Obs and Gynae Flashcards
Define Pre-eclampsia
New onset Hypertension (>140/80mmHg) after week 20 of pregnancy + either proteinurea or evidence of maternal organ dysfunction
What proteinuria findings are required for a pre-eclampsia diagnosis?
Either;
Urine Protein:creatinine ratio >30mmol/L
or
Albumin:creatinine ratio >8mmol/L
What types of maternal organ dysfunction are required for a diagnosis of pre-eclampsia?
Kidney - Renal dysfunction
Liver - Liver dysfunction (raised ATP/AAT)
Brain - Neurological dysfunction (stroke, blurred vision, ect)
Blood - Haematological disease (DIC, Thrombocytopenia, haemolysis)
Uterus - Uterine dysfunction - still birth, abnormal uterine artery doppler
Give some symptoms of pre-eclampsia (5)
Severe headache
Vomiting
Severe pain below ribs
Vision problems - Blurry/flashing lights
Sudden onset swelling of hands, feet or face
What is the target BP for pre-eclamptic patients?
135/85mmHg
What prophylactic management is given to pre-eclamptic patients? And what criteria must they fulfull?
Aspirin (75-150mg) from week 12 to birth.
Criteria;
x1 High risk factor OR >1 moderate risk factor
Give 5 high risk factors for pre-eclampsia
Previous hypertensive disease during pregnancy
Chronic kidney disease
Diabetes
Autoimmune disease - SLE/Antiphospholipid syndrome
Chronic hypertension
What are the 1st, 2nd and 3rd line therapies for chronic hypertension in pregnancy?
1st - Labetalol
2nd - Nifedipine
3rd - Methyl-dopa
What antihypertensive treatments are contraindicated in pregnancy? (5)
ACEi
ARBs
Statins
Thiazides
Thiazide diruetics
Give 6 moderate risk factors for pre-eclampsia
Nulliparus
Age >40
BMI >35
>10 year gap between pregnancies
Family history of hypertensive disease during pregnancy
Multi-fetal pregnancy
Define uterine fibroid
A benign tumour of the uterine myometrium
What are uterine fibroids composed of and what is their transverse appearance?
Whorled appearance.
Composed of smooth muscle cells and fibrous connective tissue
Describe the 3 types of uterine fibroid
Intermural - Restricted to myometrium
Submucosal - Involves endometrium, may bulge into uterine cavity
Subserosal - Bulges outside of uterus (may press on surrounding organs)
What is the name of the opening between the fallopian tubes and the uterine cavity?
Tubal Ostia
Give symptoms of uterine fibroids (3)
Heavy (sometimespainful) menses (>7 days bleeding)
Pressure symptoms;
- Rectum (constipation)
- Bladder (frequency)
- Ureter (hydronephrosis - flank pain)
Subfertility
- Submucosal can block tubal ostia
- Subserosal can inhibit implantation
Give a complication of uterine fibroids
Degenerations;
Red degenerations - Decreased blood flow - Presents with uterine pain and tenderness
Hyaline or cystic degenerations - fluid filled.
Investigations for uterine fibroid diagnosis (2)
Transvaginal Ultrasound. MRI if US intolerated
FBC - anaemia
Give some treatment options for uterine fibroids.
Monitor - Monitor size and growth (if asymptomatic)
Medical - GnRH agonist- Leuprorelin
Surgical - Hysteroscopic myomectomy (preserves fertility)
- Uterine artery embolisation (doesn’t preserve fertility)
- Hysterectomy
For the treatment of uterine fibroids, why would uterine artery embolization be favoured over a hysteroscopic myomectomy?
Favoured in high risk patients;
- Obese
- Chronic Hypertension
- Diabetes
How does Leuprorelin work and what are it’s main side effects?
GnRH agonist. Induces a temporary menopausal state by inhibiting the production of oestrogen.
Main side effects; osteoporosis, hot flushes, depression
What testing should be offered to rule out pre-eclampsia between 20 and 35 weeks in women with chronic hypertension?
