O&G Flashcards
sites for ectopic preganancy
fallopian tubes (97%) ovaries abdomen C-section scar
risk factor for ectopic pregnancy
previous ectopic
pelvic surgery - (C-section, appendectomy, sterilisation)
endometriosis
clamydia
presentation of ectopic preganancy
typically at 6-8 weeks after LMP vaginal bleeding pelvic discomfort pain when opening bowels hypovolaemic shock - hypotension, tachycardia
investigations for ectopic pregnancy
urine/serum beta HCG
transvaginal US
serial serum-hCG
explain serial beta-hCG use is ectopic pregnancy
use if US can’t find ectopic but it is suspected
increase > 60% sugest intrauterine pregnancy
<66% increase or <15% decrease suggest ectopic
>15% decrease suggests failing PUL
management of ectopic pregnancy
expectant management (conservative - wait for spontaneous resolution) medical management (Methotrexate) surgical management (salpingostomy or salpingectomy)
define miscarriage
any pregnancy loss before 24 weeks gestation
risk factors for miscarriage
old maternal age
PCO
smoking and alcohol
uterine malformations ( ascending UTIs, bicornuate)
cause of miscairrage
cervical incompetence/weakness
transplacental foetal infection - syphilis, rubella
rhesus isoimmunisation
explain rhesus isoimmunisation
Antibodies in the mothers blood attacks RBC in the foetus
Due to rhesus D antigen (RhD) on RBCs
Can only occur when all 3 apply
1) Mother is RhD negative
2) Foetus is RhD positive
3) Mother has previously been exposed to RhD+ blood and has become sensitised (previous pregnancy, miscarriage, ectopic, c-cestion)
what are the types of miscarriage
threatened inevitable incomplete complete delayed/missed septic recurrent
presentation of miscarriage
vaginal bleeding +/- clots
suprapubic pain
postcoital bleeding
investigations for miscarriage
serum beta hCG (drop of >50% in 48hrs suggests failing pregnancy
transvaginal US
A gestational sac, mean diameter >25, with a visible yolk sac
Crown-rump length of embryo > 7mm and no obvious foetal heart beat
Empty uterus (if ectopic is ruled out) = complete miscarriage
Retained tissue = incomplete miscarriage
rhesus blood group
cytogenetic of products of conception (in recurrent miscarriages)
Management of miscarriage
threatened or complete - analgesia + counselling + anti D
inevitable/incomplete/missed - above + manual evacuation, misoprostol (for bleeding), can consider conservative with antibiotics
examples of gestational trophoblastic disease
partial hydatidiform mole complete hydatidiform mole invasive mole choriocarcinoma placental site trophoblastic tumour
management of trophoblastic gestational disease
desired fertility - dilation and evacuation with mechanical suction with 12 month follow up and strict adherence to contraception
not desiring fertility: hysterectomy
management of viable twins in gestational trophoblastic disease
elective termination via dilation and evacuation
if termination not desired manage as a high risk pregnancy with close observation specifically for eclampsia and thyrotoxicosis
define hyperemesis gravidarum
persistent vomiting during pregnancy resulting in weight loss, ketosis, electrolyte disturbances and volume depletion
investigations for hyperemesis gravidarum
urine ketones
check for UTIs
U&Es, LFTs
USS - multiple pregnancies, molar pregnancies
management of hyperemesis gravidarum
IV fluids (avoid dextrose)
IV anti-emetics (ondansetron)
omeprazole
replace electrolytes/vitamins as required
define infertility
Primary = inability to achieve pregnancy after 12 months of regular unprotected sex Secondary = infertility after previously been pregnant
causes of male infertility
obstructive azoospermia - normal sperm production but not present in ejaculate (blockage of vas or epididymis, CF causing congenital absence of vas)
non-obstructive azoospermia - testicular failure (high FSH, low Testosterone) e.g. due to obesity, endocrinopathies, chemotherapy
XXY Klinefelter’s, Y microdeletions
unstimulated spermatogenesis - hypogonadotropic hypogonadism
causes of female infertility
anovulation due to
group 2 =hypothalamic pituitary ovarian axis dysfunction (PCOS, adrenal dysfunction, thyroid dysfunction)
group 1 = hypothalamic pituitary failure (weight, stress, exercise, kallmans, pituitary tumour, sheehans)
