Obgyn Flashcards
1
Q
prolactinoma pres
A
child bearing age females
amenorrhea/ oligomen
infertile
galactorrhoea
ED men
visual problems in macroadenoma (eyes on boobs)
RF: MEN-1 or FIPA mutations, oestrogen therapy
2
Q
Prolactinoma Ix
A
High serum prolactin
Pituitary MRI
Computerized visual field exam
3
Q
Prolactinoma tx
A
asympt = observation
sympt = 1st dopamine agonist (cabergoline or bromocriptine), 2nd = COCP, 3rd = trans-sphenoidal surgery, 4th = sellar radiotherapy
skip COCP if wanting to get preg
4
Q
What are charcoal swabs used for
A
- BV
- Candida
- Gonorrhoea (specifically endocervical swab after NAAT swab)
- Trich (specifically posterior fornix swab)
- Other bac, e.g. group B strep
5
Q
What are NAAT swabs used for
A
Directly for DNA or RNA via endocervical, vulvovaginal swabs or first catch urine:
- Chlamydia
- Gonorrhoea (after NAAT, charcoal is needed for sensitivities, etc)
- Mycoplasma genitalum (too slow growing for culture)
6
Q
what is seen on microscopy with BV
A
clue cells - usually Gardnerella vaginalis
7
Q
BV tx and advice when prescribing
A
asymptomatic = none
otherwise metronidazole orally 400mg 2x day 5-7 days or vaginal gel
preg = oral
advise avoid alcohol for duration of tx
alternative = clindamycin
8
Q
thrush organism
A
candida albicans
9
Q
thrush classic pres
A
cottage cheese thick, white discharge, not smelly
itching and irritation around vag and vulva
soreness or stinging during sex or urination
satellite lesions rash (fungus causes this)
10
Q
thrush tx
A
if preg = clotrimazole 500mg via pessary single dose (anti-fungal) not tablets!
pessaries can cause damage condoms etc so alternative contraception for 5 days after use
non-preg = single dose fluconazole or clotrimazole oral tablet 140mg (contraindicated in SSRIs)
11
Q
trich organism
A
Trichomonas vaginalis = protozoan single-celled parasite with flagella, spread through sex
12
Q
trich pres and results on ix
A
frothy and yellow green discharge
strawberry cervix (colpitis macaluris) bc of tiny haemorrhages
charcoal swab taken from posterior fornix of vag
13
Q
trich tx
A
metronidazole same as BV
14
Q
chancroid organism
A
Gram-negative coccobacillus – Haemophilus ducreyi
15
Q
chancroid pres
A
PAINFUL genital ulcer – soft, ragged edges, 1-2cm
Fluctuant lymphadenitis (bubos)
16
Q
chancroid ix
A
gram stain ulcer and bubo aspirates - school of fish coccibacilli seen
culture and PCR shows h.dycreyi
Syphillis, HSV, HIV should all come back neg. Repeat HIV after 3 months to confirm
17
Q
chancroid tx
A
azithro 1mg oral single dose
ciproflox 500mg oral 2x for 3 days (not in preg)
18
Q
Behcet’s three pres
A
oral ulcers
genital ulcers
anterior uveitis
19
Q
chlamydia organism
A
gram -ve intracellular chlamydia trachomatis
20
Q
what is lympthogranuloma and its tx
A
strain of chlamydia unilaterally affecting painless ulcer, lymph nodes, inflam of rectum (proctitis, presenting as change in bowel habits, tenesmus) and groove sign, increasingly identified in MSM HIV positive, tx = doxy 100mg 2x daily for 21 days
21
Q
chlamydia ix
A
NAAT is diagnostic
vag exam shows pelvic or ab tenderness, cervical excitation, inflamed cervix, purulent discharged
22
Q
chlamydia tx
A
- 1st doxycycline 100mg 2x for 7 days
- Contraindicated in preg and breastfeeding – azithromycin, erythro or amox
TOC at 6 weeks
23
Q
syphilis organism
A
treponema pallidum – spirochete
21 day incubation
24
Q
syphilis primary stage
A
PAINLESS genital ulcer, hard raised edges (chancre), usually resolves 3-8 weeks, local lymphadenopathy in genital areas
25
syphilis secondary stage
systemic symptoms of skin or mucous membranes, e.g. maculopapular rash, low-grade fever, lymphadenopathy, alopecia, oral lesions, Condylomata lata (grey wart-like lesions around genitals and anus), usually after chancre has healed.
