O&G Flashcards
Features of genital warts on biopsy?
Basilar hyperplasia with binucleated and multinucleated cells. Hyperkeratosis with acanthosis.
Treatments for vulval warts?
Podophyllin and cryotherapy.; podophyllin is cytotoxic and thus contraindicated in pregnancy
Delivery with genital herpes?
Can give appropriate antiviral e.g. famcyclovir but if have high number of active lesions then elective C-section more appropriate
Treating gonococcal urethritis in pregnancy?
Treatment usually includes single dose of quinolone (ciprofloxain, ofloxacin) in combination with azithromycin/tetracycline. In pregnancy, cannot give tetracycline or quinolones so give single dose ceftriaxone!
WHO recommendations on breastfeeding in LBW infants?`
Infants with BW <2500g should be exclusively breastfed for first six months, ASAP after birth (when deemed clinically stable). If cannot be fed mothers milk e..g HIV then donor milk sought. If not, formula milk exclusively is recommended
Consequences of rubella infection in pregnancy?
Risk of miscarriage if get in first TM. Babies born following intrauterine infection of rubella at risk of congenital rubella syndrome of the newborn (SN hearing loss, congenital heart disease (mainly PDA), ocular abnormalities e.g. congenital glaucoma and cataracts)
Menstrual changes in hypothyroidism?
Can get oligomenorrhoea, amenorrhoea, or metromenorrhagia (get low levels of gonadotrophins so high oestrogen, get endometrial hyperplasia and breakthrough bleeding)
Risk factors for endometrial hyperplasia and cancer?
Obesity, HTN, DM, nulliparity, tamoxifen, late menopause, chronic anovulation (such as in PCOS) [all cause high endogenous or exogenous oestrogen]
Types of endometrial hyperplasia?
Can be simple or complex, with or without atypia (atypical is higher risk)
Manifestations of endometrial cancer?
Abnormal uterine bleeding and uterine enlargement
Four classic features of endometriosis?
Deep dyspareunia, infertility, cyclical pelvic pain, dysmenorrhoea, +/- menorrhagia
Diagnosing endometriosis?
Quite often diagnosis of exclusion: have normal US, normal exam, no evidence of infection. Diagnosed with explorative laparascopy (MRI good for endometriomas but not for small deposits in pelvis)
Endometriosis pathophysiology?
Get endometrial tissue outside endometrial cavity, cyclically proliferates and bleeds, irritates tissue so get adhesions and cysts known as endometriomas.
Nitrofurantoin in pregnancy?
Should be avoided near term as can induce neonatal haemolysis. and avoided during breastfeeding
Dilutional anaemia of pregnancy?
If have low Hb in pregnancy and normal MCV, then may be dilutional as get disproportional rise in plasma volume
Typical phenotype and biochemical features of PCOS?
Oligomenorrhoea, hirsutism, acne, high BMI. Elevated testosterone and LH:FSH ratio (more LH than FSH)
How would having a history of migraine with aura affect contraceptive choice?
COCP contraindicated
Prolonged third stage of labour?
Failure of placenta to be delivered within 30 minutes
Most common site of referred ovarian pain?
Periumbilical
Risk factors for cervical cancer?
Smoking, HPV, use of COC, co-infection with HIV and immunosuppression
What is the treatment protocol for high dose folic acid?
5mg daily from pre-conception until week 12
Post colposcopy treatment?
Have repeat smear after six months: if negative for dyskaryosis and HPV then three year recall
Triad of pre-eclampsia?
Hypertension, proteinuria and oedema
4Ts of PPH?
Tissue (e.g. retained placenta), tone (uterine atony, most common), trauma/tears (episiotomy etc.), thrombin (e.g. coagulation problems)
First step of PPH management caused by uterine atony?
Uterine massage and oxytocin/ergometrin infusion (ergometrin contraindicated in HTN)
Most appropriate initial investigation for postcoital bleeding?
Speculum examination of the cervix, with swabs, then referral to colposcopy. Smear only done if due anyway is as a screening test
Cervical cancer screening?
Three yearly smear, from 25-49 to look for cytological abnormalities
Most common causes of postcoital bleeding?
Cervical pathology inc. ectropion, polyps, infection, or malignancy
When is high vaginal swab indicated?
All women with vaginal discharge as main cause of GU infection
When does PMS mainly occur?
In luteal phase and therefore symptoms usually improve after onset of menses
Treating PMS?
Firstline is COCP (continuously), with SSRI if severe
Types of urinary incontinence in women?
Stress incontinence, overactive bladder, fistula, retention with overflow, congenital abnormalities
Medical termination of pregnancy?
