Lectures Flashcards
1
Q
4 risk factors for incontinence in women?
A
age
parity
obesity
smoking
2
Q
what are the 2 main types of incontinence and what is their pathophysiology?
A
urge urinary incontinence: can be caused by overactive bladder syndrome
- involuntary bladder contractions (detrusor overactivity is urodynamics finding)
stress urinary incontinence - sphincter weaknes: damage to pubourethral ligament
3
Q
other than stress incontinence and overactive bladder what are the other things which may be causing incontinence?
A
fistula neurological overflow functional mixed incontinence
4
Q
describe how overactive bladder symptoms might present
A
urgency with urgency incontinence
frequency
nocturia
nocturnal enuresis
5
Q
describe how stress incontinence would present
A
involuntary leakage on:
- cough
- laugh
- lifting
- exercise
- movement
6
Q
name some simple assessments you might do when someone presents with incontinence in clinic?
A
frequency volume chart (FVC)/bladder diary
urinalysis (MSU) and urine dip
residual urine measurement (RU) - in and out catheter or ultrasound
questionnaire (ePAQ- electronic Personal Assessment Questionnaire, there is a specific one for pelvic floor)
7
Q
what is recorded in a bladder diary?
when would you use a bladder diary?
A
voided volume frequency of urination quantity and frequency of leakage fluid intake diurnal variation
when someone is presenting with urge incontinence
8
Q
what 4 domains are on an ePAQ questionnaire for pelvic floor?
what sort of things are looked at in each domain?
A
urinary - pain, voiding, overactive bladder, stress incontinence, QoL
bowel - IBS, constipation, evacuation, continence, QoL
vaginal - pain, capacity, prolapse, QoL
sexual - urinary, bowel, vaginal, dyspareunia, overall sex life
9
Q
what two normal daily activities can trigger urge incontinence
A
washing hands
‘key in door’ - needing it as soon as you’ve got to the door of the house
10
Q
first line treatment for stress incontinence?
A
pelvic floor muscle exercises (physiotherapy)
11
Q
first line treatment for urge incontinence?
what can it be combined with?
what other things would you advise?
A
anti muscarinic - oxybutynin
with
bladder training/drill
+ simple measures
- avoid alcohol, caffeine, lose weight, smoking cessation
12
Q
if there is no improvement to stress incontinence after 6 months of PFMEs and there is no urge aspect, what treatment can be offered?
what is the aim of this?
A
surgery
- tension free vaginal tape - first line
- colposuspension
- retropubic midurethral tape
to elevate bladder neck and proximal urethra to support bladder neck
13
Q
what lifestyle measures should be recommended to women presenting with incontinence?
A
- weight loss
- smoking cessations
- reduced caffeine inftake
- avoidance of straining and constipation
- can use pads and pants
14
Q
if antimuscarinics fail for urge incontinence what else can be done?
A
botox injections (expensive and retreat every 6 months)
or
sacral nerve stimulation
or bladder bypass (catheters) leakage barriers (pads and pants)
15
Q
what do antimuscarincs do to treat urge incontinence?
what are the side effects?
how might you reduce the side effects?
A
direct relaxant on urinary smooth muscle
dry mouth, dry eyes, blurred vision, drowsy, constipated
uncommon: urine retention with overflow incontinence
PRN only (immediate release)
16
Q
which antimuscarinic is first line for urge incontinence?
who should you be careful prescribing it in?
A
oxybutynin
elderly - because can cause cognitive impairment
Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health. [2013, amended 2019]
17
Q
what is mirabegron? and what does it do?
who is it used in?
A
Beta-3 adrenergic receptor agonist - Relaxes smooth muscle detrusor and increases bladder capacity
treat women with overactive bladder but ONLY for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects.
18
Q
how does PFMEs work in reduces stress incontinence?
A
Pelvic floor muscle contraction = Clamping / compression of urethra = Increased urethral pressure = Reduced leakage
19
Q
when would you do urodynamics?
when would you not do urodynamics?
A
prior to surgery if:
suspicion of detrusor overactivity (TVT would be useless)
previous surgery for stress incontinence
suspicion of incomplete bladder emptying
wouldn’t do if you’re just going to conservatively manage this patient
20
Q
what happens in urodynamics?
