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Obs and Gynae Flashcards

1
Q

What is an ovarian cyst

A

A fluid filled sac in the ovary, may be benign or malignant

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2
Q

What are the risk factors for ovarian cyst

A
  • Family Hx
  • Obesity
  • Smoking
  • Early menarche/late menopause
  • BRCA 1/2
  • Nulliparity
  • HRT- oestrogen only
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3
Q

What are protective factors for ovarian cyst

A
  • Multiparity
  • Breastfeeding
  • Combined oral contraceptive
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4
Q

How you calculate risk of malignant ovarian cyst

A
  • RMI (Risk of malignancy index) score
  • 1 for pre-menopause, 3 for post-menopause
    x
  • 0 for 0 features on USS, 1 for 1 and 3 for 2+
    x
  • CA125 score
    RM| 250+ NEEDS REFERRAL TO GYNAE
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5
Q

How might ovarian cysts present

A
  • Chronic pelvic pain
  • Deep dyspareunia
  • Vaginal bleeding
  • Frequency/constipation (cyst pressing on bladder/bowel)
  • Weight loss/ malaise/ sweats
  • Acute sudden onset severe pain in torsion/rupture
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6
Q

What investigations might you perform for ovarian cysts

A
  • USS
  • Bloods
  • Biopsy
  • CA125
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7
Q

How would you treat ovarian cysts

A 
BENIGN
- Watchful waiting
- Cystectomy 
MALIGNANT
- Hysterectomy + bilateral salpingo-oophorectomy + lymph nodes
- Chemo/radiotherapy
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8
Q

What is polycystic ovarian syndrome (PCOS)

A
  • PCOS is characterised by excessive androgen production and presence of multiple cysts on the ovaries
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9
Q

Describe the pathophysiology of PCOS

A
  • Excess LH production causes excess ovarian production of androgens (testosterone)
  • Insulin resistance also occurs
  • Despite the increased levels of LH the raised androgens stop an LH surge occurring so ovulation is not triggered meaning follicles remain as cysts in the ovaries
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10
Q

How might PCOS present

A
  • Excess weight gain
  • Male pattern hair (alopecia + facial/chest/back hair)
  • Amenorrhoea/oligomenorrhoea
  • Chronic pelvic pain
  • Acne/oily skin
  • Infertility
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11
Q

What investigations might you do in PCOS

A
  • USS of ovaries
  • Bloods (testosterone and LH raised), TFTs to rule out thyroid
  • ?cortisol
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12
Q

What is the diagnostic criteria for PCOS

A
  • Rotterdam criteria (2 of 3)
    1) Polycystic ovaries on USS
    2) Clinical or biochemical signs of hyperandrogenism
    3) Oligo/anovulation
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13
Q

How would you manage PCOS

A

Tailored to individual symptoms
Oligo/amenorrhoea (trigger ovulation to dec. cancer risk)
- Combined oral contraceptive or progesterone analogue
Obesity
- Lifestyle advice
- Orlistat / off licence metformin
Infertility (for people wanting to conceive)
- Clomifene +/- metformin
Hirsutism
- Anti-androgen medication

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14
Q

What are fibroids

A
  • Benign tumour of the uterine smooth muscle
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15
Q

What are the risk factors for fibroids

A
  • Prev. fibroids/ family Hx
  • Early menarche/ late menopause (growth thought to be stimulated by oestrogen)
  • Inc. age
  • African-American
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16
Q

How might fibroids present

A
  • Most are asymptomatic
  • Heavy periods
  • Pelvic pain/ deep dyspareunia
  • Constipation/ frequency/ Abdo. distention
  • Subfertility
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17
Q

What investigation might you do for fibroids

A
  • USS

- Bloods

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18
Q

How might you manage fibroids

A
  • Watch and wait
  • Tranexamic acid
  • GnRH analogues goserelin (not a long term option due to demineralisation of bone)
  • Hysterectomy/ myomectomy/ Hysteroscopy + removal of fibroids
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19
Q