Dual regime with oral mifepristone and vaginal misoprostol. Can be done before 14 weeks.
Misoprostol uses?
As dual therapy with mifepristone for medical termination or monotherapy for miscarriage or induction of labour
Features of placenta accreta?
Complication of pregnancy where placenta implants into myometrium. Risk factors are previous C sections, myomectomy, Asherman, PID. Get heavy bleeding. May need hysterectomy.
Placenta accreta, increta, percreta?
Attaches to myometrium (superficial), invades into myometrium through myometrium into perimetrium
BV?
Overgrowth of anaerobes e.g. gardnerella, loss of lactobacilli. 50% asymptomatic. Get discharge (grey white, thin, fishy odour) and increased pH. Diagnose with pH testing and triple swabs, treat with oral metro
Indications for induction of labour?
Fetal: >10 days post-date, growth restriction, diabetes, deteriorating haemolytic disease or foetal abnormalities.
Maternal: PET, deteriorating medical conditions, treatment needed for malignancy
When is ARM performed?
When in active labour but waters not broken, or to induce labour with syntocinon if prostaglandin pessary fails
Most common cause of DIC in pregnancy?
Placental abruption
Choosing antihypertensive in pregnancy?
Avoid labetalol in asthmatics, avoid methyldopa in patients with history of depression. Nifedipine and methyldopa are second-line.
Ovarian cysts in post-menopausal women?
Should always be assumed to be malignant
Treatment of ovarian cancer?
TAH with BSL is firstline surgery
Causes of PMB?
Most common is vaginal atrophy, then endometrial hyperplasia and cancer, use of HRT, cervical cancer
Fibrinogen in DIC?
Low
Managing pre-existing DM in pregnancy?
Should be seen every 1-2 weeks in ANC/DM clinic, offered serial growth scans 4-weekly from 28-36 weeks, offered induction at 37-38+6 weeks, and not permitted to go beyond 40+6 gestation. Also get retinal screening at booking appt and second test at 28 if normal, earlier (16-20) if abnormal
Definition of proteinuria?
Classed as persistent urinary protein of >300mg in 24h
HIGH risk factors for pre-eclampsia?
Personal history of PET, essential HTN, T1/T2 DM, CKD, AID e.g. SLE and APLS
MODERATE risk factors for pre-eclampsia?
BMI of >35 at booking, FHx of PET, age of 40 or above, primigravida, multip, interpregnancy interval of >10 years
Incontinence with no preceding symptoms?
More likely to be stress than urge (as get urge with urge)
What is stress incontinence?
Episodic, involuntary leakage of small amounts of urine following coughing, sneezing, lifting, standing and on exertion
Risk factors for stress incontinence?
Vaginal delivery, obesity, pelvic surgery, age, family history, meds e.g. alpha receptor antagonists like doxasozin (relax detrusor so pressure of urethra drops below bladder)
What is overflow incontinence?
Presence of physical obstruction to bladder outflow e.g. pelvic tumour, faecal impaction, prostatic hyperplasia. More common in men.
What is true incontinence?
Get urinary leakage all the time because of fistula between bladder/ureter and vagina. Associated with trauma or invasive pelvic cancer
Risk factors for molar pregnancy?
East Asian ethnicities, extremes of reproductive age
Common clinical features of hydatidiform mole?
Vaginal bleeding, excessive vomiting, large-for-dates uterus, very high hCG, with USS showing ‘snowstorm’ appearance and cystic components. Main differential is miscarriage.
Management of molar pregnancy?
Surgical: either dilatation and evacuation or hysterectomy. Former has higher risk of post-operative gestational trophoblastic neoplasia i.e. choriocarcinoma.
At what gestation would the fundus be palpable at the height of the umbilicus?
20 weeks
Symptoms of normal menopause?
Hot flushes, mood changes, MSK sx, sleep disturbances, sexual dysfunction, vaginal dryness
What must be ruled out in patient with short history of urinary incontinence?
CES (anal tone and perineal sensation)
Dosing levothyroxine in pregnancy?
As soon as pregnancy confirmed, increase dose by 25mcg (as get physiological increase in most patients) and repeat doses 2 weeks later. TFTs done in every trimester.
Symptoms of fibroids?
Main is menorrhagia, and IDA, dysmenorrhoea, abdominal discomfort, pressure symptoms, infertility, recurrent miscarriages
Management of fibroids?
Start with TXA, then can try mefenamic acid (NSAID). Can offer GnRH analogues (temporarily shrink). Surgical is uterine sparing e.g. myomectomy or uterine artery embolisation, definitive is hysterectomy. Only myomectomy of these is fertility-preserving.