A
probe in bladder and rectum
void in front of investigators (cystometry)
instilling the bladder with normal saline and participant telling the investigators of desires to void
jumping/coughing being observed for leakage
21
Q
what are the 5 types of prolapse and categorise into which compartment they come from
A
anterior: urethrocoele, cystocoele
middle compartment: utero-vaginal prolapse
posterior: rectocoele
enterocoele
22
Q
what piece of equipment do you need to examine a suspected prolapse?
A
sim’s speculum
+ sponge forceps
23
Q
what symptoms might someone describe coming in with prolapse?
A
'something coming down' feeling of fullness sexual dysfunction urinary symptoms bowel symptoms
NB: always ask about bowel symptoms! esp rectocoele may cause problems with defecation ‘digitate to defecate’
24
Q
what are risk factors for prolapse?
A
obesity
multiparity
menopause
(chronic raised pressure - COPD/constipation)
25
what measurement is used to describe a prolapse?
pelvic organ prolapse quantification (POP-Q)
26
what are the management options for prolapse?
when would you move to the second option?
conservative: weight loss, pessary
surgical - repair (e.g anterior repair) or total vaginal hysterectomy with vault suspension
only surgical if:
symptomatic (dyspareunia, discomfort, obstruction, bothersome)
or
severe (outside vagina, ulcerated, failed conservative measures)
27
what are the 2 consequences or that can occur with pelvic floor damage?
stress incontinence
| prolapse
28
types and examples of analgesia for labour
non-pharmacological therapies
- trained support
- acupuncture
- hypnotherapy
- massage
- TENS
- hydrotherapy
pharmacological therapies
- oral - paracetamol, codeine
- inhalational - entonox (nitrous oxide)
- single shot parenteral opioids (morphine/diamorphine injection)
- PCO opioids - pressed just as contraction comes (remifentynyl)
regional techiniques - epidurals
29
what nerves are related to uterine contractions
T10-L1
30
challenge of analgesia in labour
providing analgesia that matches the waxing and waning of the labour pain (waves of really strong pain, then little)
31
entonox
| - what is it, describe its use and possible effects
50% n2o, 50% o2 'gas and air'
rapid onset of analgesia
minimal side effects
self limiting - breath in to get the effects, breath out effect wears off
theoretical risk of bone marrow suppression
green house gas
32
systemic analgesia for labour
simple analgesia:
paracetamol and codeine
opioids -
single shot, usually IM - morphine, diamorphine, pethidine
or patient controlled analgesia via IV cannula (remifentanil)
33
regional techniques
epidural and spinal - numbing nerves leading from the
spinal goes into CSF
epidural goes into the epidural space - MORE COMMON IN LABOUR WARD - analgesia but not anathesia - so she can move around still
34
what level do you insert epidural for labour into and why?
L3/4 (tuffiers line) because the spinal cord terminates at L2
35
indications of epidural for labour
- maternal request
- pregnancy induced hypertension/ pre-eclampsia
- cardiac/other medical disease (anyone that you don't want to have massive surges in BP)
- augmented labour with oxytocin infusion (they experience more pain in their contractions)
- multiple births
- instrumental/operative delivery likely
(may need the second delivery to be under anaesthesia, quicker to get this and take them to theatres)
36
contraindications to epidural labour
absolute - maternal refusal, local infection, allergy to local anaesthetic (but make sure clarify), severe coagulopathy (risk of epidural hematoma which can lead to cauda equina)
relative - systemic infection, hypovolaemia, abnormal anatomy, fixed cardiac output (aortic and mitral stenosis)
37
what drugs do you put in a epidural/spinal?
bupivacaine - local anaesthetic
fentanyl and diamorphine - opioid
38
adverse effects of regionals
cardiovascular
respiratory (SOB/resp depression)
neurological
drug related - adverse effects/if you put the wrong drug in
headache - CFS leaks out and cause a headache from low CSF pressure
may prolong labour, may increase instrumental delivery rates but NO increased in c-section rates!
