O&G Flashcards
Define primary amenorrhoea
No periods by age 15 in girls with normal secondary sexual characteristics (such as breast development),
or by 13 in girls with no secondary sexual characteristics
Define secondary amenorrhoea
Cessation of menstruation for 3-6 months in women with previously normal and regular menses
or
6-12 months in women with previous oligomenorrhoea
PCOS features
- Subfertility and infertility
- Oligomenorrhea and amenorrhoea
- Hirsutism, acne (due to hyperandrogenism)
- Obesity
- Acanthosis nigricans (due to insulin resistance)
What would you expect PCOS bloods to show?
Get insulin resistance so high insulin and high LH usually seen. There is overlap with metabolic syndrome.
Raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. This is best measured days 1-3 of bleed
Prolactin may be normal or mildly elevated.
Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
Sex hormone-binding globulin will be low - Insulin suppresses hepatic production of SHBG, so get higher levels of free circulating androgens.
gonadotrophins and progesterone
Consider OGTT
What are the Rotterdam criteria?
PCOS diagnostic criteria:
Need 2 out of these 3:
1) Oligo/amenorrhoea
2) Clinical and/or biochemical signs of hyperandrogenism - e.g. hirsutism, acne, or elevated levels of total or free testosterone
3) Polycystic ovaries on USS
defined as the presence of 12 or more follicles (measuring 2–9 mm in diameter) in one or both ovaries and/or increased ovarian volume (greater than 10 cm3).
PCOS management
1) Weight management advice
2) For Hirsutism & Acne: COCP might help (3rd gen) as these have fewer androgenic effects. Co-cyprindiol can also be used - has an anti-androgen action.
If not helping, topical eflornithine can be tried.
Spironolactone, flutamide and finasteride may be used under specialist supervision
3) For infertility: Specialist led - usually clomifene 1st line then metformin or combination
What is androgen insensitivity syndrome?
X-linked recessive
End-organ resistance to testosterone causes genotypically male children (46XY) to have a female phenotype.
Features
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
Diagnosis
46XY genotype testing
Management
counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy
Turners syndrome:
45,XO or 45,X.
Features:
Short stature
widely spaced nipples
webbed neck
bicuspid aortic valve
coarctation of the aorta
primary amenorrhoea
high-arched palate
gonadotrophin levels will be elevated
horseshoe kidney: the most common renal abnormality in Turner’s syndrome
Define premature ovarian failure
How would you investigate?
cessation of menses for 1 year before the age of 40
High FSH (over 20) with no periods in a woman under 40 = ovarian failure
What is Sheehan syndrome?
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
Features may include:
agalactorrhoea
amenorrhoea
symptoms of hypothyroidism
symptoms of hypoadrenalism
What is urge incontinence
- AKA Overactive bladder.
-Is due to detrusor overactivity
-The urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
What is stress incontinence
Due to e.g. coughing/sneezing.
What is overflow incontinence?
Incontinence due to bladder outlet obstruction, e.g. due to prostate enlargement
How do you investigate incontinence
- Bladder diary (min 3 days)
- Vaginal examination - ? prolapse/ ‘Kegel’ exercises
- urine dipstick and culture
- urodynamic studies
Management of urge incontinence
- Bladder retraining - min 6 weeks.
- Medications: antimuscarinics are first-line (oxybutynin, tolterodine or darifenacin).
Immediate release oxybutynin should, be avoided in frail older women.
- Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management of stress incontinence
Pelvic floor exercises.
Surgical options: e.g. retropubic mid-urethral tape procedures
Duloxetine (SNRI) may be offered if they decline surgery.
How long is VZV immunoglobulins effective for? ie what time frame does it need to be given in?
10 days.
If continuous exposures, this is defined as 10 days from the appearance of the rash in the index case.
What is shingles?
Shingles is caused by the reactivation of dormant VZV in dorsal root ganglion.
VZV
1)Risks to mum?
2)Risks to foetus
3) Risk to baby
1) - Maternal pneumonitis
2) - Fetal varicella syndrome (if below 20 weeks) - get things such skin scarring, microphthalmia, underdeveloped limbs, microcephaly and learning disabilities
3) Shingles particularly if 3rd trimester.
Severe neonatal varicella if mum develops rash between 5 days before and 2 days after birth.
How to manage chicken pox exposure in pregnancy?
If under 20 weeks and mum is not immune then VZIG. If in doubt do urgent blood test for antibodies.
If over 20 weeks can give VZIG OR antivirals. These have to be given 7-14 days after exposure ( more effective).
How to manage actual chicken pox in pregnancy
Ask a specialist.
Likely to say if over 20 weeks aciclovir if within 24 hours from rash onset.
If under 20 weeks aciclovir ‘with caution’
What is HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
Severe form of pre-eclampsia.
Pre-eclampsia definition
-New-onset blood pressure ≥ 140/90 after 20 weeks of pregnancy, AND 1 or more of:
-Proteinuria
-Other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Moderate risk factors for pre-eclampsia
-First pregnancy
-Age 40 years or older
-pregnancy interval of more than 10 years
-BMI of 35 or more at first visit
- family history of pre-eclampsia
-multiple pregnancy