group 3 = ovarian failure (chemo/radiotherapy, turner’s)
tubal causes
scarring, obstruction, adhesions (STIs, ectopic pregnancies)
PID, endometriosis, fibroids, polyps
investigations for male infertility
FSH, testosterone karyotype (CF carrier, Y deletions) semen analysis (concentration, motility, morphology)
oligospermia = low sperm asthenospermia = immotile sperm teratospermia = abnormal morphology
investigations for female infertility
TV USS
cervical sear, chlamydia, gonorrhoea,
ovarian function (luteal phase progesterone, LH, FSH, anti mullerian hormone
hystero-salpingo-gram, hysteroscopy
management of infertility
lifestyle (smoking, alcohol, weight)
folic acid
group 2 - clomifene, letrozole, FSH injection
group 1 - gonadotrophin releasing hormone injections
ART (IUI, IVF, ICSI)
tubal catheterisation
surgical correction of epididymis blockage
types of epithelial ovarian cancers
High grad serous
Resembles fallopian tube mucosa
P53 and BRAC1 mututions
Those that arise from ovarian surface epithelium and Mullerian inclusion cysts
Endometrioid and clear cell – likely due to ovarian endometriosis, associated with PTEN loss
low grade serous – KRAS and BRAF mutations
risk factors for ovarian cancers
BRCA 1, 2, Lynch syndrome II
nulliparity, early menarche, late menopause
never on OCP
presentation of ovarian cancer
pelvic mass altered bowel habits abdominal pain early satiety urinary urgency
investigations for ovarian cancer
USS, CT CA125 >35 RMI cytology of plural or ascitic fluid biopsy, histology FIGO staging
management of ovarian cancer
surgery
chemotherapy - carboplatin, VEGF inhibitor, aromatase inhibitor
prophylactic bilateral Salpingo-oophrectomy
types of endometrial cancers
most commonly adenocarcinomas - 2 types - oestrogen excess (endometrial adenocarcinoma), non oestrogen excess (papillary serous, clear cell)
others = leiomyosarcomas, uterine carcinomas
risk factors for endometrial cancer
lynch syndrome obesity nulliparity HRT PCOS tamoxifen use
presentation of endometrial cancer
post menopausal bleeding
post coital bleeding
altered menstrual pattern
persistent vaginal discharge
investigations for endometrial cancer
Pelvic and transvaginal US - endometrial thickening >5mm
hysteroscopy and biopsy
CT CAP
management of endometrial cancer
total hysterectomy + bilateral salpingo-oopherectomy + lymphadenectomy
adjuvant vaginal brachytherapy or pelvic external beam radiotherapy
chemo for late stages, serous or clear cell
types of cervical cancer
80% squamous cell carcinoma
15% adenocarcinoma
4-5% Adenosquamous
<1% endometroid, clear cell, serous, neuroendocrine
risk factors for cervical cancer
HPV - strains 16, 18 highest risk smoking immunosuppression multiple sexual partners early onset sexual activity
describe the HPV vaccination program
against strains 6, 11, 16, 18
given to all females aged 11-13
2 s/c injections 6 months apart
describe the screening program for cervical cancer
pap smear
offered to women aged 25 - 65 (25-49 = every 3 years. 50-65 = every 5 years)
looks for precancerous lesions/cancerous cells at the transformation zone
includes HPV testing
presentation of cervical cancer
abnormal vaginal bleeding post coital bleeding mucoid/purulent discharge dyspareunia pelvic pain obstructive renal failure
investigations for cervical cancer
VE and speculum - masses, bleeding
colposcopy, biopsy, histology
HPV testing
CT/MRI/PET
FIGO staging for cervical cancer
I – confined to cervix
II – invades beyond uterus but not lower third of the vagina
III – involves lower third or extends to pelvic wall
IV – extends beyond the pelvis
management of cervical cancer
LLETZ/cone biopsy/trachelectomy + pelvic lymphadenectomy
radical hysterectomy
chemo and radiotherapy
types of vulval cancers
90% squamous cell carcinomas
others = adenocarcinomas, melanomas, BCC, sarcomas
describe VIN
vulval intraepithelial neoplasia (Classes I, II, III)
precursor to squamous carcinoma
Management of VIN
I = symptomatic relief after excluding invasive disease, eradiated HPV
II/III - surgical excision/laser ablation/chemical ablation (imiquimod)
plastic and reconstruction input
types of vulval squamous cell carcinoma
SSC associated with VIN
usually <60 y.o.
