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O&G Flashcards

1
Q

sites for ectopic preganancy

A 
fallopian tubes (97%)
ovaries
abdomen
C-section scar
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2
Q

risk factor for ectopic pregnancy

A

previous ectopic
pelvic surgery - (C-section, appendectomy, sterilisation)
endometriosis
clamydia

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3
Q

presentation of ectopic preganancy

A 
typically at 6-8 weeks after LMP
vaginal bleeding
pelvic discomfort
pain when opening bowels
hypovolaemic shock - hypotension, tachycardia
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4
Q

investigations for ectopic pregnancy

A

urine/serum beta HCG
transvaginal US
serial serum-hCG

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5
Q

explain serial beta-hCG use is ectopic pregnancy

A

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

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6
Q

management of ectopic pregnancy

A 
expectant management (conservative - wait for spontaneous resolution)
medical management (Methotrexate)
surgical management (salpingostomy or salpingectomy)
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7
Q

define miscarriage

A

any pregnancy loss before 24 weeks gestation

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8
Q

risk factors for miscarriage

A

old maternal age
PCO
smoking and alcohol
uterine malformations ( ascending UTIs, bicornuate)

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9
Q

cause of miscairrage

A

cervical incompetence/weakness
transplacental foetal infection - syphilis, rubella
rhesus isoimmunisation

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10
Q

explain rhesus isoimmunisation

A

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)

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11
Q

what are the types of miscarriage

A 
threatened
inevitable
incomplete
complete
delayed/missed
septic
recurrent
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12
Q

presentation of miscarriage

A

vaginal bleeding +/- clots
suprapubic pain
postcoital bleeding

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13
Q

investigations for miscarriage

A

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)

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14
Q

Management of miscarriage

A

threatened or complete - analgesia + counselling + anti D
inevitable/incomplete/missed - above + manual evacuation, misoprostol (for bleeding), can consider conservative with antibiotics

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15
Q

examples of gestational trophoblastic disease

A 
partial hydatidiform mole
complete hydatidiform mole
invasive mole
choriocarcinoma
placental site trophoblastic tumour
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16
Q

management of trophoblastic gestational disease

A

desired fertility - dilation and evacuation with mechanical suction with 12 month follow up and strict adherence to contraception
not desiring fertility: hysterectomy

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17
Q

management of viable twins in gestational trophoblastic disease

A

elective termination via dilation and evacuation
if termination not desired manage as a high risk pregnancy with close observation specifically for eclampsia and thyrotoxicosis

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18
Q

define hyperemesis gravidarum

A

persistent vomiting during pregnancy resulting in weight loss, ketosis, electrolyte disturbances and volume depletion

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19
Q

investigations for hyperemesis gravidarum

A

urine ketones
check for UTIs
U&Es, LFTs
USS - multiple pregnancies, molar pregnancies

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20
Q

management of hyperemesis gravidarum

A

IV fluids (avoid dextrose)
IV anti-emetics (ondansetron)
omeprazole
replace electrolytes/vitamins as required

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21
Q

define infertility

A 
Primary = inability to achieve pregnancy after 12 months of regular unprotected sex
Secondary = infertility after previously been pregnant
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22
Q

causes of male infertility

A

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

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23
Q

causes of female infertility

A

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

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24
Q

investigations for male infertility

A 
FSH, testosterone
karyotype (CF carrier, Y deletions)
semen analysis (concentration, motility, morphology)
oligospermia = low sperm
asthenospermia = immotile sperm
teratospermia = abnormal morphology
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25
Q

investigations for female infertility

A

TV USS
cervical sear, chlamydia, gonorrhoea,
ovarian function (luteal phase progesterone, LH, FSH, anti mullerian hormone
hystero-salpingo-gram, hysteroscopy

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26
Q

management of infertility

A

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

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27
Q

types of epithelial ovarian cancers

A

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

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28
Q

risk factors for ovarian cancers

A

BRCA 1, 2, Lynch syndrome II
nulliparity, early menarche, late menopause
never on OCP