What is endometriosis

A
  • Endometrial tissue growth in areas outside uterine cavity. Common areas include ovaries, peritoneum, bladder and pouch of Douglas.
  • Most common in 25-40
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20
Q

What are the risk factors for endometriosis

A
  • Early menarche
  • Family Hx
  • Heavy periods/ short cycles
  • Uterine defects
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21
Q

How might endometriosis present

A
  • Cyclical pelvic pain (may be constant)
  • Heavy, painful periods (dysmenorrhoea)
  • Subfertility
  • Painful bowels
  • Deep dyspareunia
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22
Q

What investigations might you do for endometriosis

A
  • USS

- Laproscopy (gold standard)

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23
Q

How might you manage endometriosis

A
  • Pain - Analgesic ladder
  • Periods - COCP or merina coil
  • Surgical excision
  • Hysterectomy + bilateral salpingo-oophorectomy
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24
Q

What is Pelvic inflammatory disease (PID)

A
  • An infection of the female upper genital tract

- Mostly caused by STIs (chlamydia/gonorrhoea)

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25
What are the risk factors for PID
- Sexually active - IUD/pelvic surgery - Prev. PID/STI - Unprotected sex - Recent partner change
26
How might PID present
- Pelvic/lower abdo. pain - Deep dyspareunia - Post- coital bleeding - Abnormal offensive discharge - Menstrual abnormalities - Dysuria - Fever/ N+V/ severe abdo pain (advanced)
27
What investigations might you do for PID
- Endocervical swab - STI screen - Urine dip (rule out UTI) - Pregnancy test (rule out ectopic)
28
How might you manage PID
- Broad spectrum antibiotics - Analgesia - Avoid sex - Contact tracing
29
What complications can arise from PID
- Ectopic pregnancy (scarring of fallopian tubes) - Infertility - Chronic pelvic pain
30
What is a Bartholin's cyst
- A fluid filled sac within one of the Bartholin's glands in the vagina - They secrete mucus to help lubricate vagina, can get blocked leading to a cyst or abscess
31
What are the risk factors for Bartholin's cyst
- Vulvar surgery - Previous cyst - STIs can cause cysts/ abscess
32
How might Bartholin's cyst present
- Mostly asymptomatic - Cyst- Soft, non-tender vulval lump - Abscess - Hard, painful, vulval lump (may be cellulitis) - Superficial dyspareunia - Vulvar Pain
33
What investigations might you do for Bartholin's cyst
- Clinical diagnosis - Biopsy in suspicious/ over 40 - STI screen if indicated
34
What is the management of Bartholin's cyst
- Watch + wait - Drainage with word catheter - Antibiotics if systemically unwell
35
What is bacterial vaginosis
- An infection of the lower genital tract, occurring due to disturbance of the normal vaginal flora causing an increase in pH
36
What are the risk factors for bacterial vaginosis
- Sexually active - Douching/ overwashing vagina - Antibiotics - IUD - Black
37
How might bacterial vaginosis present
- White thin, fishy smelling discharge | - Usually no pain or itchiness
38
What investigations might you do for bacterial vaginosis
- Clinical diagnosis | - High vaginal smear
39
How might you manage bacterial vaginosis
- Metronidazole oral or vaginal gel
40
What is vulvovaginal candidiasis
- A fungal infection of the lower genital tract (aka. thrush/yeast infection)
41
What are the risk factors for vulvovaginal candidiasis
- Pregnancy - Diabetes - Antibiotics - Steroids/immunosuppression
42
How might vulvovaginal candidiasis present
- Itchiness/ pain - White curd like discharge usually inoffensive - Satellite lesions/ redness - Dysuria
43
What investigations might you do for vulvovaginal candidiasis