26
syphilis tertiary stage
many years after initial infection, multi-organ pres, esp development of rare gummas (soft, non-cancerous growth), aortic aneurysms
poss neurosyphilis - headache, altered behaviour, dementia, Tabes dorsalis (demyelination affecting spinal cord posterior columns), Ocular syphilis (eyes), paralysis, sensory impairment
Argyll-Robertson pupil – a constricted pupil that accommodates when focusing on near object, but doesn’t react to light. Often irregular shaped and referred to as ‘prostitutes pupil’
27
syphilis tx and tx SEs
Single deep IM dose of benzathine benzylpenicillin
oral doxy 2nd line
neurosyph - aqueuous benpen
SE = Jarisch-Herxheimer reaction – fever, chills, tachy, rash, literally pt will feel like they’re dying
28
HSV-1 causes what and lies dormant in what nerve ganglia?
cold sores (herpes labialis)
trigem ng
29
HSV-2 causes what and lies dormant in what nerve ganglia?
genital ulcers - multiple, tender, erythematous, painful
sacral ng
30
herpes gold std ix
NAAT swab
31
herpes tx
Aciclovir 200mg 5x a day for genital herpes
32
herpes in preg tx - meds and mode of birth
<28 weeks = aciclovir + prophylactic aciclovir from 36 weeks + normal delivery if asymptomatic
28 weeks = aciclovir + prophylactic aciclovir from 36 weeks + c section
33
genital warts caused by what strains of HPV
6 and 11
34
genital warts tx
- Multiple, non-keratinized warts = podophyllotoxin 0.5% solution or 0.15% cream, imiquimod 5%, sinecatechins 10%
- Solitary, keratinized warts = ablative methods – cryotherapy, excision, electrocautery
35
gonorrhoea organism
Neisseria gonorrhoeae = gram negative intracellular diplococci
Infects mucous membranes with columnar epithelium, e.g. endocervix, urethra, rectum, conjunctiva and pharynx
36
gonorrhoea tx
- Single dose IM ceftriaxone 1g if sensitivities not known or if preg
- Single dose oral ciprofloxacin 500mg if sensitivities known
Follow-up TOC 72 hours after treatment for culture (symptomatic pts), 7 days after tx (RNA NAAT) or 14 days after tx (DNA NAAT)
37
gonorrhea common complications
1. infertility
2. PID
epidymo-orchitis (men), prostatitis, conjuctivitis, septic arthritis etc.
- Gonococcal conjunctivitis in neonates – ophthalmia neonatorum – contracted from mother during birth, medical emergency, associated with sepsis, perforation of eye and blindness
- Disseminated Gonococcal Infection (GDI) = untreated gon infection where bac spreads to skin and joints. Causes skin lesions, polyarthralgia, migratory polyarthritis, tenosynovitis, systemic symptoms
38
HIV screening test options
1st fourth gen lab combined test for HIV antibodies and p24 antigen - window period of 45 days
Point-of-care HIV antibody tests - results within minutes- 90 day window period
39
normal range CD4 count
500-1200 cells/mm3
<200 = high risk infections
40
HIV tx
specialist centre / GUM referral
ART meds - aim for normal CD4 count and undetectable viral load (<20 copies/ml)
Prophylactic co-trimaxole if CD4<200 bc risk PCP
Close monitoring CVD, yearly smears, vaccinations (avoid BCG and typhoid bc live)
41
Preg HIV monitoring and meds
36 weeks viral load checked
<50 copies/ml = normal vag delivery
>50 = consider pre-labour c section
>400 = pre-labour c-section
IV zidovudine as infusion during labour+delivery if viral load unknown or >1000, then as prophylaxis for baby. avoid breastfeeding.