39
anaesthesia for operative delivery
regional anaesthesia
- epidural top up
- spinal (into the CSF) --> more commonly for c-section
- CSE
general anaesthesia
but better for regional because mum can be awake for baby and see immediately, partner present, improved post op analgesia
40
indication for GA in delivery
- imminent threat to mother and/or foetus
- contraindication to regional
- maternal preference
- failed regional technique
41
what anaesthesia are you most likely to use for a c-section?
spinal
42
what regional analgesia are you most likely to use for labour pains on the ward?
epidural
43
what is menorrhagia?
heavy menstrual bleeding occurring at the expected intervals of the menstrual cycle - subjective, interfere with their quality of life
44
intermenstrual bleeding
bleeding between periods - abnormal, requires investigation
45
abnormal uterine bleeding
summary term for
volume or length of bleeding for
intermenstrual bleeding, post coital bleeding etc etc
46
causes of heavy menstrual bleeding?
coagulopathy
ovulatory
endometrial dysfunction
fibroids (benign tumours of myometrium - often asymptomatic)
polyps (benign localised growths of the endometrium)
adenomyosis (endometrial tissue within the myometrium - like endometriosis)
(endometriosis but not normally the PC)
47
how does gynae malignancy present?
prolonged intersmenstual bleeding
post coital bleeding
post menopausal bleeding
48
what is dysfunctional uterine bleeding?
heavy menstrual bleeding in the absence of pathology
49
investigations of menorrhagia?
FBC +/- hematinics
coat screen
TFT
TVS
hysteroscopy
50
when to biopsy in hysterectomy
indicated if aged >45yr and any of: inter menstrual bleeding, unresponsive to treatment and new onset/change in menstrual pattern
```
consider at any age if:
persistent IMB ro irregular bleeding
infrequent heavy bleeding who are obese or PCOS
women taking tamoxifen
treatment for HMB has been unsuccessful
new onset/change in menstrual pattern
```
51
treatment of heavy menstrual bleeding
reassurance
if wanting baby soon:
methanamic acid
tranexamic acid
progestagens - northesiterone
if not wanting baby soon:
mirena coil
COCP (back to back for 3 years)
POP
hysterectomy in older women
52
methanamic acid is better for
NSAIDs
| better just for pain symptoms
53
tranexamic acid is?
good for bleeding
| inhibits tissue plasminogen activitor
54
what is the first line treatment for HMB?
mirena coil (unless wanting to get pregnant)
55
when to refer women to secondary care?
pathology
fibroids >3cm
failed primary care treatment
wanting surgery
56
endometrial ablations
laser, electrosurgery, and balloons
57
inidcation for endometrial abalations?
heavy mentrsual loss
completed family
....
58
CI to endometrial ablatiion
malignancy
acute PID
wanting to have a baby
....
59
how to treat fibroids >3cm with fertility sparing surgery?
myomectomy/resection of fibroids
| uterine artery embolisation
60
obstetric emergencies - what are they?
maternal - APH, PPH VTE, Pre-eclam
fetal- fetal distress, cord prolapse, shoulder dystochia
61
antepartum hemorrhage define and what are the common causes
bleeding from anywhere in the genital tract after 24th week of pregnancy
```
can be from:
uterus (low lying/placenta previa, abruption, vasa previa)
cervix (tumour, polyp, ectropion)
vagina (vagina tear, infection)
vulval (lesions)
```
no identifiable cause in 40%
62
when is low lying placenta diagnosed?
| what should you do?
20 week anomaly scan
repeat scan at 32 weeks (if major) then 36 weeks (if minor, or again after major)
DO NOT DO BIMANUAL
safety net for PV bleeds
plan
if <2cm from os - c section at 37 weeks (before if bleeding)
if 2-3cm - consider NVD/c-section
>3cm - NVD
if rhesus neg = give anti D injection
63
acute bleeding placenta preavia mx
ABCDE
examination - general and abdo, speculum but not bimanual
USS to diagnose preavia
fetal monitoring - CTG
+/- delivery with steroids if <34 weeks
64
if there is accreta how do you deliver?
| what do you need to make sure you have done before?
c-section between 36-37 weeks at a tertiary centre
discussed and consented for hysterectomy, leaving placenta in place, cell salvage and interventional radiology (uterine artery embolisation)
cross matches and blood ready in theatre
65
what is the biggest risk factors for accreta?
previous c-section
66
who does vasa praevia normally present?
rupture of membranes at the same time the bleeding starts
| CTG anomalies
67
what is placental abruption?
how might it present?
premature separation of the placenta from the uterine wall before delivery of the baby
can be concealed or revealed haemorrhage
woody-hard, tense uterus
TENDER abdo/uterus
fetal distress on CTG
maternal shock out of proportion to bleeding (concealed haemorrhage)
68
complications of APH?