Placental Growth Factor (PIGF) testing
What 3 clinical features must be present for diagnosis of hyperemesis gravidarum?
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
What electrolyte imbalances are commonly seen in hyperemesis gravidarum?
Hyponatraemia and Hypochloraemia
Give 5 clinical features of hyperemesis gravidarum
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance (hyponatraemia/hypochloremia)
Ketosis
Hypovolemia
Give 5 risk factors for hyperemesis gravidarum
Trophoblastic disease (choriocarcinoma)
- Will present with a high Beta HCG level)
Multiple pregnancies
Hyperthyroidism
Nulliparity
Obesity
What are the 1st and 2nd line treatments for hyperemesis gravidarum?
1st line - Antihistamines - Oral Cyclazine or Promethazine
2nd line - Antiemetics - Ondanstatron or Metoclopromide
Why is metoclopromide use limited to 5 days?
Can cause extrapyramidal side effects (such as eyes locking in one place)
What risk does ondanstatron use bring during pregnancy?
Increased risk of fetus developing cleft lip/palate
Give 5 complications of hyperemesis gravidarum
Wernicke’s encephalopathy
Mallory weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Fetus; small for gestational age, pre-term birth
Name 2 methods of emergency hormonal contraception.
Emergency Pill - Levonorgestrel
Morning-after pill - Ulipristal
What is the maximum timeframe that levonorgestrel (emergency pill) can be taken in?
Within 72 hours of unprotected sexual intercourse.
What is the maximum timeframe that ulipristal (morning after pill) can be taken in?
No later than 120 hours after intercourse
How long after ulipristal (morning after pill) use can hormonal contraception be restarted?
5 days after Ulipristal use
How long should breastfeeding be delayed after ulipristal (morning after pill) use?
1 week after Ulipristal use
What conditions are required to make Lactational amenorrhea an effective contraceptional method?
Amenorrhea + Baby Aged <6 months + Exclusively Breast Feeding
Give 3 advantages and disadvantages of lactational amenorrhea as an effective contraceptional method.
Advantages;
LAM is effective for up to 6 months post partum.
It encourages breast feeding for up to 6 months post partum
Can be used immediately after childbirth
Disadvantages;
Doesn’t protect against STIs (inc HIV)
Becomes unreliable after 6 months when other foods get introduced
Frequent breast feeding can be inconvenient
Give 2 long term complications of hysterectomy with antero-posterior repair
Enterocoele (small bowel prolapse
Vaginal vault prolapse
How is vaginal vault prolapse managed?
Sacrocolpopexy (using mesh to lift top of vagina and adhere to sacrum)
Name and describe 2 types of breech presentation
Frank breech (Hips flexed and knees extended)
Footling breech (feet are positioned next to buttocks- carried higher morbidity)
What management is recommended is fetus is breech at 36 weeks gestation? and when do NICE recommend it’s use?
External cephalic version (ECV)
NICE recommend ECV is offered from 36 weeks in nulliparous and from 37 weeks in multiparous.
If a baby is in breech position at the time of delivery, what method of delivery is recommended?
Caesarean section
Give 6 contraindications to External Cephalic Version (ECV)
Where caesarean delivery is required
Antepartum haemorrhage within last 7 days
Abnormal cardiotocography
Major uterine anomaly
Ruptured membranes
Multiple pregnancy
What is the ectocervix and what cell type is it made up of?
Outer part of the cervix that opens into the vagina
Stratified Squamous Non Ketatinized Epithelium
What is the endocervix and what cell type is it made up of?
The opening of the cervix that leads to the uterus
Mucus secreting simple columnar epithelium.
Which of the 4 breast quadrants is most common for malignancies to present?
Superior lateral quadrant (axillary tail)
What congenital abnormality does folic acid help prevent?
