O&G PACES Flashcards
What investigations are routinely given and offered in the booking visit?
1) USS - 11-13 (+6) weeks - date using CRL, detect multiple pregnancy
2) Combined test - beta-hCG, PAPPA + nuchal translucency measurement (NTM) - screening for Down’s syndrome
3) Bloods: FBC, serum antibodies (e.g. anti-D), Syphilis, Rubella immunity, HIV/Hep B offered, haemaglobin electrophoresis if at risk, GTT if at risk.
4) Urine dip, microscopy and culture - protein, nitrites, glucose, screen for bacteruria
How can you work out the estimated due date (EDD) (3 ways)
- Naegle’s rule –> date of LMP + 12 months - 3 months + 7 days
- 280 day wheel (often gives a slightly different date)
- USS measurements
What are Korotkoff sounds, describe accurately what they are and how they are identified
When measuring blood pressure, you aim to get the systolic and the diastolic pressures. Normally the blood is being pumped along the brachial artery in a smooth line - laminar flow, doesn’t make a noise. When you inflate the cuff to the same as the systolic pressure, the artery becomes occluded, preventing flow of blood. Then pressure is released down again, and at the point of systolic pressure blood is squeezed through the arm past the cuff during systole, creating turbulent flow which is audible - this is the first Korotkoff sound. As pressure is slowly dropped in the cuff, thumping sounds are heard, until eventually they become muffled and then silent - because less restriction means that blood flow is able to become laminar again, which doesn’t produce sounds.
What are the symptoms and signs of pre-eclampsia
Headache, flashing lights, oedema, hyper-reflexia
what is the preinvasive stage of cervical cancer?
CIN - cervical intraepithelial neoplasia
What is the cause of CIN and cervical cancer?
HPV - human pappilomavirus
Which subtypes of HPV cause the majority (70%) of invasive cancers
16, 18 - are the types which are vaccinated against
31, 33 also
wen is the smear recommended and how often should it be repeated?
between 25-64
3 yearly between 25-49, and then 5 yearly from 50-64
then can stop at age 65 providing the last 3 previous smears have been negative
which part of the cervix should cells be taken from in a smear test?
the transformation zone
what 4 groups can cytology report the cervical cells from a smear?
- BNC - borderline nuclear changes
- mild dyskaryosis
- moderate dyskaryosis
- severe dyskaryosis
Why can’t a diagnosis of CIN - cervical intraepithelial neoplasm or cancer be made from a smear test? What’s the point of it then
it’s a cytological test, and the diagnosis can only be made histologically –> however the degree of dyskaryosis corresponds to the grade of CIN
What should be done immediately if moerate or severe dyskaryosis is found on a smear?
refer to colposcopy clinic
what is a colposcope
binocular microscope which allows a close examination of the vaginal and cervical epithelium. This allows the clinician to better assess the cervix and obtain a tissue sample in order to make a firm diagnosis
Which types of epithelium covers the ectocervix and endocervix?
ecto- squamous epithelium
endo - columnar epithelium
where is the position of the squamcolumnar junction? (SCJ)
it is not fixed - changes throughout life under the influence of oestrogen.
in younger women, where does the scj tend to be visible?
On the ectocervix: can see red columnar epithelium area near to the cervical os and then the paler squamous epithelium surrounding it
Why does columnar epithelium on the cervx appear more red than squamous epithelium?
Because it consists of a single layer of cells and so the blood vssels are nearer the surface
What is a visible area of columnar cells seen on the surface of the cervix called?
an ectropion
Which subtypes of HPV are associated with genital warts?
6 and 11
What % of CIN3 will progress to invasive cancer if untreated?
50%
What can invasive cancer of the cervix present with
- post coital bleeding
- post menopausal bleeding
- intermestrual bleeding
- abnormal vaginal discharge
What is the appropriate management of CIN2 or 3?
loop excision of the transition zone - which is performed with a diathermy loop in the colposcopy clinic using local anaesthetic. Can be under GA if it’s a large area or if patient cannot tolerate. Tissue removed and sent to histology, only takes about 10 mins.
What is the TZ (transition zone) of the cervix?
area between the old squamo-columnar junction and the new one - area where dysplasia is most commonly seen due to all the squamous metaplasia going on.
What is the cure rate of LETZ (loop excision or the transition zone)
95% cure, 5% need a second LETZ which will then be curative in most cases.
what are the 2 main aetiological causes of PID?