```
premature labour/delivery
blood transfusion
acute tubular necrosis (+/- renal failure)
DIC
PPH!!! risk
ITU admission
fetal morbidity (hypoxia) and mortality
```
69
what is primary post partum hemorrhage?
within 24 hours of delivery, blood loss >500mls
70
what is secondary PPH?
after 24 hours and up to 12 weeks post delivery
71
whats the difference between minor and major PPH?
minor = 500ml-1L
major < 1L
massive = >1.5L
72
4 Ts for PPH and how do you manage these?
tone (boggy) - ensure uterus contracted (bimanual compression massage, uterotonics - last resort is hysterectomy)
tissue - ensure placenta complete (manual removal of placenta/POC)
trauma - look for tears (repair)
thrombin - check clotting (transfuse)
73
risk factors for PPH?
```
big baby
polyhydramnios
grand multiparity
multiple pregnancy
prolonged labour
maternal pyrexia
instrumental delivery
shoulder dystochia
previous PPH
```
74
severe pre-eclamspia
hypertension + proteinuria
+/- at least one of the following
- severe headache
- visual dis
- papiloedma
- clonus /brisk reflexes
- liver tenderness
- abnormal liver enemies
- platelet count falls to <100 x10^9
75
treatment of severe pre-eclampsia
stabilised blood pressure (labetalol or nifedipine if asthma)
check bloods including platelets, renal and liver function
magnesium sulphate - prevention of eclampsia
monitor urine output (+fluid restrict)
treat coag defects
fetal wellbeing (CTGS, USS for metal growth)
DELIVERY IS DEFINITIVE MANAGEMENT
76
what is definition of eclampsia and how do you prevent it?
how do you treat?
hypertension and proteinuria WITH seizures
magnesium sulphate
also treat with magsul
stabilise blood pressure
77
how do you monitor fetal compromise?
CTG
78
cord prolapse
what should you do?
occurs when the cord is presenting after rupturing of membrane
999 if at home
trendelenburg position - feet higher than head
79
complications of shoulder dystocia?
maternal: PPH, extensive vaginal tear, psycholocial
neonatal: injury to brachial plexus injury (erbs palsy) hypoxia, fits, CP
80
risk factors for shoulder dystocia
macrosomia
high maternal BMI
....
81
what women are high risk antenatally and therefore should be seen by a consultant?
any medical condition basically: diabetes, hypertension, cardiovascular, renal, respiratory
older women and younger women - extremes of age
obese and underweight
substance misuse/smoking
(domestic violence - specialist midwives tho)
previous obstetrics complications - 3/4th degree tear, small baby, big baby, recurrent miscarriages
82
what puts baby at risk of growth restriction?
smoking, pre-eclampsia, previous small baby,
83
how can be monitor foetus antenatally?
USS - head circumference, abdominal circumference, growth (plot on personalised growth chart)
liquor volume - black space around the baby on USS
doppler - resistance in the placenta and flow through the umbilical cord
CTG - cardiotocography (heart of baby, and uterine contractions - only how often the uterine contractions are not the strength)
84
how to monitor the foetal heart rate intrapartum?
intermittent auscultation - pinard or doppler device
(for low risk women in labour - every 15 mins for 1 minute in the first stage, then after every contraction in stage 2)
continous monitoring with a CTG
(for higher risk women)
scalp ECG - GOLD STANDARD FOR DIRECT FHR monitoring BUT it is invasive and increased risk of infection and requires membranes to be ruptured
abdominal fetal ECG - non invasive and being researched
85
benefits drawbacks or intermittent vs continuous auscultation of foetus?