Neural tube defects (i.e spina bifida)
What groups of women are at increased risk of neural tube defects? (6)
Previous child with NTD
Diabetes mellitus
Women on antiepileptics
Obese
HIV +ve taking co-trimoxazole
Sickle Cell
Give 4 causes of folic acid deficiency
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
What type of anaemia occurs in folic acid deficiency?
Macrocytic, megaloblastic anaemia
Define endometrial hyperplasia
Irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio
What is the most common clinical feature of endometrial hyperplasia?
Abnormal uterine bleeding
(Heavy, intermenstrual, irregular, unscheduled (on HRT) or post-menopausal bleeding)
Give 5 risk factors for endometrial hyperplasia
Obesity
Anovulation (PCOS or Perimenopause)
Oestrogen secreting tumours - Granulosa cell tumours
Drug induced (tamoxifen or oestrogen replacement)
Post-menopause
What are the 2 types of endometrial hyperplasia
Endometrial hyperplasia without atypia
Atypical hyperplasia
What are the 1st, 2nd and 3rd line diagnostic tests (confirms diagnosis) for endometrial hyperplasia
1st line - Endometrial Biopsy (Dilation and Curettage)
2nd line - Diagnostic Hysteroscopy (if biopsy is inconclusive or if hyperplasia is in a polyp)
3rd line - Transvaginal Ultrasound Scan
What finding on a transvaginal ultrasound scan would suggest endometrial cancer?
Endometrial thickness >3/4mm
(caveat - cut off may be larger in women on HRT or Tamoxifen presenting with abnormal uterine bleeding)
What is the 1st and 2nd line medical therapy for endometrial hyperplasia WITHOUT atypia
1st line - Levonorstegrel-releasing intrauterine system (LNG-IUS)
2nd line - Oral Progesterone (Medroxyprogesterone/norethisterone)
What is the 1st line treatment for heavy menstrual bleeding?
1st line - Levonorstegrel-releasing intrauterine system (LNG-IUS)
Describe how women with endometrial hyperplasia without atypia should be monitored following treatment.
Endometrial surveillance should be conducted at 6 monthly intervals.
At least 2 consecutive 6 monthly negative biopsies are required for discharge.
What is the 1st line treatment for atypical endometrial hyperplasia?
Total hysterectomy
What monitoring requirement is required for women with endometrial hyperplasia wishing to conceive?
Disease regression should be achieved in at least 1 sample before attempting to conceive.
For a woman with endometrial hyperplasia on sequential HRT, how should her HRT treatment be changed?
Change from sequential to continuous progestogen (i.e using LNG-IUS or oral)
Give 4 tumour markers for endometrial cancer
CA-125, CA15-3, CEA, Prolactin
What medications are known to increase the risk of endometrial hyperplasia and cancer? (2)
Tamoxifen (breast cancer treatment)
Aromatase inhibitors (anastrozole, exemestane and letrozole)
What is tamoxifen and what is it’s MOA?
Selective oestrogen receptor modulator that inhibits proliferation of breast cancer by competitive antagonism of oestrogen receptors.
Why does tamoxifen promote development of fibroids, endometrial polyps and hyperplasia?
Acts as a partial agonist to oestrogen receptors in the vagina and uterus.
What hormone is responsible for endometrial hyperplasia?
Oestrogen
What hormone is responsible for endometrial shedding?
Progesterone
When does conception occur and how is a pregnant woman’s estimated due date calculated?
Conception occurs 2 weeks after the patient’s last period.
Calculation.
1. Determine first day of last menstrual period.
- Count back 3 months from that date.
- Add 1 year and 7 days to that date
What does the ectoderm give rise to?
Skin, Peripheral + Central nervous system, eyes and inner ears
What does the mesoderm give rise to?
Heart and circulatory system, bones, ligaments, kidneys and reproductive system
What does endoderm give rise to?
Lungs and intestines
What cells produce Beta human chorionic gonadotrophin (Beta-HCG)?
Trophoblastic cells of the placenta
Give 2 functions of beta HCG in early pregnancy?