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29
Q

presentation of ovarian cancer

A 
pelvic mass
altered bowel habits
abdominal pain
early satiety
urinary urgency
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30
Q

investigations for ovarian cancer

A 
USS, CT
CA125 >35
RMI
cytology of plural or ascitic fluid
biopsy, histology
FIGO staging
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31
Q

management of ovarian cancer

A

surgery
chemotherapy - carboplatin, VEGF inhibitor, aromatase inhibitor

prophylactic bilateral Salpingo-oophrectomy

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32
Q

types of endometrial cancers

A

most commonly adenocarcinomas - 2 types - oestrogen excess (endometrial adenocarcinoma), non oestrogen excess (papillary serous, clear cell)
others = leiomyosarcomas, uterine carcinomas

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33
Q

risk factors for endometrial cancer

A 
lynch syndrome
obesity
nulliparity 
HRT
PCOS
tamoxifen use
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34
Q

presentation of endometrial cancer

A

post menopausal bleeding
post coital bleeding
altered menstrual pattern
persistent vaginal discharge

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35
Q

investigations for endometrial cancer

A

Pelvic and transvaginal US - endometrial thickening >5mm
hysteroscopy and biopsy
CT CAP

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36
Q

management of endometrial cancer

A

total hysterectomy + bilateral salpingo-oopherectomy + lymphadenectomy
adjuvant vaginal brachytherapy or pelvic external beam radiotherapy
chemo for late stages, serous or clear cell

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37
Q

types of cervical cancer

A

80% squamous cell carcinoma
15% adenocarcinoma
4-5% Adenosquamous
<1% endometroid, clear cell, serous, neuroendocrine

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38
Q

risk factors for cervical cancer

A 
HPV - strains 16, 18 highest risk
smoking
immunosuppression
multiple sexual partners
early onset sexual activity
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39
Q

describe the HPV vaccination program

A

against strains 6, 11, 16, 18
given to all females aged 11-13
2 s/c injections 6 months apart

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40
Q

describe the screening program for cervical cancer

A

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

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41
Q

presentation of cervical cancer

A 
abnormal vaginal bleeding
post coital bleeding
mucoid/purulent discharge
dyspareunia
pelvic pain
obstructive renal failure
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42
Q

investigations for cervical cancer

A

VE and speculum - masses, bleeding
colposcopy, biopsy, histology
HPV testing
CT/MRI/PET

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43
Q

FIGO staging for cervical cancer

A

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

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44
Q

management of cervical cancer

A

LLETZ/cone biopsy/trachelectomy + pelvic lymphadenectomy
radical hysterectomy
chemo and radiotherapy

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45
Q

types of vulval cancers

A

90% squamous cell carcinomas

others = adenocarcinomas, melanomas, BCC, sarcomas

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46
Q

describe VIN

A

vulval intraepithelial neoplasia (Classes I, II, III)

precursor to squamous carcinoma

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47
Q

Management of VIN

A

I = symptomatic relief after excluding invasive disease, eradiated HPV

II/III - surgical excision/laser ablation/chemical ablation (imiquimod)
plastic and reconstruction input

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48
Q

types of vulval squamous cell carcinoma

A

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

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49
Q

presentation of VIN

A 
pruritus
pain
ulceration
leucoplakia
lump
50
Q

presentation of vulval SSC

A

pain, mass, bleeding, discharge
skin changes - elevations, ulcerations
inguinal lymphadenopathy

51
Q

investigations for vulval cancer

A

incisional biopsy
lymph node assessment: US, CT, MRI
FIGO staging

52
Q

management of vulval cancer

A

vulvectomy + inguinal lymphadenectomy + skin grafts/flaps

Chemotherapy (reduce size before surgery, with radiotherapy in late stage or adjuvant post surgery)

53
Q

define menopause

A

when menstruation permanently ceases due to loss of ovarian follicular activity
diagnosed after 1 year of amenorrhoea

54
Q

causes of heavy menstrual bleeding

A

uterine: fibroids, endometrial polyps, PID, endometrial cancer
absence of uterine pathology: PCOS, hyperprolactinaemia, thyroid dysfunction
secondary to: von williebrand disease, anticoagulation use

55
Q

Assessment of HMB

A

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

56
Q

management of HMB

A

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
57
Q

causes of primary amenorrhoea

A

genito-urinary malformations: imperforate hymen. absenct vaginal/uterus
Turner’s
hypothalamic: low BMI, stress, illness