- Usually clinical diagnosis - Urine dip to rule out UTI - Smear in recurrent/ complicated
44
How might you manage vulvovaginal candidiasis
- Vaginal clotrimazole | - Oral fluconazole
45
What is urinary incontinence
- The involuntary leakage of urine
46
What are the two main types of urinary incontinence
1) Stress - Involuntary leakage of urine due to increases in intra-abdominal pressure 2) Urge - Aka. over-active bladder syndrome. Presence of urgency without UTI or other obvious pathology
47
How might stress incontinence present
``` - Leakage of urine on exertion eg. Laughing Coughing Sneezing Exercise ```
48
How might urge incontinence present
- Patient will complain of urgency resulting in leakage | - May also be frequency and nocturia
49
What investigations might you do for urinary incontinence
- Urine dip to exclude UTI - Frequency volume chart - In stress is normal, in urge frequency is raised
50
How do you manage stress incontinence
- Lifestyle changes - Pelvic floor exercises/ physio - Surgery- tension free vaginal tape - Duloxetine (if surgery fails/contra-indicated)
51
How do you manage urge incontinence
- Lifestyle changes - Bladder re-training - Anti-cholinergics- oxybutynin - botulinum toxin A (botox) - Surgery
52
What is the menopause
- Cessation of menstruation | - Average age is 51
53
When can menopause be diagnosed
- After 12 months amenorrhoea | - If hysterectomy diagnosed at onset of menopausal symptoms
54
What is the perimenopause
- Period leading up to menopause | - Characterised by irregular periods, hot flushes, mood swings and urogenital atrophy
55
What are the symptoms of the menopause
- Hot flushes - Mood swings/ irritability - Decreased sex drive - Aches/pains - Dry vagina
56
What are the long term consequences of the menopause
- Stroke/ CVD - Dementia - Osteoporosis
57
What does HRT cause increased risk of
- Stroke - Breast cancer - Venous thromboembolism - Must weigh up risks vs benefits and be wary when giving to patients at inc. risk of these conditions
58
What are the types of HRT
- Combined sequential (oestrogen + progesterone 12-14 days per 28 - causes a bleed) - Combined continuous (Oestrogen + progesterone daily - bleed free) - Mirena coil - Tibolone (synthetic Oestrogen + progesterone, equivalent to combined cont.)
59
What is premature ovarian insufficiency
- Menopause at less than 40 years old - Can be natural or iatrogenic causes - Mostly idiopathic
60
How do you manage premature ovarian insufficiency
- Hormone replacement - Dec. symptoms and risk of oestrogen deficiency - Continue until at least 51 yrs
61
What is the aetiology of cervical cancer
- 3rd most common in world, 12th in uk - Primarily of younger people - peak at 25-29 - Strong association with HPV, hence vaccination scheme in schools
62
What are the risk factors for cervical cancer
- HPV!!!!! IMPORTANT - Smoking - Family Hx - Oral contraceptive pill long term - STIs
63
How might cervical cancer present
- Abnormal vaginal bleeding - Dyspareunia - Pelvic pain - Vaginal discharge - B- symptoms - Often are picked up on cervical cancer screen
64
What investigations might you do for cervical cancer
- If pre-menopausal then do a chlamydia screen, if negative then colposcopy + biopsy - If post-menopausal then colposcopy + biopsy - CT/MRI
65
How might you manage cervical cancer
- Surgical - may preserve fertility, or hysterectomy - Hysterectomy + bilateral salpingo-oopherectomy (full pelvic clearance) - Chemo/radiotherapy
66
What are the risk factors for endometrial cancer
- Early menarche/ late menopause (inc. proliferation) - Low parity - HRT (only oestrogen) - Tamoxifen - Inc. age - PCOS - Obesity
67
How might endometrial cancer present
- Post menopausal bleeding (most common) - Vaginal discharge - B-symptoms
68
What investigations might you do for endometrial cancer