- transmission - usually sexual related
2. iatrogenic
give 4 iatrogenic causes of PID
- IUD insertion
- hysterosalpingography
- endometrial biopsy
- uterine cutterage
What is a common investigation in a woman with abnormal bleeding where it is difficult to gain much info from a speculum/
endometrial pipelle sample / biopsy
What are the 3 most common organisms causing infection in PID?
- chlamydia trachomitis
- N gonorrhoea
- mycoplasma hominis
what are some risk factors for PID
- multiple sexual partners
- menstruating teens
- previous Hx of PID
- STIs
- non use of barrier contraceptive
give some differentials for PID
- ectopic pregnancy
- appendicitis
- ovarian cyst rupture
- ovarian torsion
- endometriosis
- UTI
What kind of pain is seen in PID?
severe recent onset bilateral lower abdominal pain
What investigations should you consider to confirm suspicion of PID?
- bHCG
- bloods: FBC, WCC. CRP, U+E, LFTs
- triple swabs: lack of infection doesn’t exclude PID
- urine dip and MSU
- TV USS pelvis
- CT abdo/pelvis - if suspecting abcess or ovarian cyst
- ? endometrial biopsy
- ?laparoscopy/hysteroscopy
what is the outpatient reginmen of antibiotics for a PID patient
cef + doxy + metro
500mg single dose IM ceftriaxone, then oral doxy 100mg bd and metronidaxole 400mg BD for 14 days
What advice should you give to patient regarding sex with partner after Tx for PID?
- avoid unprotected sex until patient and partner have completed follow up - finished course of Abx.
- partner hsould be offered broad spec Abx e.g. single dose azithromycin
- contact tracing within 6 months of symptoms
What are the complications of PID?
- Fitz Hugh curtis syndrome (rare - liver capsule inflammation & adhesions)
- infertility
- ectopic pregnancy (x6 more common)
- chronic pelvic pain
- Reiter’s syndrome
- preterm delivery
How many couples are affected by infertility?
15%
what is the syndrome in which males have more than one X chromosome - aka 47XXY
Kleinfelter syndrome
what are the 4 aetiological categories for infertility?
- anovulation
- male factor
- Fertilisation disorder
- implantation defect
What investigations should you consider in a couple presenting with primary infertility?
Male - semen analysis (motility, morphology, sperm count)
Female
- LH, FSH, day 3-5
- mid luteal progesterone (day 21)
- rubella
- TFTs (hyper/hypo thyroid can cause decreased feritlity and menstrual disturbances)
prolactin
- USS if thinking PCOS
- hysterosalpingogram
- laparoscopy and dye (looks for blocked tubes, adhestions, cysts, fibroids, infection)
- ovarian reserve testing
what is a normal male sperm count
40-300 million per ml is the normal range
anything <15 million/ml is considered a low sperm count
How does a mirena IUS prevent pregnancy?
Releases a progestogen hormone which is similar to progesterone - natural hormone produced by the ovaries.
Progestogen thickens the mucus from the cervix (opening of the womb), making it harder for sperm to move through it and reach an egg. It also causes the womb lining to become thinner and less likely to accept a fertilised egg. In some women, the IUS also stops the ovaries from releasing an egg (ovulation), but most women will continue to ovulate.
`in pregnancy, why does the corpues luteum not degenerate as it does in normal mensturation?
because in pregnancy hCg levels rise, which functions in a smilar way to LH which means that the corpus lutteum remains viable, therefore continues to produce progesterone. (In menstruation, LH and FSH become suppressed due to negative feedback from oestrogen and inhibin and so corpus luteum degenrates).
What actually causes the endometrium to shed in a period?
the corpus luteum degenerates due to low FSH and LH
this means progesterone production is suppressed
- this causes spiral arteries of the functional endometrium to contract, causing ischaemia - which is shed
What is the window of fertility?
5 days before ovulation, to 1-2 days after
normally ovulate on day 14 of cycle
Wha are the Rotterdam criteria for PCOS?
- polycystic ovaries (12+ on transvaginal ultrasound)
- oligomenorrhoea/amenorrhoea - (>35 days apart)
- hyperandrogenism (clinical / biochemical signs, or elevated testosterone)
what should you consider in the management of PCOS?
amen/oligomenorrhoea - mirena coil, COCP
insulin - metformin
hirsutism - weight loss, hair removal, eflornithine cream, anti-androgens e.g. yasmin
weight loss - orlistat, diet and exercise advice
infertility - SERMs e.g. clomifene citrate
What is the first line drug for infertility in PCOS
clomifene citrate - (SERM) -
How does clomifene citrate help fertility in PCOS
selective estrogen receptor modulator - so it inhibits oestrogen’s negative feedback suppression of LH and FSH, therefore high levels and high oestrogen help follicle maturation at the beginning of the cycle.