58
Q

causes of secondary amenorrhoea

A

PCOS
pituitary: prolactinoma, pituitary adenoma
thyroid dysfunction

59
Q

Define dysmenorrhoea

A

primary - pain in the absence of underlying pelvic pathology

secondary - pain caused by pelvic pathology (endometriosis, PID, fibroids) or IUD insertion

60
Q

investigations for dysmenorrhoea

A

pregnancy test
TV US - fibroids, adnexal pathology, endometriosis
hysteroscopy, pipelle biopsy
endocervix/vaginal swabs: STIs

61
Q

management of dysmenorrhea

A

lifestyle - diet, exercise
NSAIDs
hormonal; - COCP, mirena coil
treat underlying cause

62
Q

define endometriosis

A

an oestrogen dependent benign inflammatory disease characterised by ectopic endometrium

63
Q

common sites for endometriosis

A

ovaries, fallopian tubes
pelvic peritoneum
uterosacral ligament
Less common: bladder, rectum, colon

64
Q

explain the retrograde menstruation theory

A

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

65
Q

aetiological theories for endometriosis

A

retrograde menstruation theory
Mullerian rest theory
vascular and lymphatic dissemination

66
Q

presentation of endometriosis

A 
dysmenorrhoea
cyclic pelvic pain
pelvic mass
alterend bowel habits
urinary symptoms
subfertility
67
Q

complications of endometriosis

A

chronic pain
infertility
cyst formation and rupture
adhesions and scarring -> ureteric/bowel obstruction

68
Q

investigations for endometriosis

A

VE/bimanual (mass, fixed retroverted uterus, uterosacral ligament nodules or tenderness)
TVUS
rectal endoscopic US
gold standard - diagnostic laparoscopy and biopsy

69
Q

management of endometriosis

A

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

70
Q

Define PCOS

A

a syndrome associated with set of symptoms as a result of elevated testosterone
Anovulatory symptoms (amenorrhoea, oligomenorrhoea)
symptoms of hyperandrogenism (hirsutism, acne, alopecia)

71
Q

presentation of PCOS

A

amenorrhoea/oligomenorrhoea
hirsutism
severe acne

72
Q

complications of PCOS

A 
infertility
diabetes
hypertension
endometrial cancer
depression
73
Q

Diagnosis of PCOS

A

rotterdam criteria: 2 of 3

1) clinical/biochemical evidence of hyperandrogenism
2) oligomenorrhoea/amenorrhoea
3) US features of PCO

74
Q

investigations for PCOS

A

pelvic US
serum androgens (free testosterone, DHEAS, androstenedione)
serum LH and FSH
serum 17-hydroxyprogesterone

TFTs
serum prolactin

OGTT
lipid profile

75
Q

Management of PCOS

A

weight loss
metformin
eflornithine (topical cream for hirsutism)

Fertility conserving
letrozole
clomifene
gonadotrophin injections (FSH)

non fertility conserving
COCP
spironolactone
corticosteroids
finasteride
76
Q

common causative organisms of PID

A

chlamydia
gonorrhoea
mycoplasma
gardnerella

77
Q

risk factors for PID

A

previous STIs, previous PID
unprotected sex, multiple partners, young onset of sexual activity
IUD

78
Q

presentation of PID

A 
history of prior STI
bilateral abdominal pain
abnormal vaginal bleeding, (post coital, inter-menstrual or menorrhagia)
purulent vaginal discharge
fever, nausea, vomiting
79
Q

complications of PID

A 
chronic PID
infertility
ectopic pregnancy
tubo-ovarian abscess
Fitz hugh curtis syndrome
80
Q

clinical findings in PID

A

discharge, bleeding
cervical motion tenderness
uterine tenderness
adnexal tenderness

81
Q

investigations for PID

A 
swabs - vaginal, rectal, throat
vaginal secretions wet mount microscopy
vaginal secretions culture
WCC, CRP, ESR
pelvic CT
82
Q

Management of PID

A

ceftriaxone, doxycycline, metronidazole

consider removal of IUD

83
Q

define menopause

A

LMP > 1 year ago

84
Q

symptoms of menopause

A 
hot flushes and sweats
loss of libido
mood changes
joint and muscle pain
urinary symptoms
85
Q

diagnosis of menopause

A 
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
86
Q

management of menopause

A

lifestyle (exercise, reduce alcohol, smoking and stress)
HRT (best for vasomotor symptoms)
CBT (mood and anxiety)