Treating PCOS with acne/hirsutism/irregular menstruation and don’t want to conceive?
Use co-cyprindiol (anti-androgen): blocks sebum production and inhibits ovulation (so good if want contraception too)
Diagnosing fibroids?
Pelvic ultrasound
Confirmed parvovirus B19 infection in pregnancy?
Confirm with second blood sample. Referral to fetal medicine as fetal infection can cause severe anaemia, heart failure and hydrops
Three criteria needed to diagnose PCOS?
Oligomenorrhoea, clinical evidence of hyperandrogenism, cystic appearance of ovaries?
Easiest test for ovulation?
Day 21 progesterone
Most common ovarian tumours?
Epithelial inc. serous (can be benign or malignant)
Clear cell carcinoma?
Rarer type of ovarian cancer, 50-70 years, poor prognosis, associated with endometriosis
What drug can be used to induce multiple ovulations in IVF patients?
Clomiphene
Management of stress incontinence?
Firstline is lifestyle and pelvic floor exercises, second line is duloxetine (SNRI) if unsuitable for surgery
Management of menopausal symptoms?
Start with lifestyle measures, then can try HRT/SSRIs. CBT if have mood disturbance, anxiety or depression
Treating prolonged third stage?
After 30 minutes, can get IV access, Xmatch blood, IM syntocinon (if not bleeding) then observe for up to an hour
Risk factors for ectopic pregnancy?
History of PID, previous ectopic, endometriosis, tubal surgery, IUS, use of POP
Symptoms of ectopic?
Abdominal pain, usually worse on one side, may get scanty brown discharge, may get shoulder tip pain, rectal pain, pain on defecation, diarrhoea or urinary symptoms.
Managing ectopic?
If ruptured and unstable may need emergency laparotomy +/- salpingectomy. If stable then laparoscopic salpingectomy or salpingotomy
When might salpingotomy be preferred to salpingectomy for ectopic?
If other tube absent for some reason, as preserves fertility
Risk factors for placental abruption?
Maternal HTN, cocaine, smoking, trauma, age over 35
Contraindications to IUS?
Distorted fibroid uterus, PID, current pregnancy, gynae malignancy, postpartum endometritis, septic abortion etc.
GDM levels?
Fasting of >5.6 or OGTT of >7.8
When is mefenamic acid contraindicated for menorrhagia?
IBD and others
Treating candidiasis?
Advice: good hygiene, emollients, loose-fitting underwear. Pharmacological: antifungal cream/pessary
Nipple thrush?
Painful, itchy nipple, worse after feeds. Nipples erythematous. Baby may have white patches in mouth. Treat with topical antifungal.
Treating generalised tonic-clonic in pregnancy?
Lamotrigine
Whereabouts in uterine tube is an ectopic pregnancy most likely to occur?
Ampulla
Who should be screened for thyroid disorders in pregnancy?
Current/prev thyroid disease, FHx of thyroid disease in first degree relative, AID such as coeliac, T1/T2/GDM
Why are thyroid hormones important in pregnancy?
Fetus relies on maternal supply for first 12 weeks for brain development, then develops own thyroid. Mothers fT4 rises early to compensate so must increase levothyroxine. Hypothyroidism is associated with all negative outcomes really.
Missed miscarriage?
Os closed, no bleeding, sac small for dates, can recall bleeding or abdo pain. Fetus dies in utero but not expelled
Complete miscarriage?
All POC passed, cervix closed, uterus empty
Incomplete miscarriage?
Some POC expelled, vaginal bleeding, os open or closed
Inevitable miscarriage?
Os open, active bleeding demonstrated, POC present
Threatened miscarriage?
Bleeding, but os closed, fetal heart rate detected
Mid cycle pain with some fluid in pouch of Douglas?
May be mittlschmerz
Three Ps that determine labour rate and outcome?
Powers (strength of uterine contractions), Passage (size of pelvic inlet or outlet), Passenger (fetus size, anomalies, alive or dead)
When should lactational mastitis be treated with empirical antibiotics?
If symptoms have not improved despite continued expression for 12-24 days, there is a nipple fissure which appears infected or if breast milk culture is positive.
Managing miscarriage with endometritis?
Surgical evacuation
Three types of GTD?
Hydatidiform mole, choriocarcinoma, placental site trophoblastic tumour
Why monitor bhCG after molar pregnancy?
If fail to drop, may have been invasive mole or given rise to choriocarcinoma (luckily very methotrexate sensitive)
Who gets combination HRT?
Women with uterus
Oestrogen preparations and VTE?
Oral oestrogen increases VTE risk so be wary if have RFs e.g. obesity, while transdermal do not
Amnio vs CVS?
