O&G Flashcards
Cancer screening:
- cervical
- breast
-bowel
-targeted lung
Cervical: every 3 years (25-49yo), every 5years (50-64yo)
Breast: every 3 years(50-70yo)
Bowel: one off flexisig 55yo, home kit (FIT test) every 2 years (60-74yo in England).
Targeted lung: low dose CT scan offered to 55-74yo at high risk of cancer & reinvited every 2 years
How do you test if someone has ovarian failure as a cause of secondary amenorrhoea?
FSH>=20IU/l
Emergency contraception ?options
(UPSI - unprotected sexual intercourse)
FIRST LINE - Copper IUD: use 5days post UPSI or within 5days of expected ovulation. Directly toxic to sperm, reduce sperm numbers that reach uterus, damage embryo before implant, interfere with implantation.
Levonorgestrel: progesterone only pill. Used within 3days of UPSI. Inhibit ovulation.
Ullipristal acetate: selective progesterone receptor modulator. Use 5days UPSI. Inhibit/delay ovulation.
Causes of post coital bleeding
Cervical ectropion (most common)
Vaginits
Vaginal cancer
cervical cancer (most malignant cause)
Cervicitis
Cervical polyps
Trauma
Types of miscarriage: threatened, complete, incomplete, missed, inevitable
Threatened: minimal pain, less bleeding compared to menstruation, closed cervix, fetal heart visualised
Complete: no pain, less bleeding compared to menstruation, closing cervix, empty uss
Incomplete: pain +/-, a lot more bleeding compared to menstruation, open cervix, retained products/no fetal heart
Missed: no pain, minimal bleeding, closed cervix, small uterine size, no fetal heart
Inevitable: pain +, more bleeding compared to menstruation, open cervix, fetal heart may/may not be visualised
Normal physiological changes of blood test when comparing pregnancy and pre-pregnancy state
Hb drops
Haematocrit drops
WBC increase
Platelet count drops
Urea and creat drops
GFR increases
Albumin, ALT, AST drops - dilutional effect
ALP rise due to placental production
Cause of chancroid
Haemophilia ducreyi
-painful genital ulcer
- tender inguinal lymphadenopathy
Cause of chancre
Treponema pallidum (syphilis)
- small painless ulcer
Cause of strawberry cervix
Trichomonas vaginalis
- frothy greenish discharge with fishy odour
- tx: metronidazole
Cause of lymphogranuloma venereum
Chlamydia trachomatis
- painless genital ulcer
- painful lymphadenopathy ‘buboes’ or abscess
Risk factor for endometrial cancer
Obesity
Nulliparity
Late menopause
Fhx
Tamoxifen
HRT
Pelvic irradiation
Diabetes
Pcos
Red degeneration of fibroid
Degeneration of myoma
Uss shows mixed echodense or echolucent appearance
Tx: supportive - analgesia, rehydration
How to check cervical ripeness?
PEDSS
Position
Effacement
Dilation
Softness/consistency
Station of foetus
Risk factor of hyperemesis gravidarum
Nulliparity
Fhx
Personal history
Multiple pregnancy
Female foetus
Age<30yo
Trophoblastic disease
Maternal obesity
Non smoker
Smoking in pregnancy - what are the features?
Miscarriage 2x risk
Preterm labour
Lighter for date babies
Reduced reading ability up to 11yo
Reduced ovulation
Abnormal sperm production
Definition of preterm, term and postterm delivery
<37 week
37-42 week
>42 week
Asthenozoospermia
Oligospermia
Azoospermia
Hypospermia
Teratospermia
Asthenozoospermia: reduced sperm motility
Oligospermia: low sperm count
Azoospermia: no sperm in ejaculate
Hypospermia: reduced semen volume
Teratospermia: poor sperm morphology
Iron supplement - what are the indication during pregnancy
Hb<100
MCV<84
What and when to check that one is ovulating?