87
Q

explain HRT

A

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

88
Q

risks associated with HRT

A

endometrial, ovarian and breast cancer
VTE
cardiovascular disease
stroke

89
Q

contraindications to HRT

A 
history of breast cancer
untreated endometrial hyperplasia
current or recurrent VTE
thrombophilic disorders
liver disease with abnormal LFTs
90
Q

describe the micturition cycle

A 
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)
91
Q

causes of stress incontinence

A

intrinsic sphincter deficiency/primary urethral weakness
insufficient suburethral support
defective striated or smooth muscle of the urethra and mucosal/submucosal cushions

92
Q

investigations for urinary incontinence

A

urinalysis
bladder diary
cystoscopy and renal tract imaging
urodynamic testing (uroflowmetry, filling and voiding cystometry)

93
Q

management for SUI

A

lifestyle - avoid caffeine and alcohol
first line = pelvic floor exercises
Duloxetine (SNRI)
surgical - midurethral sling, colposuspension, intramural bulking

94
Q

causes of overactive bladder incontinence

A

bladder stones/tumours
diabetes
acute UTI
parkinson’s, stroke, MS

95
Q

management of OAB

A 
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

96
Q

describe the structural support of the pelvic floor

A

vaginal wall
transverse cervical ligaments
round and broad ligaments
uterosacral ligament

97
Q

risk factors for prolapse

A 
vaginal delivery (big baby, long time)
high parity
obesity, constipation
98
Q

symptoms of prolapse

A

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)
99
Q

management of prolapse

A

lifestyle - smoking and weight loss
pelvic floor exercises
intra vaginal pessaries
surgery

100
Q

physiological changes in pregnancy

A

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

101
Q

what are some fetal complications of multiple pregnancies

A

miscarriage
congenital abnormalities
growth restriction

102
Q

what are some maternal complications of multiple pregnancies

A

hyperemesis
pre-eclampsia
gestational diabetes
placenta previa

postpartum haemorrhage
postnatal depression/anxiety/poor relationship

103
Q

complications associated with monochorionic twins

A

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)

104
Q

3 stages of labour

A 
1 = reg contractions to cervix fully dilated
2 = full dilation to delivery of baby
3 = delivery of baby to delivery of placenta
105
Q

what are the 8 cardinal movements of labour

A 
engagement
descent
flexion
internal rotation
extension
external rotation
restitution
expulsion
106
Q

indications for induction of labour

A 
big baby
pre-eclampsia
post date
GDM
IUGR
107
Q

methods of induction

A

sweep
foley’s balloon
prostin (gel) or propess (slow release pessary)
oxytocin infusion

108
Q

analgesia used in labour

A

entonox gas
opioids - IM diamorphine
regional blocks - epidural or spinal

109
Q

when is labour diagnosed

A

regular painful contractions
at least 3cm dilated
cervix fully effaced

110
Q

management of gestational diabetes

A

aim for glucose 4-7mmol/l
diet, metformin, insulin
stop all antiglycaemic medication post partum

111
Q

define pre-eclampsia

A

new onset hypertension accompanied with proteinuria or other evidence of systemic involvement after 20 weeks gestation

112
Q

risk factors for pre-eclampsia

A

primiparity
previous pre-eclampsia
BMI > 30
chronic hypertension

113
Q

presentation of pre-eclampsia

A 
headaches
scotoma, flashing lights
abdominal pain
oedema
seizure (indicates eclampsia)
114
Q

investigations for pre-eclampsia

A

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

115
Q

management of pre-eclampsia

A

frequent BP monitoring
aspirin at week 12 if high risk
IV labetalol
plan for delivery

116
Q

management of eclampsia

A 
magnesium sulphate (IM or IV)
monitor magnesium levels (toxicity can cause resp/cardiac failure)
urgent delivery of baby
117
Q

management of pregnancy in WWE

A

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

118
Q

Causes of APH

A 
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)
119
Q

causes of PPH

A

tone - failure of the uterus to contract down
trauma - tears (usually 3rd/4th degree labial tear)
tissue - placenta praevia or abruption
thrombophilia

120
Q

management if PPH

A

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

121
Q

skin changes in pregnancy

A 
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)

finals (13 decks)

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