O+G 1 Flashcards
What’s puberty?
Onset of sexual maturity, development of secondary sex characteristics
What’s menarche? When does it occur
Onset of menstruation
Average age 13
When does GnRH get released?
From age 8
What does GnRH do?
Stimulates release of FSH and then LH (stimulate oestrogen release from ovaries)
LH
Luteinizing hormone
Term used for breast development. When does it occur
Thelarche. 9-11 years
Term used for growth of pubic hair. When does it occur?
Adrenarche. 11-12 years
By what age to the epiphyses fuse
16
Days 1-4 of the menstruation cycle is known as what? What happens during this phase?
Menstruation
- Endometrium is shed
- Myometrial contraction which can be painful
Days 5-13 of the menstruation cycle is known as what? What happens during this phase?
Proliferative phase
- GnRH (hypothalamus) stimulate LH and FSH release
- follicular growth
- follicles produce oestradiol and inhibin which suppress FSH secretion (negative feedback) so only one follicle/oocyte matures
- oestradiol levels continue to rise to maximum levels. now a positive feedback causing an LH surge.
- ovulation follows 36 hours after LH surge
- oestradiol causes the endometrium to reform and proliferate (it thickens as the stromal cells proliferate and the glands elongate)
Days 14-28 of the menstruation cycle is known as what? What happens during this phase?
Luteal/secretory phase
- follicle from release egg becomes corpus luteum
- corpus luteum produces oestradiol and progesterone which causes secretory changes in the endometrium
- glands swell and blood supply increases
- if no fertilisation corpus luteum starts to fail
progesterone and oestrogen levels fall
When does progesterone peak?
Day 21 of a 28 day cycle
Normal menarche occurs below what age?
16
Normal menopause occurs after what age?
45
Normal menstruation is less than how many days?
8 days in length
Normal menstrual blood loss is less than?
80ml
Normal cycle length
23-35 days
What does IMB stand for?
intermenstrual bleeding
Define menorrhagia
heavy menstrual bleeding
Clinical definition: excessive bleeding that interferes with a woman’s physical, emotional, social and material quality of life
Objective definition: blood loss >80 ml
Define irregular periods
Periods outside the range of 23-35 days with a variability of >7 days between the shortest and longest cycle
What is post coital bleeding?
Bleeding after intercourse
What is primary amenorrhoea?
Periods never started
What is secondary amenorrhoea?
Periods stop for 6 months or more
What is oligomenorrhoea?
Infrequent periods (>35 days-6 months)
What is postmenopausal bleeding?
Bleeding 1 year after the menopause
What does dysmenorrhoea mean?
Painful periods
What is premenstrual syndrome?
Psychological and physical symptoms worse in the luteal phase
Epidemiology of HMB
1/3 of women but most don’t seek medical help
Aetiology of HMB
Most unknown
30% uterine fibroids
10% polyps
Endometrial and cervical carcinoma
Adenomyosis
PID
Ovarian tumour
Rare:
- thyroid disease
- haemostatic disorders (von Willebrand’s disease, anticoagulant therapy)
Causes of irregular bleeding
- chronic pelvic infection
- ovarian tumours
- endometrial and cervical malignancy
Investigations for menorrhagia
- Hb checked
- coagulation and thyroid function tests (to exclude systemic causes if history is suggestive of it)
- transvaginal US to assess endometrial thickness, exclude uterine fibroid or ovarian mass and detect larger intrauterine polyps.
When would you do an endometrial biopsy (pipelle biopsy or hysteroscopy)?
- endometrial thickness >10mm
- polyp is suspected
- > 40 years old with recent onset menorrhagia or also has IMB or has not responded to treatment
preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
Chorioamnionitis
Treatment of severe chorioamnionitis at 37 weeks
IV antibiotics and c-section
Incidence of chorioamnionitis
5%
Cause of chorioamnionitis
Ascending bacterial infection of the amniotic fluid / membranes / placenta
A 28-year-old pregnant woman with pre-eclampsia suffered an eclamptic seizure at 11 am yesterday. She was started on magnesium, the baby was delivered an hour later at midday, but she had another eclamptic seizure at 2 pm. She has been well since then, as is the baby. When should the magnesium infusion be stopped?