Progesterone
Mid-luteal phase (ie one week before period - IE day 21 out of 28day cycle or day 28 out of 35day cycle)
Tx of menorrhagia
Mirena 1st line
Trenaxamic acid
Nsaids - only take during menstruation
Cocp
Norethisterone
Mechanism of action of:
COCP
MIRENA
POP (emergency)
Cocp- prevent ovulation via HPO axis
POP (except desogestrel)- increase volume and viscosity of cervical mucus, endometrial changes, reduction in cilia activity
POP (desogestrel): suppress ovulation, also thickens cervical mucus
Mirena- changes to cervical mucus, endometrial changes (atrophy)
Copper coil - toxic to ovum and sperm, anti-implantation effect
Pop (emergency)- delays ovulation, prevent follicular rupture and causes luteal dysfunctuon
Ullipristal (emergency) - delays ovulation for at least 5 days
Difference between lentigo and malasma
Lentigo - flat brown lesions which do not darken in sun exposure
Malasma aka chloasma - macules and larger patches that is brought on by pregnancy or sun exposure
Test for downs
Combined testing - mum’s age, nuchal translucency, HCG, Papp
If greater than 1:200, offered either chorionic villus sampling (<13 weeks) or amniocentesis (>15 weeks gestation)
When & whom do you give anti -d
Rhesus negative mothers
28 & 34 weeks
Definition of:
Dysmenorrhagia - primary Vs secondary
Menorrhagia - metrorrhagia, menometrorrhagia, dub
Primary dys - cramping pain due to menstruation (NO pelvic pathology)
Secondary dys - menstrual related pain due to another medical or physical condition such as endometriosis/fibroids
Metrorrhagia - breakthrough bleeding either between periods or not related to periods
Menometrorrhagia - heavy and prolonged bleeding that occurs in irregular intervals
Dub - excessive bleeding due to hormonal problems usually lack of ovulation
Placental abruption
Placenta praevia
Vasa praevia
Premature separation of placenta from uterus.
Praevia - implantation of placenta over the internal cervical os.
Vasa - foetal vessels running close to internal cervical os.
Cocp and cancer
HRT and cancer
COCP: Protective for endometrial, ovarian and colorectal cancer. Can increase risk of breast and cervical cancer.
HRT: Increase risk for breast and endometrial cancer.
Tx options of endometriosis
COCP (for those who wanted contraception) or NSAIDs (for those who didn’t want contraception)
Danazol (once tried COCP/POP/NSAIDs but no response)
Oral or depot medroxyprogesterone acetate
Levonorgestrel IUS
GnRH analogues (before surgical procedure)
Laparoscopic ablation (most effective method)
Fibroadenoma Vs lipoma Vs breast cancer in signs
Fibroadenoma - small, smooth, rubbery, firm, mobile. breast mice. Found in 20-30yo
Lipoma - small, mobile, palpable, painless. Found in 40-60yo.
Cancer- dimpling
Fat necrosis - similar to cancer. Only a biopsy can differentiate
Catamenial epilepsy
Seizures linked with menstrual period
Which hormone (sexual) have effect on seizure (specifically the catamenial)?
Oestrogen lowers seizure threshold
Progesterone increases seizure threshold
what is the Amstel criteria?
- clue cells on saline smear
- pH >4.5
- thin, grey and homogenous discharge
- positive whiff test
if 3 or more present, patient has bacterial vaginosis
treatment of maternal hyperthyroidism when pregnant
carbimazole or propylthiouracil
(as these can cross the placenta and cause fetal hypothyroidism)
BUT carbimazole can be teratogenic -> therefore, avoid in 1st trimester & can be started in 2nd trimester.
when would you do block and replace for maternal hyperthyroidism?
when maternal TSH antibody is affecting the fetus (in a mum who had ablative therapy for Grave’s disease) and causes fetal hyperthyroidism.