associated with cervical cancer and HPV 16/18
SSC associated with dermatoses
>60 y.o.
keratinised and well differentiated
presentation of VIN
pruritus pain ulceration leucoplakia lump
presentation of vulval SSC
pain, mass, bleeding, discharge
skin changes - elevations, ulcerations
inguinal lymphadenopathy
investigations for vulval cancer
incisional biopsy
lymph node assessment: US, CT, MRI
FIGO staging
management of vulval cancer
vulvectomy + inguinal lymphadenectomy + skin grafts/flaps
Chemotherapy (reduce size before surgery, with radiotherapy in late stage or adjuvant post surgery)
define menopause
when menstruation permanently ceases due to loss of ovarian follicular activity
diagnosed after 1 year of amenorrhoea
causes of heavy menstrual bleeding
uterine: fibroids, endometrial polyps, PID, endometrial cancer
absence of uterine pathology: PCOS, hyperprolactinaemia, thyroid dysfunction
secondary to: von williebrand disease, anticoagulation use
Assessment of HMB
History – menarche, cycle, SHx ?preg, DHx ?contraceptives, cervical screening, ?migraines, smoking/alcohol/drugs, FHx
Examination – abdominal, bimanual, speculum
Bloods – FBC, coag screen, ferritin, TFTs
Swabs -?STI
Imaging – USS ?structural abnormalities ?pelvic mass, hysteroscopy
Pathology – biopsy to exclude endometrial cancer in women >45 with ineffective treatment
management of HMB
first line
fertility desired = tranexamnic and mefinamic
not desired = merina coil
other options systemic hormonal (COCP, GnRH analogues, ulipristal acetate - progesterone receptor modulator) surgical - endometrial ablation. hysterectomy
causes of primary amenorrhoea
genito-urinary malformations: imperforate hymen. absenct vaginal/uterus
Turner’s
hypothalamic: low BMI, stress, illness
causes of secondary amenorrhoea
PCOS
pituitary: prolactinoma, pituitary adenoma
thyroid dysfunction
Define dysmenorrhoea
primary - pain in the absence of underlying pelvic pathology
secondary - pain caused by pelvic pathology (endometriosis, PID, fibroids) or IUD insertion
investigations for dysmenorrhoea
pregnancy test
TV US - fibroids, adnexal pathology, endometriosis
hysteroscopy, pipelle biopsy
endocervix/vaginal swabs: STIs
management of dysmenorrhea
lifestyle - diet, exercise
NSAIDs
hormonal; - COCP, mirena coil
treat underlying cause
define endometriosis
an oestrogen dependent benign inflammatory disease characterised by ectopic endometrium
common sites for endometriosis
ovaries, fallopian tubes
pelvic peritoneum
uterosacral ligament
Less common: bladder, rectum, colon
explain the retrograde menstruation theory
Retrograde menstruation is the most commonly accepted theory
Endometrial debris flow backwards through fallopian tubes and into peritoneal surfaces
Fails to explain the low rate of disease in comparison to retrograde flow which is fairly common
A reason may be that retrograde menstruation relies of a deficient cell mediated response as many patients with endometriosis are found to have a reduced macrophage response in clearing menstrual effluent
aetiological theories for endometriosis
retrograde menstruation theory
Mullerian rest theory
vascular and lymphatic dissemination
presentation of endometriosis
dysmenorrhoea cyclic pelvic pain pelvic mass alterend bowel habits urinary symptoms subfertility
complications of endometriosis
chronic pain
infertility
cyst formation and rupture
adhesions and scarring -> ureteric/bowel obstruction
investigations for endometriosis
VE/bimanual (mass, fixed retroverted uterus, uterosacral ligament nodules or tenderness)
TVUS
rectal endoscopic US
gold standard - diagnostic laparoscopy and biopsy
management of endometriosis
NSAIDS + COCP
progesterone - IM methypreogesterone, mirena coil
GnRH agonists (down regulates oestrogen)
cystectomy
ablative therapy of endometrial implants (electrosurgery/laser ablation/radical excision)
hysterectomy +/- BSO +/- peritoneal excisions
Define PCOS
a syndrome associated with set of symptoms as a result of elevated testosterone
Anovulatory symptoms (amenorrhoea, oligomenorrhoea)
symptoms of hyperandrogenism (hirsutism, acne, alopecia)
presentation of PCOS
amenorrhoea/oligomenorrhoea
hirsutism
severe acne
complications of PCOS
infertility diabetes hypertension endometrial cancer depression
Diagnosis of PCOS