How long can you have clomifene for and what are the risks of long term use?
6 months, no more thna 1 year - risk of endometrial cancer
What must you warn patients about with the use of clomifene
- should not use for more than a year, risk of endometrial cancer
- higher risk of multiple pregnancy as more follicles may mature
- risk of ovarian overstimulation syndrome
What surgery can be offered to treat tubal damage infertility as a result of PID?
laprascopic adhesiolysis and salpingostomy
what methods of assisted conception are there?
- intrauterine insemination
- IVF
- intracytoplasmic sperm injection
- oocyte donation
- preimplantation genetic diagnosis
- surrogacy
what is the live birth rate after IVF treatment in a) ,35s and b) <40?
a) 35%
b) <10%
How do you help fertility in patients with cervical causes of fertility disorder, such as antisperm antibody production or cone biopsy?
intrauterine insemination (IUI)
What does CGIN mean?
cervical glandular intraepithelial neoplasm - abnormal glandular cells in the endocervix. Similar pre-cancer to CIN but rarer.
What blood test should you do to asess ovarian reserve
antimullerian hormone
What is the main solution to male factor infertility due to poor motility?
intracytoplasmic sperm injection
What is the chance of CINIII developing to cancer in 8-15 years?
30%
What % of cervical smear results are normal?
92%
What should be done if the cervical smear test is inadequate?>
should repeat within 6 months. If 3 tests are inadequate then should refer to colposcopy
What is the management for PPROM?
preterm premature rupture of membranes - admit, monitor closely infection markers and temperature to screen for sepsis (chorioamnionitis). Give prophylactic antibiotics - erythromycin for 10 days. Can give tocolytics to prevent labour and allow time to give corticosteroids to prevent fetal respiratory distress syndrome and NEC.
`what is the management of a DVT in pregnancy?
Depends on clinical suspicion of a PE… do a doppler ultrasound to look for the clot, can give LMWH –> clexane or enoxaparin usually. Warfarin is contraindicated as its teratogenic, and thrombolytics are dangerous as risk of maternal haemorrhage.
what is the management when you see Borderline dyskaryosis (HPV negative) on a cervical smear?
nothing - just repeat smear in 3 years
A 19-year-old woman at ten weeks gestation presents to her general practitioner with intermittent vaginal bleeding over the previous month and hyperemesis. Obstetric examination reveals a non-tender, large-for-dates uterus. These symptoms are strongly suggestive of which condition?
Molar pregnancy
What organisms most commonly causes bacterial vaginosis?
Gardnerella vaginalis
How do you diagnose bacterial vaginosis?
- clinical features of thin, ‘fishy’ grey discharge
- on microscopy clue cells - stippled vaginal epithelial cells
- vaginal pH >4.5
- positive whiff test (add potassium hydroxide - fishy odour)
What is the treatment of BV?
oral metronidazole for 5-7 days
What are the risks of BV in pregnancy?
- chorioamnionitis
- preterm labour
- low birth weight
- late miscarriage
On a CTG, what can reduced variability be caused by?
- foetal sleeping is the most common cause, should not be more than 40 mins
- foetal acidosis (and hypoxia)
- foetal tachycardia
- drugs - opiates/benzos/methyldopa
- prematurity
- congenital heart problems
what is defined as an acceleration on a CTG?
abrupt increase in baseline HR of >15 bpm for >15 seconds
what is defined as a deceleraton on a CG?
decrease of >15bpm for >15 seconds
what are early decelerations on a CTG and why do they happen?
- deceleration of >15bpm for >15seconds starting at the beginning of a contraction and recovering when the contraction stops - due to increased ICP due to squashing of the baby’s head which increase vagal tone
What is variable deceleration?
SHOULDERING - When decels occur unrelated to contractions, and vary in duration. Often seen in patients with decreased amniotic fluid volume, and often caused by cord compression
how can variable decelerations sometimes be resolved?
if the mum changes position - which can relieve the cord compression.
what are late decelerations and what do they indicate?
decels that begin at the peak of contractions and only recover after contractions have finished - indicates insufficient blood flow to the uterus and placenta and therefore potentially foetal hypoxia and acidosis
what can reduced utero-placental flow be caused by?
maternal hypotension
pre-eclampsia
uterine hyperstimulation