so give anti-thyroid drug (for the fetus) and levothyroxine (for the mum)
side effect when used during pregnancy
tetracycline -> teeth discolouration- (if taken in 2nd/3rd trimester)
ACEi -> impaired fetal renal function, oligohydramnios, skull abnormalities
Streptomycin -> auditory and vestibular nerve damage
beta-blockers -> intrauterine growth retardation, bradycardia, neonatal hypoglycaemia
NSAIDs -> closure of ductus arteriosus, persistent pulmonary hypertension of newbown, delay labour, impair placenta blood flow
blood-stained discharge from nipple and small lumpy mass
?diagnosis
duct papilloma
local areas of epithelial proliferation in large mammary ducts.
hyperplastic lesions rather than malignant or premalignant
fibroadenosis - what is it?
fibrocystic disease OR benign mammary dysplasia
- seen in middle aged women
- painful, lumpy breast that flare during menstruation
which one is associated with male infertility?
- sodium valproate
- varicocele
- epididymal cyst
- hydrocele
varicocele
(the most correct answer from the list)
painless penile sore with weight loss
?diagnosis
squamous cell carcinoma
syphillis chancre does NOT cause weight loss
PCOS - which is higher - LH or FSH
LH is higher than FSH
triad of abdo pain, uterine rigidity, vaginal bleeding ?diagnosis
placental abruption
USS at these weeks - what for?
- 11-14 weeks
- 18 weeks
11-14 weeks: dating scan
18 weeks: anomaly scan
how to detect neural tube defects during pregnancy?
ultrasound for at risk ladies
amniocentesis if uncertain USS images -> measure alpha-fetoprotein and neuronal acetylcholinesterase
how to screen for Down’s in pregnancy?
combined test at 11-13 weeks - include nuchal transclucency, free b-hcg, pregnancy associated plasma protein and the woman’s age
if >1:200, then offered chorionic villus sampling (<13 weeks gestation) or amniocentesis (>15 weeks gestation)
what antibodies would be raised in maternal hyperthyroidism during pregnancy?
thyroid peroxidase auto-antibodies
(if this is positive, then 50% chance of postpartum thyroiditis)
Adenomyosis - what is it? treatment?
ectopic endometrial tissue and stroma within the tissue myometrium
risk factors: increase parity, early menarche, short menstrual cycles, increase BMI, OCP, tamoxifen, prior to uterine surgery
tx: check if they want to be pregnant or not (definitive tx: hysterectomy)
- NSAIDs
- OCP
- levonogestrel intrauterine system
- danazol
- aromatase inhibitors (eg anastrozole)
- endometrial ablation
- adenomyomectomy
-
Painful ulcer with tender inguinal lymphadenopathy
haemophilus ducreyi
- causes chancroid
painless ulcer with painful lymphadenopathy ‘buboes’ or abscess
chlamydia trachomatis - causes lymphogranuloma venereum
small painless ulcer - chancre
?diagnosis
syphilis caused by treponema pallidum
post-coital bleeding. no cervical motion tenderness, friable cervix when scraped with a swab. mucopurulent discharge from cervical os. cervix can be moved from side to side
post-coital bleeding and offensive discharge. ulcerated lesion on cervix.
?diagnosis
urogenital chlamydia causing cervicitis
cervical cancer
how to write gravida and para?
gravida- total nubmber of times pregnant including the current one
para- X + Y
(X= no of pregnancies beyond 24 weeks)
(Y= no. of losses before 24 weeks)
Fetal alcohol syndrome
microcephaly
thin upper lip
indistinct philtrum
flat midface
low nasal bridge
micrognathia
small palpebral fissures
investigation for endometrial cancer
USS may be suggestive BUT definitive diagnosis is made on endometrial sampling or currettage
UKMEC - what is it?
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Changes in 2016
breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
In miscarriage situation - which rhesus negative mums should STILL be given anti-D injection?
surgical or medical terminations of pregnancy
spontaneous miscarruage followed by medical or surgical evacuation
spontaneous complete miscarriage >12 weeks gestation
significant transplacental haemorrhage (due to procedures or trauma)
ectopic pregnancy
threatened miscarriage >12 weeks
breast lump - small, hard, tethered to skin and skin puckering
?diagnosis
breast cancer
what are the normal ECG changes in pregnancy?