Signals ovaries to stop releasing eggs.
Increases production of oestrogen and progesterone
What hormone is responsible for oedema in pregnancy? And why?
Corticotrophin Releasing Hormone (CRH).
Stimulates ACTH production (especially aldosterone and cortisol)
What is the most common type of anaemia in pregnancy?
Iron deficiency anaemia
What haematological finding would be seen in iron deficiency anaemia?
Microcytic hypochromic blood film .
When should pregnant women be screened for anaemia?
Early pregnancy (at booking appointment) and at 28 weeks.
What is the treatment for iron deficiency anaemia?
Low dose iron supplementation - 200mg Ferrous Sulphate daily
What is the 2nd most common form of anaemia in pregnancy?
Folate deficiency anaemia
What haematological finding would be seen in folate deficiency anaemia?
Macrocytic anaemia
What is the treatment for folate deficiency anaemia in pregnancy?
Folic acid 5mg per day
If a woman is <20 weeks pregnant and is not immune to varicella zoster virus (but is exposed), what treatment should they be given?
Varicella zoster immunoglobulin (VZIG) given ASAP
If a woman is >20 weeks pregnant and is not immune to varicella zoster virus (but is exposed), what treatment should they be given?
Varicella zoster immunoglobulin (VZIG) OR Antiviral (Acyclovir) 7-14 days after exposure
Give 5 symptoms of premenstural dysmorphic disorder
Depressed mood and irritability
Abdominal bloating
Fatigue
Breast tenderness
Headaches
During what phase of the menstrual cycle does premenstural dysmorphic disorder (and PMS) tend to present?
During the luteal phase (Day 14-28 - Post ovulation)
What physiological change happens during the luteal phase?
Endometrial lining of the uterus gets
What cell type does FSH bind to? and what do they stimulate production of?
Granulosa cells.
Stimulates production of aromatase, leading to production of oestrogen
What cell type does LH bind to? and what do they stimulate production of?
Theca cells.
Promotes production of Androstenedione, which later becomes oestrogen.
Where is progesterone produced? (2)
Corpus luteum
Placenta (at 8-12 weeks)
Name 3 forms of oestrogen and describe where their produced
E2 - Estradiol (most active)
E1 - Estrone (fat cells and adrenal glands)
E3 - Estriol (placenta)
What is the dominant form of oestrogen in the menopause?
Estrone (produced by fat cells and adrenal glands)
What is the dominant form of oestrogen during pregnancy?
Estriol (produced by the placenta)
Give 2 protective features of oestrogen
Cardioprotective (makes walls of blood vessels more flexible and lowers LDL levels)
Osteoprotective (sustains bone density)
What anticoagulation treatment should be offered to pregnant women at high risk of DVT? and why?
Low Molecular Weight Heparin
Warfarin can cross the placenta and is teratogenic
What treatment can be given to reverse the effects of LMWH in pregnant women?
Protamine sulfate
Give 3 side effects of protamine sulfate
Sudden fall in BP
Bradycardia
Pulmonary hypertension
When (in weeks) is the anomaly scan performed?
20 weeks
When (in weeks) is the first dose of Anti D prophylaxis given to rhesus negative women?
28 weeks
When (in weeks) is the early scan to confirm dates performed?
10 - 13+6 weeks
If a 37 week pregnant woman presents with severe pre-eclampsia (acute severe headache, vomiting, blurred vision and hypertension (>140/90) what is the appropriate management?
IV Magnesium Sulphate and plan immediate delivery
What is the appropriate management for any new hypertension (>140/90) after 20 weeks gestation + proteinuria?
Emergency referral to obstetrics
What is shoulder dystocia
Complication of vaginal cephalic delivery whereby the anterior fetal shoulder becomes stuck on the maternal pubic symphesis
What manoeuvre is performed to manage shoulder dystocia in pregnancy?