42
PEP how many hours after exposure
within 72 hrs
43
pubic lice organism
Phthirus pubis
44
pubic lice tx
refer gum, contract tracing, etc
Insecticides: Permethrin 5% cream or Malathion 0.5% aq solution
decontamination clothes etc
45
How often is mammo screening
every 3 years for women between 50-70 yrs
annually if high risk + chemoprevention offered: tamoxifen if premeno, anastrozole if postmeno (except if osteoporosis). Offered risk-reducing bilateral mastectomy or bilateral oophorectomy
46
most common metastases of breast cancer
2Ls and 2Bs:
lungs, liver, bones, brain
47
triple assessment for breast cancer
1. clin assessment (hx+exam)
2. imaging (US or mammography)
3. histology (fine needle aspiration or core biopsy)
48
what is neoadjuvant therapy
chemo to shrink tumour before surgery
49
what is adjuvant chemo
chemo after surgery to reduce recurrence
50
what med supresses lactation
cabergoline
51
tender
palpable
benign, warty lesion
with clear /blood-stained nipple discharge
papilloma
52
nipple producing thick sticky substance
peri-menopausal
mammary ductal ectasia
also known as plasma cell mastitis
53
symptoms fluctuating with menstrual cycle
tender lump
fluctuating breast size
fibrocystic breast changes
54
small and mobile (breast mouse)
painless
smooth
round
well-circumscribed
firm
fibroadenoma
55
painless
firm
irregular
fixed in local structure
skin dimpling or nipple inversion
associated with oil cyst
possibly after trauma to breast
fat necrosis
56
firm
mobile
painless
after stopping lactating
galactocele
57
large
fast-growing
40-50yrs old
phyllodes tumour (usually benign)
rapid phyllis even when old
58
smooth
well-circumscribed
mobile
fluid filled
more tender before periods
breast cysts
59
RF breast cancer
increased hormone exposure
- early menarche
- late menopause
- nulliparity / late first preg
- oral contraceptives or HRT
mutations
- BRCA
- advancing age
- caucasian
- obesity
- alcohol and tobacco use
- hx breast ca
- previous radiotherapy
60
massive RF for mastitis
smoking
61
two week wait for breast if:
unexplained breast lump >30 yrs
unilateral nipple changes >50 yrs
62
consider urgent referral for breast if:
- Unexplained lump in axilla in pts >30 yrs
- Skin changes suggestive to breast cancer (dimpling or oedema – peau d’orange)
63
non urgent breast referral if:
<30 yrs
64
tx for hyperemesis gravidarum
rest, avoid triggers, bland food, ginger, accupressure
1st meds = antihistamines (oral cyclizine, promethazine)
2nd meds = oral ondansetron (not in first trimester bc cleft palate) or metoclopramide (EPSEs if used > 5 days)
65
what is the Hyperemesis gravidarum triad
- 5% pre-preg weight loss
- Dehydration
- Electrolyte imbalance
66
admit for hyperemesis gravidarum if?
- Nausea/vomiting unable to keep down liquids/ oral antiemetics
- Continued vomiting w ketonuria and or weight loss (>5% of body weight) despite tx w oral antiemetics
- Confirmed or suspected comorbidity
67
absolute contraindications UKMEC4 for COCP
FB SUBMITS
- factor V leiden
- breast cancer (current)
- SLE
- uncontrolled htn
- breastfeeding <6 weeks postpartum
- migraine with aura
- IHD / stroke
- thromboembolitic disease
- smoking >15 cigs a day and >35 yrs
68
2 COCP pills missed
week 1?
week 2?
week 3?
1 - emergency contraception if unprotected sex was had
2 - no need for emergency contraception
3 - finish pills current pack + omit 7 day pill free interval
69
UKMEC4 for pop
current breast cancer
70
miscarriage tx
< 6 weeks = expectant management if no complications
> 6 weeks = refer to EPAU
misoprostol
surgical = manual vacuum aspiration can be done if <10 weeks
71
switching from POP to COCP, how many days extra protection?
7 days
72
mastitis tx
continue breastfeeding and simple analgesia/ warm compresses
if no improvement 12 hrs later, give oral fluclox
73
how long does POP take to first work
2 days
74
emergency contraception within 120 hrs
ulipristal
75
emergency contraception for an asthmatic
levonorgesterel within 72 hrs
76
induction of labour if bishop score <_6
vaginal prostaglandins / oral misoprostol
consider balloon catheter
77
induction of labour if bishop score >6
amniotomy and IV oxytocin infusion
78
best measure of ovulation
prog levels 7 days before last day of menstrual cycle
79
cystocele surgical tx
anterior colporrhapy
80
stress incontinence tx
1st = pelvic floor muscle training
lifestyle (weight loss, caffeine reduce, smoking reduce)
2nd = duloxetene
81
urge incontinence tx
1st = lifestyle + bladder retraining
2nd = anticholingergics (oxybutynin, tolterodine, etc.) or mirabegron
82
hormone levels in menopause
low oestrogen and prog
high LH and FSH
83
depo injection SEs
weight gain + osteoporosis
84
asherman's pres and ix/tx
- Typically after recent d&c, uterine surgery or endometritis, with:
- Secondary amenorrhoea (absent periods)
- Sig lighter periods
- Dysmenorrhoea
- Poss infertility
gold ix/tx = hysteroscopy
People cause hysterical (hysteroscopy 1st tx) damage, Vansh tries to repair (adhesions), people take an absent period from alcohol (lighter periods, amenorrhoea)
85
what is the name of the phenomenon associated with lichen sclerosis
Koebner phenomenon - signs and symptoms worse with friction e.g. tight underwear
86
lichen sclerosis tx
clobetasol propionate 0.05% (dermovate) for 4 weeks
87
lichen sclerosis associated with what conditions and cancer
autoimmune e.g. T1DM, alopecia, vitiligo, hypothyroid
Risk of squamous cell carcinoma of vulva
88
atrophic vaginitis tx contraindicated in what conditions
topical oestrogen:
breast cancer
angina
VTE
89
vulval cancer typical pres
old age 75+
immunosupression
lichen sclerosis
HPV
vulval lump
ulceration
lymphodenopathy
labia majora affected
90
cervical cancer most common type
squamous cell
91
what HPV strains are associated with cervical cancer
16 and 18
92
cervical cancer RF and typical pres
HPV association
COCP use >5 yrs
smoking
fhx
HIV
increased no. full term pregs
poss exposure to diethylstilbesterol during fetal development (was used to prevent miscarriages before 1971)
asymptomatic / non specific
post-coital bleeding
abnormal bleeding, discharge, pain
93
smear schedule based on age?