LAD
small Q waves & inverted T wave in lead III
ST depression & inversion or flattening of T wave in inferior & lateral leads
atrial and ventricular ectopics
bleeding, tender tense uterus and fetal distress
?diagnosis
placental abruption
painless vaginal bleeding with non-tender abdomen and no fetal distress
?diagnosis
placental praevia
continuous vaginal bleeding during induction of labour and fetal distress
?diagnosis
vasa praevia
Up to how many weeks can you request for abortion?
24 weeks gestation
what is the age for:
- NEVER able to consent for sex
- consent for sex
13
16
what is the UKMEC for progesterone only pill?
UKMEC 3: IHD & stroke, past breast cancer, severe decompensated cirrhosis, liver tumours (benign adenoma and malignant)
UKMEC 4: current breast cancer
Leiomyoma VS leiomyosarcoma VS adenomyosis
Leiomyoma - fibroids (benign tumours in the myometrium)
Leiomyosarcoma: rare malignancies that are difficult to distinguish from fibroids
Adenomyosis: extension of endometrial tissue and stroma into uterine myometrium
20 weeks gestation - lower abdominal discomfort following a minor fall. pain increased over time and tender in the lower abdomen. USS shows fluid in the lower pelvis below the fallopian tubes and the ovaries.
?diagnosis
ruptured ovarian cyst
alternatives to hormone replacement therapy to control/reduce hot flushes in menopause?
citalopram/anti-depressants!
clonidine
gabapentin
other lifestyle changes: increase exercise, lighter clothing, sleeping in cooler room, reduce spicy food, caffeine, smoking, alcohol
Goserelin - what is it used for and what are the side effects?
LHRH agonists/GnRH agonist
used for prostate cancer, breast cancer, endometriosis, for endometrial thinning prior to endometrial ablation or resection, before surgery to remove fibroids
SE: osteoporosis
types of POP - give examples and what happens if missed one pill?
traditional- levonogestrel (LNG), norethisterone (NET)
newer- desogestrel (DSG), drospirenone (DRSP)
what constitutes a missed pill:
LNG/NET: 3 hours late
DSG: 12 hours late
DRSP: 24 hours late
take the missed pill and take extra precautions for 48hrs
what is the normal results for pregnancy?
- WCC
- FBC
- platelet
- U&E (sodium, potassium, urea, creat, eGFR)
- albumin
- bilirubin
- ALT
- AST
- ALP
- TFT (T3, T4, TSH)
- total calcium
- magnesium
- cardiac output
- tidal volume
- urinary frequency
WCC increased
FBC decreased (but if Hb is <110 at booking or <105 at 28 weeks with normal/low MCV, need to start iron supplementation)
platelet decreased
U&E decreased (but GFR increased)
albumin decreased
bilirubin decreased
ALT, AST unchanged/slightly decreased
ALP increased
TSH decreased in 1st trimester, normal in 2nd and increased in 3rd
T3/T4 unchanged
Total calcium decreased
Magnesium unchanged
CO increases
Tidal volume increases
Urinary frequency increases
how long can you detect HCG in pregnancy?
as early as 8/9 days and in 98% patients, by day 11
level peak at 10-12 weeks gestation
and until 20 weeks of gestation
will be positive 5days post miscarriage
also positive in trophoblastic disease
treatment of these antenatal infections:
- listeria
- syphilis
- toxoplasmosis
listeria: amoxicillin & gentamicin
syphilis: benzathine benzylpenicillin
toxoplasmosis: spiramycin (for tetus: pyrimethamine & sulfadiazine)
treatment of UTI in pregnancy
nitrofurantoin (but avoid this at term due to risk of neonatal haemolysis)
trimethoprim
risk factors for cervical cancer
HPV 16 & 18 & 33
smoking
HIV
young age of first coitus
high number of sexual partners
young age of first pregnancy
high parity
low socioeconomic class
a sexual partner with multiple sexual partners
what drugs cause these:
- Ebstein’s anomaly
- placental abruption
- jitteriness,fits, irritability
- benzodiazepines/lithium
- coccaine use
- heroin
24yo, deep dyspanerunia and dysmenorrhoea and not secual active until 2 months ago
?diagnosis
endometriosis
24 yo dysmenorrhoea, irregular periods and recurrent episodes of yellow-green vaginal discharge
?diagnosis
chronic pelvic inflammatory disease
Tx of fibroids
transcervical resection of fibroid- for submucous fibroid & helps retain fertility
myomectomy - for large intramural fibroid
Foetal hydrops
- caused by what viral infection during pregnancy?