McRoberts’ manoeuvre (patient is asked to lie on their back with their legs pushed outwards and up towards their chest)
(hips fully flexed and abducted)
What additional measure can aid the effectiveness of a McRoberts’ manoeuvre?
Suprapubic pressure
What medication can be used to suppress lactation?
Cabergoline
What is the moa of cabergoline?
Dopamine receptor agonist which inhibits prolactin production, causing suppression of lactation.
What medication is given to soften the cervix in induction of labour?
Misoprostol (prostaglandin E1)
What medication is given to treat severe cholestasis during pregnancy?
Ursodeoxycholic acid
What supplementation should pregnant obese women be given? (BMI >30)
5mg folic acid
Define endometriosis
Endometriosis describes the growth of ectopic endometrial tissue outside of the uterine cavity
What is the gold standard investigation for endometriosis?
Laparoscopy
Give 4 symptoms of endometriosis
Chronic pelvic pain (worsens before onset of menses)
Dysmenorrhea
Dyspareunia
Subfertility
Give 2 clinical features you may find on examination of a patient with endometriosis.
Uterosacral ligament nodularity (on bimanual examination)
Pelvic mass (ovarian endometriomas - ‘chocolate cysts’)
What are the 1st, 2nd and 3rd line treatments for endometriosis?
1st - NSAIDs and/or Paracetamol
2nd - Combined Oral Contraceptive Pill or Progesterones
3rd - GnRH analogues (i.e leuprorelin)
Describe adenomyosis
Adenomyosis is characterised by the presence of endometrial tissue within the myometrium (due to hyperplasia of the endometrial basal layer)
Give 3 risk factors for adenomyosis
Multiparity (more common in multiparous women towards the end of their reproductive age)
Uterine fibroids
Endometriosis
Give 4 clinical features of adenomyosis
Dysmenorrhoea (painful menses)
Abnormal uterine bleeding
Chronic pelvic pain (aggravated during menses)
Globular, uniformly large uterus that is soft but tender on palpation
What may a transvaginal ultrasound/MRI show for a patient with adenomyosis? (2)
Asymmetric myometrial wall thickening.
Myometrial cysts
What hormone stimulates the proliferation of endometrium in endometriosis?
Oestrogen
What 2 bacteria most commonly cause pelvic inflammatory disease?
Neisseria Gonorrhoeae and Chlamydia trachomatis
What kind of bacteria is Neisseria gonorrhoeae and what type of agar can it be grown on?
Gram negative diplococcus
Grown on Chocolate Agar
Give 2 risk factors for PID
Multiple sexual partners/unprotected sex
History of prior STIs
Give 4 complications of PID
Fitz-High-Curtis syndrome (right upper quadrant pain, associated with peri-hepatitis)
Ectopic pregnancy
Tubo-ovarial abscess
Tubal infertility
What bacteria is associated with Fitz-Hugh-Curtis syndrome in PID?
Chlamydia trachomatis
What tests would you perform in a patient with PID to exclude other causes of their symptoms? (3)
Pregnancy test - Exclude ectopic pregnancy
High vaginal swab - Exclude bacterial vaginosis and candidiasis
Microscopy - Look for endocervical or vaginal pus cells (if absent, PID is unlikely)
Give 5 clinical signs of PID on examination
Lower (bilateral) abdominal tenderness
Adnexal tenderness
Cervical motion tenderness
Uterine tenderness (on bimanual examination)
Abnormal cervical or vaginal mucopurulent discharge (on speculum examination)
Give 4 differentials for PID
Ectopic Pregnancy
Ruptured corpus luteal cyst
Acute appendicitis
UTI
What is the antibiotic treatment regimen for treating PID?
Single IM dose of ceftriaxone + Oral Doxycycline (100mg) + Oral Metronidazole (400mg)
What type of antibiotic is ceftriaxone and give 3 side effects
Cephalosporin.