rotterdam criteria: 2 of 3
1) clinical/biochemical evidence of hyperandrogenism
2) oligomenorrhoea/amenorrhoea
3) US features of PCO
investigations for PCOS
pelvic US
serum androgens (free testosterone, DHEAS, androstenedione)
serum LH and FSH
serum 17-hydroxyprogesterone
TFTs
serum prolactin
OGTT
lipid profile
Management of PCOS
weight loss
metformin
eflornithine (topical cream for hirsutism)
Fertility conserving
letrozole
clomifene
gonadotrophin injections (FSH)
non fertility conserving COCP spironolactone corticosteroids finasteride
common causative organisms of PID
chlamydia
gonorrhoea
mycoplasma
gardnerella
risk factors for PID
previous STIs, previous PID
unprotected sex, multiple partners, young onset of sexual activity
IUD
presentation of PID
history of prior STI bilateral abdominal pain abnormal vaginal bleeding, (post coital, inter-menstrual or menorrhagia) purulent vaginal discharge fever, nausea, vomiting
complications of PID
chronic PID infertility ectopic pregnancy tubo-ovarian abscess Fitz hugh curtis syndrome
clinical findings in PID
discharge, bleeding
cervical motion tenderness
uterine tenderness
adnexal tenderness
investigations for PID
swabs - vaginal, rectal, throat vaginal secretions wet mount microscopy vaginal secretions culture WCC, CRP, ESR pelvic CT
Management of PID
ceftriaxone, doxycycline, metronidazole
consider removal of IUD
define menopause
LMP > 1 year ago
symptoms of menopause
hot flushes and sweats loss of libido mood changes joint and muscle pain urinary symptoms
diagnosis of menopause
clinical diagnosis (LMP>1year) if <45 y.o. = FSH (2 results >30, 8 weeks apart) if >50 and wants to stop hormonal contraception = 1 result >30 = can stop contraception in 12months
management of menopause
lifestyle (exercise, reduce alcohol, smoking and stress)
HRT (best for vasomotor symptoms)
CBT (mood and anxiety)
explain HRT
replaces E2
many types available (oral tablets, transdermal patch, vaginal ring, gel/cream)
given with progesterone (tablet, patch, IUS) to protect against endometrial cancer but increase risk of breast cancer
risks associated with HRT
endometrial, ovarian and breast cancer
VTE
cardiovascular disease
stroke
contraindications to HRT
history of breast cancer untreated endometrial hyperplasia current or recurrent VTE thrombophilic disorders liver disease with abnormal LFTs
describe the micturition cycle
bladder fills (low sympathetic sensory input from stretch receptors) first sensation to void (onufs nucleus -> contracts EUS) desire to void micturition (inhibition of onufs and pelvic nerve to bladder -> detrusor contraction)
causes of stress incontinence
intrinsic sphincter deficiency/primary urethral weakness
insufficient suburethral support
defective striated or smooth muscle of the urethra and mucosal/submucosal cushions
investigations for urinary incontinence
urinalysis
bladder diary
cystoscopy and renal tract imaging
urodynamic testing (uroflowmetry, filling and voiding cystometry)
management for SUI
lifestyle - avoid caffeine and alcohol
first line = pelvic floor exercises
Duloxetine (SNRI)
surgical - midurethral sling, colposuspension, intramural bulking
causes of overactive bladder incontinence
bladder stones/tumours
diabetes
acute UTI
parkinson’s, stroke, MS
management of OAB
avoidance of alcohol, caffeine bladder retraining (scheduled voiding) oxybutynin (anticholinergic) - if contraindicated then B3 adrenoreceptor agonist
detrusor muscle botox injections
percutaneous sacral nerve stimulation
augmented cystoplasty
describe the structural support of the pelvic floor
vaginal wall
transverse cervical ligaments
round and broad ligaments
uterosacral ligament
risk factors for prolapse
vaginal delivery (big baby, long time) high parity obesity, constipation
symptoms of prolapse
can be asymptomatic
vaginal
sensation of pressure, fullness, heaviness
sensation of “something coming down” - worse at end of day, better lying down
bleeding, discharge
dyspareunia
urinary symptoms bowel symptoms (constipation, incontinence)
management of prolapse
lifestyle - smoking and weight loss
pelvic floor exercises
intra vaginal pessaries
surgery
physiological changes in pregnancy
RAAS stimulated -> increase BV
physiological anaemia, low platelets and low haematocrit