Magnesium treatment should continue for 24 hours after delivery or after last seizure
Define pre-eclampsia
- condition seen after 20 weeks gestation
- pregnancy-induced hypertension
- proteinuria
When should magnesium sulphate be used?
To both:
- prevent seizures in patients with severe pre-eclampsia
- treat seizures once they develop.
Guidelines on its use suggest the following:
- should be given once a decision to deliver has been made
- in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
- urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
- treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Epidemiology of endometrial cancer
classically seen in post-menopausal women but around 25% of cases occur before the menopause.
It usually carries a good prognosis due to early detection
Risk factors for endometrial cancer
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
*the oral contraceptive pill is protective
Features of endometrial cancer
- post-menopausal bleeding is the classic symptom
- pre-menopausal women may have a change intermenstrual bleeding
- pain and discharge are unusual features
Investigations for endometrial cancer
- first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- hysteroscopy with endometrial biopsy
Management of endometrial cancer
- localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy.
- Patients with high-risk disease may have post-operative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
AFP increase associated with…
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
AFP decrease associated with…
- Down’s syndrome
- Trisomy 18
- Maternal diabetes mellitus
What is the treatment of choice for stage I and II endometrial carcinoma?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
What is provera? How does it work?
Provera is a progesterone used as a hormonal treatment for endometrial carcinoma - it acts by slowing the growth of malignant cells in the endometrium.
How do you treat stage IIB endometrial carcinoma?
Wertheim’s radical hysterectomy which includes removal of lymph nodes
A 57-year-old lady presents to the postmenopausal bleed clinic with a 2 week history of light vaginal bleeding, and mild pain on intercourse. She is otherwise well. On vaginal examination she is tender and has slight dryness. What should be done next in clinic?
Trans-vaginal ultrasound (TVUS)
Atrophic vaginitis is a diagnosis of exclusion. Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS. While this is most likely atrophic vaginitis, it still must be investigated to rule this out. Once a TVUS is done, if it comes back normal then either discharge with cream or referral to HRT clinic would be the most appropriate, but TVUS must be done first. If it is abnormal (>4mm), then endometrial biopsy would be done. Laparoscopy would not help.
What’s the diagnosis?
Post-menopausal woman with vaginal dryness, dyspareunia and occasional spotting. On examination the vagina may appear pale and dry
Atrophic vaginitis
Treatment for atrophic vaginitis
vaginal lubricants and moisturisers, if these do not help then topical oestrogen cream can be used
A 19-year-old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding. Her ultrasound scan confirms a viable intrauterine pregnancy. However, the high vaginal swab has isolated group B streptococcus (GBS). How should she be managed?
Intrapartum intravenous benzylpenicillin only
Women who have had a previous baby infected with GBS are also offered intrapartum intravenous benzylpenicillin in future pregnancies.
What is known to be the most frequent cause of severe early-onset infection in the newborn and can cause significant morbidity and mortality?
Group B strep
What proportion of mothers are carriers of GBS?
20-40%
Risk factors for Group B Streptococcus (GBS) infection:
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection
- maternal pyrexia e.g. secondary to chorioamnionitis
Guidelines for GBS
- universal screening for GBS should not be offered to all women
- the guidelines also state a maternal request is not an indication for screening
- women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered maternal intravenous antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
- if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
- maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
- maternal intravenous antibiotic prophylaxis should be offered to women in preterm labour regardless of their GBS status
- women with a pyrexia during labour (>38ºC) should also be given intravenous antibiotics
- benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Symptoms of ovarian cancer
- bloating
- reduced eating
- abdominal/pelvis pain
- weight loss
- urinary incontinence
- toilet changes
A 30-year-old woman is 24 weeks pregnant and she receives a letter about her routine cervical smear. She asks her GP if she should make an appointment for her smear. All her smears in the past have been negative. What should the GP advise?
Reschedule the smear to occur at least 12 weeks post-delivery
NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear. If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
What type of cervical cancer can be missed when screening?
Cervical adenocarcinomas (15% of cervical cancers)
Who is screened for cervical cancer and how often?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
How is cervical screening performed?
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC includes:
- reduced rate of inadequate smears
- increased sensitivity and specificity
It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.
You receive the results of a 29-year-old female who has recently had a routine cervical smear. Her last smear 4 years ago was reported as normal. The results are reported as follows:
Moderate dyskaryosis
What is the most appropriate management?