Abdo pain, Diarrhoea, agranulocytosis (rare)
What type of antibiotic is doxycycline and give 3 side effects
Tetracycline
Angioedema, Diarrhoea, Henoch-Schonlein purpura (IgA vasculitis rash)
Give 2 side effects of metronidazole
Dry mouth and myalgia (muscle ache)
What type of antibiotics are Ofloxacin and Levofloxacin and give 3 side effects
Quinolones
Decreased appetite, GI discomfort, QT prolongation
Give 3 symptoms of long QT
Syncope
Palpitations
Dizziness
What 3 symptoms primarily make up interstitial cystitis?
Urinary frequency, urgency and suprapubic pelvic pain (pain is relieved by voiding and worsened by bladder filling)`
What are the 3 types of ovarian cyst?
Follicular cyst (most common)
Corpus luteum cysts
Dermoid cysts (most likely to cause torsion)
Give 5 risk factors for ovarian cysts
Early menarche
Endometriosis
Polycystic ovarian syndrome
Pregnancy (3rd trimester)
Tamoxifen treatment
Give 3 clinical features of ovarian cysts
Pelvic pain
Bloating and early satiety
Palpable adnexal mass
What is the 1st line investigation for ovarian cysts?
Transvaginal Ultrasound
What is the most sensitive marker for epithelial ovarian cancer?
Human Epididymis Protein 4 (HE4)
Ovarian cysts of what size typically cause ovarian torsion?
> 6cm
Give 4 clinical features of ovarian torision.
Sudden onset pelvic/lower abdo pain
Nausea, vomiting or diarrhoea
Abdominal/pelvic tenderness
Palpable adnexal mass +/- tenderness (on palpation)
What is the most common type of ovarian cyst?
Follicular cyst
Give 2 risk factors for ovarian torsion
Ovarian Cysts >6cm
Dermoid cysts
What type of ovarian cysts is most likely to present with intraperitoneal bleeding?
Corpus luteal cyst
What effect does hyperandrogenism (in PCOS) have on insulin sensitivity
Increases insulin resistance, leading to hyperinsulinemia (increasing risk of developing type 2 diabetes)
What criteria must a patient fulfil to be diagnosed with metabolic syndrome?
3/5 of the following;
Elevated waist circumference (>88cm for women and >102cm for men)
Elevated triglycerides (>150mg/dl) or drug treatment for elevated triglycerides (fibrates/omega 3 acid ethyl esters)
Low HDL cholesterol (<40mg/dl for men, <50mg/dl for women) or drug treatment for low HDL
Elevated blood pressure or on antihypertensive treatment
Elevated fasting glucose (>100mg/dl) or drug treatment for elevated glucose
Give 4 diseases associated with PCOS
Metabolic syndrome
Insulin resistance (type 2 diabetes)
Endometrial cancer (due to unopposed oestrogen activity)
Non alcoholic fatty liver disease
Give 4 clinical features of PCOS
Irregular menses
Female of reproductive age (symptoms start at time of puberty)
Infertility
Skin conditions (acanthosis nigricans, hirsutism, acne, oily skin)
What medication can mask the symptoms of PCOS?
Oral contraceptives
What features are required for diagnosis of PCOS? (once other causes of irregular menses and hyperandrogenism have been excluded)
Infrequent/no ovulation (characterised by irregular menses)
Clinical and/or biochemical signs of hyperandrogenism (skin changes or increased total/free testosterone)
Polycystic ovaries on ultrasound scan
How are polycystic ovaries defined on US scan?
Defined as presence of 12 or more follicles (measuring 2-9mm in diameter) in one or both ovaries and/or increased ovarian volume >10cm3)
Give 4 other causes of hyperandrogenism in a patient with suspected PCOS and features that would help you exclude them.
Congenital Adrenal Hyperplasia (ambiguous genitalia)
Cushing disease (increased 24 hour urine free cortisol)
Hypothyroidism (increased TSH)
Acromegaly (increased IGF-1)
Suggest 2 biochemical markers which may be raised in PCOS
Raised LH/FSH
Raised testosterone
How is type 2 diabetes risk assessed in patients with PCOS with risk factors? (what are the risk factors) (3)
75 mg Oral glucose tolerance test.