CTG can see variability and decelerations better, which can be done longer term
but there is no benefit of using it in low risk women
86
what should the baseline heart rate be on a CTG
110-160bpm
87
what should variability be on CTG
>5bpm
| poor variability could be hypoxia or might be asleep (max 40 mins)
88
how many contractions should you be having in 10 minutes?
max 4 - if you are 5 in 10, you are hyperstimulating the uterus and might consider giving tocolysis
89
what pneumonic is used to describe a CTG?
DR C BRAVADO
define risk
contractions
baseline HR
variability
accelerations
declerations
90
late decelerations - what are they and what do it mean?
trough of decel is after the contraction peak
sign of hypoxia in themselves
further intervention to monitor or just deliver!
91
early decelerations are...
normal/abnormal?
why do they happen?
normal
due to pressure on the baby head
92
what is FGM?
all precedures involving partial or total removal or female external genital or other injury to the female orangs for non-medical reasons
93
types of FGM
type 1 - cliteroidectimy
type 2 - excision of cit and labia minora
type 3- infibulation: narrowing/sowing up of the vaginal orifice
type 4 - anything else - pricking, piercing, inciting, scraping and cauterisation
94
why is FGM done?
in some places -
social norm/expected
status and respect
preserves girls chastity/virginity
part of being a women
its rite of passage
upholds family honour
cleanses and purifies the girl
fulfils a perceived religious requirement (but there is no religious text saying this, actually forbidden in islam even though its there)
gives them the sense of belonging to the community
it gives the girl social acceptance - esp for marriage
95
what countries most often still ahem FGM?
most commonly in african continent - somalia (T3), eygpt (T1-2), ethiopia, sudan
96
FGM hotspots in the UK
london, cardiff, manc, sheffield (lots of somalian), birmingham, oxford, reading...
97
the law and FGM
offence to perform FGM in england, wales and northern ireland (and scotland but not in the same documents????)
AND traveling for FGM if you are a UK national/permanent UK resident - under child act 198...
98
is it mandatory to record on health records if they have had FGM?
who's responsibility to inform?
yes - from sept 2014 have to record in records
under 18 - phone call to the police force in the next working day
in both cases even if its a clitoral piercing
99
what are the gynaecological complications of FGM?
```
dyspareunia
sexual dysfunction with anorgasmia
chronic pain
keloid scar formation
dysmenorrhoea
urinary outflow obstruction
PTSD
difficulty conceiving
```
100
what are the obstetric complications of FGM?
fear of child birth
increased risk of:
C section, PPH, episiotomy, severe vaginal lacerations
extended hospital stay
difficulty in monitoring in labour:
difficultly performing vaginal exams in labour, applying metal scalp electrodes, metal blood sampling, catherterising the bladder
101
how do you management infibulation?
DE-INFIBULATION
ideally pre-conception reversal of infibulation
ideally done by 20 weeks antenatally
DO NOT RE-INFIBULATE EVEN IF HEMORRHAGING
102
what is our responsibilities in terms of FGM in the UK?
report all cases of FGM in he medical notes/police
103
whats the normal age of menarche?
12-13 years old but (11-14.5)
| precedent by breast development and pubic hear development and peak higher velocity
104
what are the first few periods like?
normally pain free and often long gaps in between( >45 days)
105
ameorrhoea and what are the causes
no menstruation bya e 16 in the presence of secondary characteristics (turners dryndrome, pre ovarian failure, HPO disorders, anatomical issues - imperforate hymen/septum, Mullerian agenesis, congenital adrenal hyperplasia, complete androgen insensitivity syndrome(will have undescended testicles)
or absence of secondary sexual characteristics and amonorhoeic at aged 13
seconddary amenorrhoea: cessations of menses for ... (weight loss, exessive exercise, PCOS - olingoammenorrhoea = >35 days apart)
106
precocious puberty is:
early onset of puberty
| puberty before age 8 in girls and 9 in boys
107
what is the difference between central PP or pseudopuberty PP?
central: gonadotropin - dependent (CNS abnormalities)
psuedo: gonatotropin - independent (CAH< tumours of adrenals)
108
delayed puberty what tests do you do?