Refer to colposcopy
Which are high risk HPV subtypes?
16, 18, 33
What proportion of smears are abnormal?
5%
CIN
cervical intraepithelial neoplasia
What are the possible results and management of a cervical smear?
Borderline or mild dyskaryosis
The original sample is tested for HPV*
if negative the patient goes back to routine recall
if positive the patient is referred for colposcopy
Moderate dyskaryosis
Consistent with CIN II. Refer for urgent colposcopy (within 2 weeks)
Severe dyskaryosis
Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks**)
Suspected invasive cancer
Refer for urgent colposcopy (within 2 weeks)
Inadequate
Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy
What should be done if 1 pill is missed (at any time in the cycle)?
- take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
- no additional contraceptive protection needed
The COCP is…
ethinylestradiol
What should be done if 2 or more pills are missed?
- take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
- if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
- if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
- if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
A 27-year-old woman presents to the emergency department with severe abdominal tenderness and some light vaginal bleeding.
She has had amenorrhoea for 7 weeks and a pregnancy test returns positive. An ultrasound scan shows a left-sided 2cm tubal pregnancy and a foetal heartbeat is detected.
A serum b-hCG is recorded at 2000 IU/L.
She is haemodynamically stable.
Given the diagnosis, what is the most appropriate management?
Keep the patient nil by mouth and arrange admission for urgent laparoscopy
Presence of a foetal heartbeat on ultrasound in the context of an ectopic pregnancy is an indication for surgical management
What are the 3 ways to manage an ectopic pregnancy?
Expectant
Medical
Surgical
What is expectant management and when is it appropriate?
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
Size <30mm Unruptured Asymptomatic No fetal heartbeat Serum B-hCG <200IU/L and declining Compatible if another intrauterine pregnancy
What is medical management of an ectopic pregnancy and when is it appropriate?
Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.
Size <35mm Unruptured No pain No fetal heartbeat Serum B-hCG <1500IU/L Not suitable if there is another intrauterine pregnancy
What is surgical management of an ectopic pregnancy and when is it appropriate?
Surgical management can involve salpingectomy or salpingotomy
Size >35mm Can be ruptured Severe pain Fetal heartbeat detected Serum B-hCG >1500IU/L Compatible with another intrauterine pregnancy
salpingectomy vs salpingotomy
salpingectomy, in which the affected Fallopian tube is removed, or salpingotomy, in which the tube is preserved
What should women do who are at high risk of developing pre-eclampsia? Which women have high risk?
Take aspirin 75mg od from 12 weeks until the birth of the baby.
High risk groups include:
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
What are the normal BP changes in pregnancy?
- blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
- after this time the blood pressure usually increases to pre-pregnancy levels by term
Define hypertension in pregnancy?
- systolic > 140 mmHg or diastolic > 90 mmHg
- or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
What are the 3 groups of hypertensive pregnant patients?
Pre-existing hypertension
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
Pre-eclampsia
What is pre-existing hypertension?
What’s the incidence?
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
Features of PIH
What’s the incidence?
Hypertension (as defined above) 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
Features of pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
What proportion of women get pruritis in pregnancy and what are the possible causes?
25%
Causes include:
- exacerbations of eczema
- polymorphic eruption of pregnancy
- or simply just as the result of skin stretching and changes in circulation.
- Pruritus in the absence of a rash should raise the possibility of obstetric cholestasis.
- iron deficiency anaemia
Complications of obstetric cholestasis
- prematurity
- passage of meconium
- post partum haemorrhage
- possibly stillbirth
Frequency of intrahepatic cholestasis of pregnancy
1% usually in 3rd trimester
Features of intrahepatic cholestasis of pregnancy
- pruritus, often in the palms and soles
- no rash (although skin changes may be seen due to scratching)
- raised bilirubin
Management of intrahepatic cholestasis of pregnancy
- ursodeoxycholic acid is used for symptomatic relief
- weekly liver function tests
- women are typically induced at 37 weeks
When can acute fatty liver of pregnancy occur?
third trimester or the period immediately following delivery.