- Under 25: invited 6 months before
- 25-49: every 3 years
- 50-64 – every 5 years
- 65+ - only if recent abnormal test
94
when can you have a smear after pregnancy
12 weeks post-partum
95
smear cell process
- speculum exam, cells collected from cervix and deposited into preservation fluid (liquid based cytology)
- high-risk HPV test
- if positive, then examined for dyskaryosis
96
what do you do if hrHPV comes back inadequate
- repeat sample within 3 months
- if two consecutive inadequate samples = colposcopy
97
endometrial cancer cell type
adenocarcinoma
98
endometrial cancer RFs and protective factors
Depend on pt’s exposure to unopposed oestrogen (oestrogen without progesterone)
- Increased age
- Earlier onset menstruation/ late menopause
- Oestrogen only HRT
- No or fewer pregs
- Obesity
- PCOS
- Tamoxifen
- T2DM and HNPCC or Lynch syndrome
protective:
- COCP
- mirena coil
- more pregs
- smoking
99
endometrial cancer ix
TVUS
pipelle biopsy
hysteroscopy w biopsy
100
endometrial ca tx
Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO – removel of uterus, cervix and adnexa)
101
endometrial polyps gold std ix and tx
TVUS
hysteroscopy
102
endometriosis typical pres
cyclical pelvic pain
dysmenorrhoea
deep dyspareunia
poss retroverted uterus
103
Older woman >30yrs
Menorrhagia
Large boggy uterus
Painful cramps
Typical pres of?
Adenomyosis
104
adenomyosis tx
tranxemic acid if no pain
mefenamic acid if pain
if contraception wanted- 1st Mirena coil, 2nd COCP
MY condition, bc of the tranexamic and mefenamic acid
105
Fibroids typical pres
Fat, black, old, vit D association (FiBrOiDs)
menorrhagia
poss abd mass - bloating, increased urinary freq
anaemia
dyspareunia
106
fibroids tx
<3cm = Mirena coil (IUS) 1st line, symptomatic management
>3cm = refer to gynae, symptomatic tx, GnRH before surgery, poss myomectomy (only tx whilst preserving fertility)
107
ovarian cancer RF anf PF
anything that increases duration pt is ovulating for
- age
- BRCA
- early onset periods, late menopause
- no pregs
- HRT
- obesity
- smoking
- use of clomifene
protective
- COCP
- preg
- breastfeeding
108
early satiety, bloating, pelvic pain, poss masses, urinary symptoms, older female
suspect what
ovarian cancer
109
PCOS rotterdam criteria
2/3 needed:
- oligoovulation/ anovulation
- hyperandrogenism/ hirtutism
- polycystic ovaries on US
110
PCOS ix and results
raised testo
raised LH
raised LH to FSH ratio
normal FSH
low SHBG
gold = TVUS showing string of pearls/ polycystic ovaries
diabetes screen OGTT
111
PCOS tx
reduce endometrial cancer risk: induce bleed with COCP, mirena coil or cyclical prog
infertility: 1st weight loss if overweight, or clomifene if normal weight. 2nd = metformin
hirtsutism: weight loss, COCP (co-cyprindiol)
acne: 1st COCP (co-cyprindiol), consider retinoid
112
co-cyprindiol SE
risk of VTE - stop 3 months after use
113
PID tx
CDM (cef, doxy, metro)
114
sepsis six?