```
FBC (anaemia, malnutrition), CRP (inflammatory disease) ,
U+E and LFT - renal and liver disease
bone profile
coeliac screen antibodies
TSH and free T4
```
109
what process is evaded by a cell in cancer?
| how does it do this?
apoptosis
lengthening telomeres instead of shortening them with each replication
110
what genes prevent cancer?
tumour supressor genes - p53/Rb
111
what genes stimulate cancer?
oncogenes - BRAC or HER2
112
most common gynae cancer in the UK?
endometrial cancer (used to be ovarian)
113
risk factors for endometrial cancer?
what is the main underlying pathophys which causes all of these?
```
obesity (adipose tissue converts androgens into oestrogen)
diabetes
nulliparity
late menopause
ovarian tumours
HRT
pelvic irradiation
tamoxifen
PCOS
HNPCC (hereditary non polyposis coli)
```
(unopposed oestrogen)
114
main reason to refer for suscpeted to endometrial cancer? (RED FLAG!!!)
POST MENOPAUSAL BLEEDING
115
how do you assess someone with post menopausal bleeding?
history and examination
investigations - transvaginal ultrasound (wants the endometrium to look thin = good)
endometriial biopsy
and hysteroscopy
116
what type of cancer is endometrial normally?
adenocarcinoma most commonly
117
treatment for endometrial cancer?
surgery
hysterectomy +/- pelvic lymph nodes
radiotherapy
progesterone therapy (to stabalise, can reverse but more likely to use in older ladies where the malignancy is unlikely to kill them as they are so old and have other comorbidiites which will kill first)
118
what causes cervical cancer? and risk factors?
what underlies all of these?
HPV!!!! -
16 and 18 (+31,33,45,51,53)
vaccine does: 6,11,16 and 18
```
missed vaccination
early age intercourse
multiple sexual partners
STDs
previous CIN
multiparity
```
increased exposure to HPV ^^^
multiparity/OCP/cigarette smoking(more persistant HPV)
119
what happens in HPV infection?
75% of pop will come into contact with HPV at some point
most infections are transient and will be cleared within a year
but persistent infection is associated with increased risk of high grade CIN
120
what are the two oncoprotein from HPV which cause the cancer?
E6 - blocks p53 tumour suppressor gene
| and E7 - blocks rb gene
121
most common cancer in women under 35?
cervical cancer
122
what type of cell cancer is cervical cancer?
squamous cell normally
123
what staging is used in endometrial and cervical cancer?
FIGO
| 1-4
124
best method of reducing risk of cervical cancer in the UK?
screening (smears)
125
what is done in colposcopy to treat stage 1A cervical cancer?
LLETZ
| large loop excision
126
how do you treat higher grade cervical cancers?
hysterectomy with vaginal cuff, and parametrial tissue plus nodes etc
radiotherapy, chemotherapy and palliative care if much higher grader
127
what issues may need to be considered when managing a 25 year old woman with a diagnosis of cervical cancer?
fertility
bowel bladder sexual function
her life and her work
128
causes of vulval cancer?
symptoms?
what type of cell is it?
high risk HPV
lichen sclerosis
vulval itching, soreness, persistant lump, bleeding, pain on passing urine, past history of VIN or lichen sclerosis
squamous cell carcinoma
129
what is protective against ovarian cancer?
| what is the underlying reason these are protective?
COCP
multiparity
the more times you have ovulated the higher the risk of ovarian cancer - anything that makes you not ovulate/reduces the amount you ovulate will be protective then
130
suspected ovarian cancer mx?
CA125
USS
symptoms and age
calculate risk of malignancy index -
CA125 x USS score x pre or post menopausal (1 or 3) - a score of RMI >250 referral to gynae oncology
131
what else raises CA125?
very non specific - raised in endometriosis, heart failure, pneumonia, diverticulitis, liver disease etc
so much take age and history into account mostly, never use it on its own
132
if an old lady comes in complained of soreness of passing urine and has been treated for UTI multiple times but keep coming back? what must you do?
examine the vagina!!!
| might be vulval cancer
133
21 year old complaining with IBS like symptoms what much you make sure you do?
pregnancy test
ask history around ovarian cancer!!! often present non specific
FH of ovarian, breast or bowel
bleeding
take full gynae history basically
