O&G CBLs Flashcards
At what gestation do women have a dating scan and anomaly scan?
- Dating scan ideally 10-14 weeks
- combined test for trisomy 21 !
- Anomaly scan
- 18 to 21 weeks (20+6)
- to identify abnormalities
- 18 to 21 weeks (20+6)
What is Nuchal translucency?
Ultrasound appearance of collection of fluid under skin, behind neck of foetus, in the 1st trimester
increased is > 3.5mm
Conditions to be picked up in anomaly scan
- anencephaly
- open spina bifida
- cleft lip
- diaphragmatic hernia
- gastroschisis (in sac)
- exomphalos
- cardiac abnormalities: TOF, AVSD, TOF, HLHS
- bilateral renal agenesis
- lethal skeletal dysplasia
- trisomy 18 Edwards
- trisomy 13 pataus
Turner’s syndrome commonly associated with what cardiac abnormality
Coarctation of aorta
Invasive tests offered during pregnancy
- CHORIONIC VILLOUS SAMPLING
- 11-14 weeks
- 1/2% risk of miscarriage
- foetal cells removed from chorion - Amniocentesis
- 15 weeks onwards
- 1 in 200 loss rate
- foetal cells withdrawn from amniotic fluid
Other risks
- failure to get sample
- foetal injury (rare)
- maternal bowel injury
- amniotic fluid leakage
- chorioamnionitis
- discomfort
Infective Causes of ventriculomegaly
- idiopathic
- may occur with other intracranial or CNS abnormalities
- chromosomal: TRISOMY 21
- viral infections: CMW, Toxoplasmosis
What types of screening are available in the UK for identification of foetuses with major structural abnormality?
NIPT
- 9 weeks , not on NHS
Combined
- 11-14 weeks
- PAPPA
- free beta HCG
- NT
Quadruple
- 14-20 weeks
- HCG
- AFP
- oestriol
- inhibin A
What should normal VP measurement be?
VP measurement - posterior horn of lateral ventricle in brain
< 10mm
Factors predisposing for multiple pregnancy?
- advanced maternal age (>35 years)
- previous multiple pregnancy
- use of fertility enhancing treatment
- maternal history of dizygotic twins
How might ultrasound be used to classify twin pregnancies, what signs might you look out for?
Lambda sign = dichorionic
T sign = Monochorionic
Twin to twin transfusion syndrome
Large central artery to vein connections from donor to recipient
5 stages : Quintero staging
Stage 1 - bladder of donor twin visible, doppler of both twins are normal
Stage 2 - bladder of donor not visualised, doppler still normal
Stage 3 - non visualised bladder, abnormal doppler
Stage 4 - one or both fetuses have hydrops
Stage 5 - one or both fetuses have died
MANAGEMENT
- foetoscopic laser ablation
What is the maximum vertical amniotic fluid pocket for oligohydraminos and polyhydraminos?
- Oligohydraminos: <2cm
- Polyhydraminos: >8cm
Twin reversed arterial perfusion sequence (TRAP)
one twin has absent or non-functioning heart
receives all its blood supply from normal heart.
ACARDIAC-ACEPHALIC TWIN
Mx = radio-frequency ablation needle
Twin anaemia polycythaemia sequence (TAPS)
Tiny peripheral artery to vein connections
Slow transfusion of RBC through very small placental AV anastomoses
Leads to anaemia in one twin and polycythaemia in co-twin
Male types of male sub-fertility
Normospermia = normal sperm quality
Oligospermia = reduced sperm count
Asthenospermia = reduced sperm motility
Teratospermia = reduced sperm morphology
Cryptospermia = very low sperm count (< 2 million/ml)
Combination: oligoteratoasthenospermia = low sperm count, reduced morphology and motility
Parameters recorded on male semen analysis?
- Volume > 1.5ml
- Concentration > 15million/ml
- Motility excellent + sluggish > 32%
- Total sperm count > 39 million
- Normal morphology > 4%
Outline baseline management and investigations for azoospermia (no sperm) and describe how to interpret them?
Azoospermia
1. History: childhood (undescended testes), surgery, chemo, cystic fibrosis
- Examination
- secondary sexual characteristics
- tall? Klinefelters?
- palpate testes size - Tests
- Blood: FSH, LH, testosterone, prolactin, oestradiol. TFTs, karyotype, cystic fibrosis - Radiology: USS testes
- testicular sperm extraction: TESA, PESA (epididymis), TESE (teste biopsy), MESA
Low FSH / LH / Testosterone indicative of
Hypogonadotrophic hypogonadism
Low FSH / LH
high testosterone
Anabolic steroid use
High FSH / LH /
Low testosterone
Testicular failure
Why male fertility might be declining?