- Transvaginal USS - Biopsy/ hysteroscopy + biopsy - CT/MRI for staging
69
How do you stage endometrial cancer
FIGO staging Stage I – Carcinoma confined to within uterine body. Stage II – Carcinoma may extend to cervix but is not beyond the uterus. Stage III – Carcinoma extends beyond uterus but is confined to the pelvis. Stage IV – Carcinoma involves bladder or bowel, or has metastasised to distant sites.
70
How might you manage endometrial cancer
- Hysterectomy + bilateral salpingo-oopherectomy | - Chemo/radiotherapy
71
What is an ectopic pregnancy
- Any pregnancy which has implanted outside the uterine cavity - Common sites include fallopian tubes (most common), ovaries, cervix and peritoneum
72
What are the risk factors for ectopic pregnancy
- PID - Past ectopic - Endometriosis - Pelvic surgery - IUD - IVF
73
How might an ectopic pregnancy present
- Recent onset lower abdo./ pelvic pain - Vaginal bleeding - Shoulder tip pain - Vaginal discharge
74
What investigations might you do for ectopic pregnancy
- Urine B-HCG - USS - If no pregnancy seen on USS and urine B-HCG >1500 then offer laparoscopy for diagnosis - Blood B-HCG
75
How might you manage ectopic pregnancy
1) Expectant (rare) - Monitor blood B-HCG 2) Medical - IM methotrexate - Monitor bloods, if not falling then repeat dose 3) Surgical - Salpingectomy - Salpingotomy if need to preserve fertility
76
What is a miscarriage
- A loss of a pregnancy at less than 24 weeks gestation | - More common less than 12 weeks than 12-24 weeks
77
What are the risk factors for miscarriage
- Previous miscarriage - Maternal age >30-35 - Uterine abnormalities/surgery - Obesity - Smoking
78
How might a miscarriage present
- Vaginal bleeding | - Crampy pain (like period pains)
79
What investigation might you do for miscarriage
- Transvaginal USS | - Serum B-HCG
80
How might you manage miscarriage
1) Expectant - Allow POC to pass naturally 2) Medical - Give mifepristone followed by vaginal misoprostol (prostaglandin analogue) 24-48 hours later 3) Surgical - Removal via. vacuum or excavation
81
Describe a threatened miscarriage
``` CLINICAL - Small bleed +/- pain, cervix is closed TV USS - Viable pregnancy MANAGEMENT - Reassure/ treat bleeding if required ```
82
Describe an inevitable miscarriage
``` CLINICAL - Heavy bleed/ clots, pain, cervix open TV USS - Viable or non-viable pregnancy MANAGEMENT - Medical/ surgical/ expectant ```
83
Describe a missed miscarriage
``` CLINICAL - Usually asymptomatic TV USS - No foetal heartbeat MANAGEMENT - Medical/ surgical/ expectant ```
84
Describe an incomplete miscarriage
``` CLINICAL - Bleed/ clots, pain, TV USS - Partially expelled POC MANAGEMENT - Medical/ surgical/ expectant ```
85
Describe a complete miscarriage
``` CLINICAL - Hx bleed/ clots, pain TV USS - No POC MANAGEMENT - Refer to GP ```
86
What are the moderate risk factors for pre-eclampsia
- Nulliparity - BMI >35 - Multiple pregnancy (twins+) - Family Hx pre-eclampsia - Maternal age 40+ - Pregnancy interval 10+ years apart
87
What are the high risk factors for pre-eclampsia
- Prev. pre-eclampsia - Autoimmune disease - CKD - Diabetes - Hypertension If 2+ moderate or 1+ high then give 75mg aspirin
88
How might pre-eclampsia present
- Headache - Oedema - Visual changes - Epigastric pain - Hyper-reflexia
89
What is the diagnostic criteria for pre-eclampsia
- B.P >140/90 - Proteinuria - >20 wks. gestation
90
What investigations might you do for pre-eclampsia
- B.P | - Bloods - FBC, LFT, U&E
91
How might you manage pre-eclampsia
- Inc. monitoring - Anti-hypertensives - 1st line labetalol, 2nd line nifedipine - Delivery
92
What is Eclampsia
- Occurrence of one or more convulsions in a pre-ecplamptic woman
93
How might eclampsia present
- Seizure/ convulsions - Jaundice - Headache - Oedema - Visual changes - N+V
94