Features of acute fatty liver of pregnancy
- abdominal pain
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre-eclampsia
Investigations and management of acute fatty liver of pregnancy
Investigations
- ALT is typically elevated e.g. 500 u/l
Management
- support care
- once stabilised delivery is the definitive management
HELLP
Haemolysis, Elevated Liver enzymes, Low Platelets
Define postpartum haemorrhage
Blood loss of > 500mls and may be primary or secondary
When does primary PPH occur?
Incidence?
Most common cause?
How does secondary PPH differ?
Primary PPH
- 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
Secondary PPH
- occurs between 24 hours - 12 weeks**
- due to retained placental tissue or endometritis
**previously the definition of secondary PPH was 24 hours - 6 weeks. Please see the RCOG guidelines for more details
What are the risk factors for primary PPH?
P(5)rime
- previous PPH
- prolonged labour
- pre-eclampsia
- polyhydramnios
- placenta praevia, placenta accreta
- ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
- increased maternal age
- macrosomia
- emergency Caesarean section
*the effect of parity on the risk of PPH is complicated. It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
What is ritodrine?
a beta-2 adrenergic receptor agonist used for tocolysis
Management for PPH
- ABC
- IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
- 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
A 56-year-old woman presents to the postmenopausal bleeding clinic with 2 weeks of constant vaginal bleeding. What should be your first investigation in the clinic?
The first investigation in PMB should be TVUS
Which viruses cause genital warts?
HPV 6 and 11
HPV that causes cervical cancer
16 and 18
Which cancers are associated with HPV infection?
- over 99.7% of cervical cancers
- around 85% of anal cancers
- around 50% of vulval and vaginal cancers
- around 20-30% of mouth and throat cancers
Risk factors for developing cervical cancer
- HPV
- smoking
- combined oral contraceptive pill use
- high parity
Is HPV testing done?
Yes!
Testing for HPV has now been integrated into the cervical cancer screening programme. If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV:
- if HPV negative the patient goes back to routine recall
- if HPV positive the patient is referred for colposcopy
What year was the HPV vaccine introduced and with what are women immunised? Why was it changed?
A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 and 18 but not 6 and 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 and 18.
Who and at what age do people get the HPV vaccine?
- Girls aged 12-13 years are offered the vaccine in the UK
- the vaccine is normally given in school
- information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes
- given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
What are the types of post natal depression?
Baby blues
Postnatal depression
Puerperal psychosis
What is used to screen for postnatal depression?
The Edinburgh Postnatal Depression Scale
What is the edinburgh postnatal depression scale?
Above what score indicates depressive illness of varying severity?
What is the sensitivity and specificity?
- 10-item questionnaire, with a maximum score of 30
- indicates how the mother has felt over the previous week
- score > 13 indicates a ‘depressive illness of varying severity’
- sensitivity and specificity > 90%
- includes a question about self-harm
Baby blues Incidence? When it occurs? Characteristics? Management?
- Seen in around 60-70% of women
- Typically seen 3-7 days following birth and is more common in primips
- Mothers are characteristically anxious, tearful and irritable
- Reassurance and support, the health visitor has a key role
Post natal depression Incidence? When it occurs? Features? Management? Drug of choice?
- Affects around 10% of women
- Most cases start within a month and typically peaks at 3 months
- Features are similar to depression seen in other circumstances
- As with the baby blues reassurance and support are important
- Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
- paroxetine is recommended by SIGN because of the low milk/plasma ratio
- *fluoxetine is best avoided due to a long half-life
Puerperal psychosis Incidence? Onset? Features? Management? Risk of recurrence?
- Affects approximately 0.2% of women
- Onset usually within the first 2-3 weeks following birth
- Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
- Admission to hospital is usually required
- There is around a 20% risk of recurrence following future pregnancies
What is an EID?
Enzyme inducing drug
Examples of contraceptives that are unaffected by EIDs
- Copper intrauterine device
- Progesterone injection (Depo-provera)
- Mirena intrauterine system
Which contraceptive is associated with weight gain?
contraceptive injection (Depo-Provera)
What advice should be given to patients on EIDs who wish to take COCP?
- inform them that the effectiveness is decreased and there is an increased risk of pregnancy.
- It is recommended that the dose of oestrogen is increased to 50mcg with no pill-free interval, or reduced to 4 days from 7 days (to reduce the chance of ovulation).
- In addition, barrier methods would also be advised. This applies when the patient is on an EID and for 4 weeks after stopping.