- lifestyle = sedentary, alcohol, smoking
- diet = higher oestrogen content, fast food
- environmental = pesticides, fertilisers, chemicals
Investigations for fertility in females
Ovarian reserve assessment
- Anti-mullerian hormone
- Day 2-4 FSH/LH
- Ovulation FSH / LH
- LH
- thyroid function
- prolactin
USS for pelvic anatomy
Tubal patency:
- HyCoSy
- Hysterosalpingogram (HSG)
- Laparoscopy and dye
Treatment options for female infertility
- Ovulation induction: CLOMIPHENE CITRATE (anti-oestrogen) or LETROZOLE (aromatase inhibitor)
- Artificial insemination
Investigations for PCOS
- Anti-mullerian hormone (raised >40 in PCOS)
- Early follicular phase gonadotropins LH/FSH with ratio > 3:1
- Impaired glucose tolerance test
- Ultrasound (Rotterdam criterion)
Criteria used for PCOS
ROTTERDAM CRITERIA
- oligo / anovulation
- Biochemical signs of hyperandrogenism: clinical –> acne, hirsutism, acanthosis nigrans
- Polycystic ovaries on USS
What drug might be given to induce ovulation?
CLOMIPHENE CITRATE
Types of incontinence
STRESS
- increase intrabdominal pressure
URGE
- due to involuntary contraction of bladder muscles
Overflow
- due to blockage of urethra
Mixed
- features of both
- treat the more dominant
NOTES URINARY INCONTINENCE
What questions may be helpful in forming a differential diagnosis?
OAB: frequency (8 times per day), nocturia (> 1 per night), urgency (desire to void), urge incontinence, nocturia.
Stress: leaking with coughing, laughing or straining, incontinence.
SUI: Defined as “involuntary loss of urine on effort or physical exertion, or on sneezing or coughing.”
Voiding dysfunction: hesitancy, incomplete emptying.
Lifestyle: fluid intake (caffeine), BMI and physical activity.
POP: pelvic heaviness or bulge
Bowels / sexual history / mental health concerns.
Parity.
PMHx / previous surgery / drug history.
Grade of uterine prolapse on examination
- Descent within vagina
- Descent to hymen
- Descent beyond hymen
- Uterus outside of vagina (Procidentia)
Key investigations in a patient presenting with incontinence
- Urine dipstick
a. UTI, kidney bladder stones, diabetes - Post micturition bladder scan
a. to assess post void residual volume - Bladder diary
a. minimum of three days - USS
a. to exclude pelvic mass - Proctogram / ARMS if bowel symptoms co-exist
Non-surgical treatment first line for stress incontinence
- Pelvic floor exercises (w/ physio)
- at least 3 months
- 8 pelvic contractions 3 times a day
Patient presents with the following:
Why might these be important in her main complaint of urinary incontinence.
On examination she has a BMI of 35, an elevated JVP and pitting oedema to the mid-calf. Why may these signs be important in explaining her main complaint
raised BMI associated with urinary incontinence
heart failure —> predispose to coughing
diuretic use —> increase frequency of bladder emptying
What simple non-pharma logical measures might you suggest for OAB?
Bladder re-training:
- Minimum of six weeks if there is urgency or mixed incontinence.
- Techniques to increase the length of time between feeling the need to urinate and actually having to pass urine.
Avoid caffeine or fizzy drinks
Drink more water
What surgical options are available for overactive bladder?
- BOTOX
- 80% effective, temporary - Sacral nerve stimulation
- implantation of leads into S2,3,4 - Percutaneous sacral nerve stimulation
Risk factors for development of prolapse
Increased age
Occupation where heavy lifting has been involved
Previous hysterectomy
Raised BMI of 35
Chronic cough
Grading systems used to grade size of prolapse
Baden Walker system
0 = normal position
1 = descent halfway to hymen
2 = descent to hymen
3 = descent halfway past hymen
4 = maximum descent
POP Q
22 F , AED
PC: severe adbo pain + vomitting
HPC: abdo bloated 2 wks
OE: large tender mass arising from pelvis (size 28 week pregnancy)
LMP: two weeks ago
No contraception
key investigations
Urine dipstick —> UTI
Urine pregnancy test —> pregnancy
Bloods
- FBC, U&Es, LFTs, calcium profile
- amylase
- Ca125
Urgent Imaging
- USS or CT
Differential diagnoses
22 F , AED
PC: severe adbo pain + vomitting
HPC: abdo bloated 2 wks
OE: large tender mass arising from pelvis (size 28 week pregnancy)
LMP: two weeks ago
Positive pregnancy test
Solid complex mass occupying most of abdomen
- Molar pregnancy (unlikely to be this large)
- Germ cell ovarian tumour secreting HCG
- Fibroid uterus in pregnancy with red degeneration
- Sarcoma in pregnancy
What is red degeneration?
Ischaemia or necrosis of fibroid because its too large for blood supply
Ovarian cancer key features
- abdominal pain
- abdominal distention
- reduced appetite (early satiety)
What investigations would you like to arrange next for patient with suspected ovarian cancer?
- pelvic ultrasound followed by a CT
- investigation of raised Ca125
- Image urinary tract because of abnormal U&Es
What is the risk of malignancy index used for?
OVARIAN CANCER
RMI = USS x Menopausal status x Ca125
U= 0 for ultrasound
M= 1 for premenpausal , 3 for postmenopausal
Ca125