How might you manage eclampsia
1) Stop seizure - Magnesium sulphate 2) IV Anti-hypertensives - Labetalol 3) Deliver baby when mother is stable via. C-section
95
What are the definitions for small for gestational age (SGA) and foetal growth restriction (FGR)
- <10th centile of estimated foetal weight or <10th centile of abdominal circumference - A pathological process in which the foetus' growth is restricted, commonly by genetic abnormalities or placental insufficiency
96
What investigations might you do for FGR
- USS - plot growth on growth chart - Uterine artery doppler (absent/reversed end-diastolic flow) - Karyotyping
97
How would you manage FGR
1) Surveillance - UAD every 14 days - Change modifiable risk factors 2) Delivery - Absent/reversed EDF on UAD = urgent C-section
98
What are some of the complications of FGR
- Still birth - Cancer - Hypothermia - Obesity - Birth asphyxia
99
What is an Antepartum haemorrhage (APH)
- >50mls of bleeding at >24 weeks before birth
100
What are the common and important causes of APH
``` Common - Cervical ectropion - Unexplained Important - Placental abruption - Placenta previa ```
101
What is placental abruption
- Premature separation of the placenta from the uterine wall
102
What are the risk factors for placental abruption
- Previous abruption - Pre-eclampsia - Polyhydramnios - Smoking/drug use - Multiple pregnancy
103
How might placental abruption present
- Painful vaginal bleeding | - Woody uterus
104
What investigations might you do for placental abruption
- FBC/clotting - Foetal CTG - USS
105
How do you manage placental abruption
- Maternal resuscitation | - C-section
106
What is placenta previa
- Where the placenta is partially or fully attached to the lower part of the uterus Minor - Not covering the cervical Os Major - Covering cervical Os
107
What are the risk factors for placenta previa
- Previous placenta previa - Maternal age >40 yrs - Multiple pregnancy (eg. twins) - High parity
108
What investigations might you do for placenta previa
- FBC/Clotting - Foetal CTG - USS
109
How do you mange placenta previa
- Maternal resuscitation | - C-section
110
What is primary PPH
- A loss of >500mls of blood within 24hrs of delivery - Minor = 500-1000mls - Major >1000mls
111
What are the 4 Ts for causing PPH
Tone - Uterine atony (most common) - Failure of uterus to contract following delivery Tissue - retained placental tissue Tears - episiotomy, instrumental delivery, C-section all inc. risk Thrombin - Clotting abormalities
112
How might you manage PPH
- Fluids/blood/resuscitation - Bimanual compression to stimulate uterine contractions - Drugs to stimulate uterine contractions eg. syntocinon - Repair trauma/manually evacuate tissue
113
What is cord prolapse
- When the umbilical cord descends through the cervix alongside or before the presenting part of the foetus - This causes foetal hypoxia due to compression of the cord and arterial vasospasm when exposed to cold atmosphere
114
What are the risk factors for cord prolapse
- Prematurity - Breech presentation - Abnormal/unstable lie - AROM
115
Why might you suspect cord prolapse
- Always considered in non-reassuring foetal heart and absent membranes
116
How might you manage cord prolapse
- AVOID HANDLING THE CORD - Elevate foetus pressing on cord - Encourage into left lateral position - Emergency C-section
117
What are the stages of labour
``` Stage 1 - Latent/active Stage 2 - Passive/active Stage 3 - Delivery of placenta ```
118
Describe stage 1 of labour
``` Latent - Cervix <4cm dilated - Contractions every 5-20 mins - Do not encourage pushing Active - Cervix dilated 4-9cm - Contractions every 2-10 mins - Do not encourage pushing Management - V.E every 4 hrs - If failing to progress (should progress 1cm every two hours) then AROM/oxytocin/membrane sweep ```