hypercoagulable state
increased circulating hormones -> headaches and migraines
relaxation of ligaments -> pelvic pain
increased PTH and Ca
relaxed smooth muscle -> constipation, reflux
what are some fetal complications of multiple pregnancies
miscarriage
congenital abnormalities
growth restriction
what are some maternal complications of multiple pregnancies
hyperemesis
pre-eclampsia
gestational diabetes
placenta previa
postpartum haemorrhage
postnatal depression/anxiety/poor relationship
complications associated with monochorionic twins
acute transfusion (Death of one twin in utero leads to increased risk of hypoxic-ischaemic injury in survivor due to acute transfusion from healthy to dying twin)
twin twin transfusion syndrome (chronic net shunting from one twin to the other: Donor twin = Growth restricted, oliguric, anhydramnios - Recipient twin = Polyuric, polyhydramnios, cardiac problems, hydrops
twin reversed arterial perfusion sequence (2 cords linked by a big arterio-arterial anastamosis, retrograde perfusion
One twin, called the acardiac twin or TRAP fetus, is severely malformed. The heart is missing or deformed, as are the upper structures of the body)
3 stages of labour
1 = reg contractions to cervix fully dilated 2 = full dilation to delivery of baby 3 = delivery of baby to delivery of placenta
what are the 8 cardinal movements of labour
engagement descent flexion internal rotation extension external rotation restitution expulsion
indications for induction of labour
big baby pre-eclampsia post date GDM IUGR
methods of induction
sweep
foley’s balloon
prostin (gel) or propess (slow release pessary)
oxytocin infusion
analgesia used in labour
entonox gas
opioids - IM diamorphine
regional blocks - epidural or spinal
when is labour diagnosed
regular painful contractions
at least 3cm dilated
cervix fully effaced
management of gestational diabetes
aim for glucose 4-7mmol/l
diet, metformin, insulin
stop all antiglycaemic medication post partum
define pre-eclampsia
new onset hypertension accompanied with proteinuria or other evidence of systemic involvement after 20 weeks gestation
risk factors for pre-eclampsia
primiparity
previous pre-eclampsia
BMI > 30
chronic hypertension
presentation of pre-eclampsia
headaches scotoma, flashing lights abdominal pain oedema seizure (indicates eclampsia)
investigations for pre-eclampsia
BP and urinalysis
FBC (thrombocytopenia)
LFTs (raised AST/ALT)
serum creatine (good indicator of disease progression)
umbilical artery doppler velocimetry and amniotic fluid assessment
foetal ultrasound, CTG
management of pre-eclampsia
frequent BP monitoring
aspirin at week 12 if high risk
IV labetalol
plan for delivery
management of eclampsia
magnesium sulphate (IM or IV) monitor magnesium levels (toxicity can cause resp/cardiac failure) urgent delivery of baby
management of pregnancy in WWE
folate - start at least 1 month prior to conception
adjust dose of AED (risk of teratogenicity) - preferably monotherapy
Vit K throughout pregnancy (Vit K for baby at birth)
seizure are usually self limiting but if not use rectal/IV diazepam
Causes of APH
placental abruption (part of the placenta covers the lower uterine wall - painless PV bleeding) placental praevia (full or partial detachment of the placenta from uterine wall - painful PV bleeding, "woody" appearance) uterine rupture (full thickness disruption of the uterine muscle - severe abdo pain between contractions, shoulder tip pain) vasa praevia (foetal vessels rupture during active labour - triad of painless PV bleeding, foetal bradycardia, ruptured membranes) local cause (polyps, cancer, ectropion, infection)
causes of PPH
tone - failure of the uterus to contract down
trauma - tears (usually 3rd/4th degree labial tear)
tissue - placenta praevia or abruption
thrombophilia
management if PPH
tone - bimanual compression, rusch catheter, B lynch sutures, uteritonic drugs (syntocinon, ergometrine), hysterectomy
trauma - suture the tears
tissue - remove the placenta
thrombophilia - give blood products
skin changes in pregnancy
atopic eruption in pregnancy (limbs and trunk, early onset - <3rd trimester) polymorphic eruption in pregnancy (lower abdomen with umbilical sparring, striae) pemphigoid gestinitis (urticarial wheals and bullae on abdomen)
