining lacking