119
Describe stage 2 of labour
``` Passive - not pushing Active - Encourage pushing - Cervix 9cm+/ fully dilated - Contractions every 2-5 mins Management - May need episiotomy/ forceps/ ventouse ```
120
Describe stage 3 of labour
- Delivery of placenta - Cord clamp - May need traction/ oxytocin
121
What are the 4 Ps for successful labour
``` Power - Adequate contractions Passage - Pelvic abnormalities Passenger - Lie/position - Size of baby Psychology - Support ```
122
How might chlamydia present
``` 50% of men and 70% of men are asymptomatic - Dysuria - Abnormal discharge Women - Deep dyspareunia - Lower abdo pain Men - Testicular pain ```
123
What investigations might you do for chlamydia
``` - Full STI screen Women - First catch urine, vulvo-vaginal or endocervical swab Men - First catch urine or urethral swab ```
124
How do you treat chlamydia
- Doxycycline 100mg 2x daily - IM azathioprine 1g single dose - Sexual abstinence/contact tracing
125
How might gonorrhoea present
- Abnormal discharge - Dysuria - Dyspareunia - Lower abdo pain
126
What investigations might you do for gonorrhoea
- Endocervical/vaginal swab | - First catch urine sample
127
How do you treat gonorrhoea
- IM ceftriaxone 1g
128
What are the potential complications of gonorrhoea and chlamydia
``` Women - PID - Ectopic/infertility Men - Epididymo-orchitis - Infertility Chlamydia can cause reactive arthritis ```
129
How might primary syphilis present
- Papule on genitals which develops into a painless ulcer (chancre) - Usually a singular painless, non itchy and hard ulcer
130
How might secondary (if left untreated) syphilis present
- Skin rash (on hands and soles of feet) - Fever - Malaise/arthralgia - Weight loss - Painless lymphadenopathy - Elevated plaque like lesions on moist skin (axilla, inner thighs, genitalia)
131
How do you investigate syphilis
- Swab from and active lesion | - Serology
132
How do you treat syphilis
``` Early - Penicillin IM x1 dose Late - Penicillin IM weekly for 3 weeks Contact tracing/sexual abstinence ```
133
How might Trichomonas vaginalis present
- Many cases asymptomatic - Offensive vaginal odour - Abnormal discharge - Itchy vulva/foreskin - Dysuria - Dyspareunia - Strawberry cervix
134
How might you investigate Trichomonas vaginalis
- High vaginal swab | - First void urine sample/urethral swab
135
How might you treat Trichomonas vaginalis
- Metronidazole 2g x1 | - Sexual abstinence/contact tracing
136
What is hyperemesis gravidarum
- Persistent vomiting in pregnancy that causes weight loss in excess of 5% of pre-pregnancy weight and ketosis
137
How might hyperemesis gravidarum present
- Can't keep food/fluids down - Weight loss - Malnutrition - Dehydration - Tachycardia
138
What investigations might you do in hyperemesis gravidarum
- Urine dip to check for UTI and ketones | - U&Es to check electrolyte levels
139
How might you manage hyperemesis gravidarum
- Hospital admission for fluid resuscitation and electrolyte balancing - Anti-emetics
140
What are the types of FGM
Type 1 - Partial or full removal of the clitoris Type 2 - Partial or full removal of clitoris and labia Type 3 - Narrowing of vagina via cutting/stitching of labia, with or without removal of clitoris Type 4 - Any other non-medical procedures that harm female genitalia
141
What is primary amenorrhoea
- Failure to start periods, need investigation at 16, or 14 if no breast development
142
What is secondary amenorrhoea
- Stopping of periods for >6 months, other than for pregnancy
143
What is menorrhagia
- Excessive bleeding during periods
144
What is primary dysmenorrhoea
- Painful periods with no underlying pathological cause
145
What is secondary dysmenorrhoea
- Painful periods caused by pathology

Finals (11 decks)

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