- how do we investigate?
- parvovirus b19
- USS first and then cordocentesis
how would the baby turn out if these occur in pregnancy?
- maternal diabetes
- trisomy 18
- valproate ingestion
- sacral agenesis, fetal cardiomyopathy, cardiac defects, cleft palate
- Edward’s syndrome!
- cleft palate and learning difficulties
treatment of primary dysmenorrhagia
NSAIDs - mefenamic acid, ibuprofen
COCP
treatment of primary postpartum haemorrhage
apply pressure to uterus
IV oxytocin/ergometrine
IM/intrauterine carboprost (unless asthmatic)
rectal/SL misoprostol
surgical - balloon tamponade, ligation of uterine arteries, B-lynch suture OR hysterectomy
risk factors for pre-eclampsia
age >40
nulliparity
pregnancy interval >10years
FHx
previous medical history
BMI>30
HTN/other pre-existing vascular disease
pre-existing renal disease
multiple pregnancy
what type of vaccines are these:
- gardasil
- ceravix
- gardasil 9
gardasil : HPV 6,11,16,18
ceravix : HPV 16 &18
gardasil 9 : 9 variants (6,11,16,18, 31,33, 45, 52, 58)
what is acute fatty liver of pregnancy?
rare life threatening complication of pregnancy
- ALT and AST raised (<500U/L)
- due to disordered metabolism of fatty acid - deficiency of LCHAD.
- Abdo USS -> fat deposition of liver & microvascular steatosis
- liver biopsy is rarely needed
Tx: delivery of foetus
which HRT to start for the lady?
No uterus: oestrogen-only (Elleste-Solo)
Uterus present:
- if no period for >1year: continuous progesterone (Elleste-Duet Combi)
- if still having periods/finishing: cyclical progesterone given monthly or 3 monthly (Elleste-Duet)
once the lady enters menopause, do they still need contraception?
Yes
- still need contraception for 1 year after the last period if >50yo or 2 years if <50yo.
contraceptive - when would they be effective? (these are not on 1st day period)
- IUD
- POP
- COCP
IUD: instantly
POP: 2 days (*if they have taken this in the first 5 days of cycle - no need to wait)
COCP: 7 days
Injection, implant, IUS: 7 days
which emergency contraceptive pill cannot be use for asthmatics?
ullipristal
how long post-partum can you have unprotected sex & not needing contraception for?
and what type of contraception is allowed after?
21 days post-partum
POP: can start anytime post-partum. but if taken post-21 days, then need alternative protection for 2 days.
COCP: start 6weeks-6months post-partum & breastfeeding(UKMEC 2) and alternative protection for 7 days
IUD/IUS: inserted 48hours post-partum or after 4 weeks.
what type of contraception do you need if >40yo?
DON’T PRESCRIBE implantable contraceptive device (eg Depo-Provera) as it can cause lost of bone mineral density.
If using COCP (<50yo) -> switch to non-hormonal or progesterone-only-pill (>50yo)
If using depo-provera (<50yo) -> Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice below
If using implant, POP, IUS (<50yo) ->
- Continue
- If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
- If not amenorrhoeic consider investigating abnormal bleeding pattern
what type of CYP450 effect does st john’s wart do?
CYP450 inducer!
intrauterine system VS intrauterine device
IUD: copper IUD
IUS: contain levonogestrel
which contraceptive option causes weight gain?
implantable device - ie Depo Provera