GIVE
- o2
- IV abx
- fluids
TAKE
- urine output
- blood cultures
- lactate
115
trimethoprim MOA and SE in first semester
folate antagonist - neural tube defects
116
how often is the depo injection given
IM, every 12 weeks
117
criteria and tx for low, mod and high risk ectopic
low:
- unruptured
- adnexal mass <35mm
- no visible heartbeat
- no sig pain
- no bleeding
- HCG <1500 IU/l
- patient is able to return for follow-up
repeat bHCG on day 2,4,7 to show level falling
mod:
same as above but
- HCG <5000 IU/l
- confirmed absence of intrauterine preg on US
IM methotrexate
severe:
- pain
- adnexal mass >35mm
- visible heartbeat
- HCG >5000 IU/l
- instability, etc
- or 1st line if a women wants it
surgery - laprascopic salpingectomy 1st (removes fallopian) or salpingotomy 2nd (saves fallopian tubes)
118
molar preg pres
severe morning sickness
vag bleeding first or second trimester
increased enlargement uterus
abnormally high hCG
thyrotoxicosis
119
termination of preg meds
oral mifepristone
then 48 hrs later, vaginal misoprostol
preg test after 2 weeks to confirm
120
gestinational diabetes cut off values
fasting >5.6mmol/l
2 hours >7.8mmol/l
(5,6,7,8)
121
PET high risk factors + prophylaxis
CHAD
CKD
Hx htn or pet
Autoimmune conditions
Diabetes
75mg aspirin od from 12 weeks to birth
122
PET seizure med, its SE and tx
IV mag sulfate
bronchodilator, monitor resp function
if distress, tx with calcium gluconate
123
PET tx
1) labetalol
2) nifedipine
3) methyldopa
admit if over 160/110
124
PET complications
HELLP
Haemolysis
Elevated Liver enzymes
Low Platelets
125
contraindication for iron infusion
active infection
allergy
126
what is the VTE prophylaxis + when is it contraindicated
LMWH from 28 weeks onwards, stopped during labour, then continue 6 weeks postnatally
contraindicated w PPH, spinal anaesthesia, epidurals
127
P-PROM tx
abx - erythro for 10 days (preventing chorioamniotitis)
steroids to mature lungs
induction of labour from 34 weeks
127
PPROM, maternal pyrexia + tachy and fetal tachy
chorioamniotis
128
Tocolytic med examples
Nifidipine
Terbutaline
128
what is given after instrumental delivery
single dose co-amox
129
shoulder dystocia tx
call for help
mcrobert's manouevre
suprapubic pressure
consider episiotomy
130
placenta praevia RF
chossi
C section
hx
older
smoking
structural
IVF
131
PPH amount after vag delivery vs c section
500ml after vaginal delivery
1000ml after C section
132
primary vs secondary PPH
- Primary PPH = bleeding within 24 hours of birth
- Secondary PPH = from 24 hours to 12 weeks after birth
133
When do you give anti-D prophylaxis and what is it
IM anti-D injections to rhesus neg women at 28 weeks gest and birth if baby is rhesus positive
also at any time sensitisation could occur, e.g. APH, ectopic preg surgery, abortion (if after 10 weeks gest), amniocentesis, trauma, within 72 hrs
then Kleinhauer test at 20 weeks to assess
134
most common cause of neonatal sepsis? and its tx?
maternal GBS
IV abx (ben pen/ pen G) during labour (around 4 hrs before delivery) to mother
135
LUTS
HDFUSS
haematuria
dysuria
frequency
urgency
smelly
suprapubic pain
136
most effective form of emergency contraception
copper IUD
then consider ulipristal (not in asthma) or levonorgestrel
137
what condition is associated withpost-coital bleeding
cervical cancer
138
what are the stages of fetal descent through the birth canal
Descent
Engagement
Flexion
Internal rotation
Crowning
Extension of presenting part
External rotation of head
Delivery
139
What is AFI and MVP and what are the cut offs
Amniotic fluid index - how deep fluid in 4 areas added up
Mean vertical pocket - deepest area of fluid
oligo = AFI < 5cm, MVP < 2cm
poly = AFI >25cm, MVP >8cm
140
what cancers does the COCP protect against and increase the risk of?
protect (protects the vowels):
- endometrial
- ovarian
increase risk:
- breast
- cervical
141
PID + RUQ pain is indicative of what?
fitz hugh curtis