CVS from 11 weeks, higher risk of miscarriage, amnio from 15 weeks (if high risk from NT etc.)
Trisomy screening tests?
PAPP-A, bhCG, NT (become high or low)
How does lichen sclerosus present?
Itching and burning in vulvovaginal region, associated with white papules. Form of chronic inflammation that can lead to scarring and stenosis of the introitus, caused dyspareunia
When is screening for Downs done?
11-13+6 weeks with combined test (NT, PAPP-A, bHCG), or if miss then 15-16 weeks can have quadruple test (four blood markers). Can opt out of screening too.
Likely cause of amenorrhoea and galactorrhoea?
Hyperprolactinaemia
Initial management of suspected hyperprolactinaemia?
Exclusion of hypothyroidism, chronic renal failure, pregnancy as underlying causes, then do visual field testing, MRI etc.
Septic miscarriage?
Retained products of conception either in uterus or in cervical canal. Can become infected and patient becomes septic.
Next investigation for fertility in patients with comorbidities (PID, endometriosis, previous ectopic) and after bloods?
Lap(aroscopy) and dye - checks tubal patency. Superior to hysterosalpingography because can do lysis of adhesions or remove endometriosis at the same time.
Standard treatment of PID?
IM ceftriaxone stat, then oral doxy and metro for 2 weeks
Will vaginal topical therapy improve vaginal and urinary symptoms associated with vaginal atrophy?
Yes
Fertility advice for couple trying for six months?
Lifestyle advice until reach one year
Rare complication of PPH with neuro stuff?
Sheehan syndrome - brain deprived of blood flow and oxygen, which can cause necrosis of AP. Get hypopituitarism, most commonly failure to commence lactation (low prolactin)
First and second line treatment of lichen sclerosus?
Firstline is high potency steroids topically e.g. clobetasol proprionate. Second is topical calcineurin inhibitors such as tacrolimus.
Low grade or borderline dyskaryosis with negative HPV?
Back to three yearly recall. If positive, seen within six weeks for colposcopy
Moderate or severe dyskaryosis guidelines for CIN?
Seen in 2ww
Why do molar pregnancy patients get palpitations?
bhCG and TSH act on TSH receptor, so can induce hyperthyroidism
What is the first stage of labour?
Period between onset of regular contractions to full dilatation. Separated into latent (onset of contractions to 3cm dilatation) and active (3cm to 10cm dilatation).
How fast should nulliparous woman achieve cervical dilatation?
1cm per hour
When do symmetrical or asymmetrical IUGR occur?
Symmetrical in early pregnancy, asymmetrical in advanced pregnancy
Managing percreta/accreta/increta?
Identified via US, can be further assessed with MRI, is RF for major PPH so advise C-section. Only definitive management is hysterectomy (can try to ligate uterine arteries)
Why is expectant delivery not advised for HIV positive women?
Reduces risk of prolonged ROM in community as this can increase risk of transmission
Which type of molar pregnancy is more likely to develop into choriocarcinoma?
Complete
Where does endometrial cancer first metastasise to?
The para-aortic lymph nodes
Steps to take in pregnant woman who may have been exposed to VZV?
Test for varicella zoster IgG
What diseases are screened for in routine antenatal care?
Hep B, HIV, syphilis
Analgesia in pregnancy?
Paracetamol crosses placenta but is safe, NSAIDs teratogenic, codeine safe as second-line
Common causes of post-menopausal bleeding?
Atrophic vaginits, endometrial atrophy, cervical or endometrial polyps, endometrial hyperplasia/cancer
Addisons and menopause?
Steroid cell autoantibodies seen in Addison’s cross-react with ovarian follicles and can cause premature ovarian failure and premature menopause
Levels of which two things increase in pregnancy to cause hypercoagulable state?
Fibrinogen and factor VIII
Primary and secondary PPH?
Primary is within 24 hours, secondary is 24 to 6 weeks
Advantage of transdermal HRT?
Bypasses EHC so less pro-thrombotic so can be used if have history of VTE
Anticonvulsant of choice in pre-eclampsia?
MgSO4
Delayed/absent puberty and inability to smell?
Kallman syndrome
What is Kallman syndrome?
A form of hypogonadotrophic hypogonadism, X-linked recessive. GnRh not released so get low GnRH, FSH, LH and oestrogen
Pattern of hormones in primary hypogonadism e.g. Turners and XXY?
Gonads are defective so high GnRH, high FSH and LH, low oestrogen
Nipple changes suspicious of Paget’s?
Unilateral erythema and inflammation, pain, ulceration etc.