Risk factors for use include;
Obesity (BMI >25kg)
Not Obese (BMI <25Kg) but have additional risk factors (>40 yrs old, history of gestational diabetes or FH or type 2 diabetes)
Non Caucasian ethnicity
How are symptoms of oligo/amenorrhoea managed in PCOS?
Prescribed medroxyprogesterone to induce withdrawal bleed, then refer for transvaginal US to assess endometrial thickness.
What is defined as prolonged amenorrhoea in PCOS?
<1 period every 3 months
What should pregnant women with PCOS be screened for? and how is this conducted?
Gestational diabetes
Offer 75g oral glucose tolerance test before 20 weeks gestation (if not performed preconception)
All pregnant women with PCOS should be offered OGTT at 24-28 weeks gestation
What stage of gestation should pregnant women with PCOS be offered OGTT?
24-28 weeks gestation
For a PCOS patient with infertility desiring fertility, what is the most appropriate management? (lifestyle changes, 1st line, 2nd line and adjunct)
Healthy lifestyle +/- weight loss
1st line - Letrozole
1st line - Clomifene
2nd line - Follitropin (gonadotrophin)
Adjunct - Metformin
What is the MOA for letrozole?
Selectively inhibits aromatase in peripheral tissues (thus blocking production of oestrogen)
What is the MOA for clomifene?
Non steroidal anti-oestrogen.
Stimulates the pituitary gland to increase secretions of FSH and LH, leading to increased negative feedback, thus blocking further oestrogen release
What is the 1st line treatment for a PCOS patient not desiring fertility?
Low Dose Combined Oral Contraceptive Pill
What class of drug is Drospirenone? (oral contraceptive pill)
Spironolactone analogue (has anti-androgen properties)
What should you do if Female Genital Mutilation is confirmed in a girl under 18?
Report to the medical team AND police within 1 month of confirmation
Define type 1 FGM
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
Define type 2 FGM
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
Define type 3 FGM
Narrowing of the vaginal orifice with creation of a covering seal by cutting or appositioning the labia minora/majora, with or without excision of the clitoris (infibulation)
Define type 4 FGM
All other harmful procedures to the female genitalia for non-medical purposes (pricking, piercing, incising, scraping, cauterization)
Name the top 3 countries where FGM is most prevalent
Somalia, Guinea, Djibouti
Name 3 common short term complications of FGM
Haemorrhage
Urinary retention
Genital swelling
Name 3 common long term complications of FGM
UTIs
Dyspareunia
Bacterial vaginosis
Define Turner’s Syndrome
Chromosomal disorder caused by either the presence of only one X chromosome or due to a deletion of the short arm of one of the X chromosomes
How is Turner’s syndrome denoted
45,XO or 45,X
What is the ‘classic’ presentation of Turner’s syndrome? (7)
Female
Webbed neck
Short Stature
Primary Amenorrhoea
Congenital Heart Defects
Poor social skills
Delayed/absent puberty
What congenital heart defects are common in Turner’s Syndrome? (2)
Coarctation of the aorta
Bicuspid Aortic Valve
What 4 conditions are Turner’s Syndrome Patients more at risk of developing?
Crohn’s disease
Autoimmune thyroiditis
Hypothyroidism
Horseshoe Kidney
What is the gold standard diagnostic test for Turner’s syndrome?
Karyotype testing
What gonadotrophin levels indicate ovarian failure in Turner’s Syndrome? (2)
High FSH
Low AMH (anti mullerian hormone)
Give 4 pharmaceutical managements for Turner’s Syndrome
Growth Hormone - Somatropin
Weight/height gain - Oxandrolone
Low dose oestrogen - Estradiol
Ovarian HRT - Oestrogen + Progesterone
Turner’s Syndrome - What murmur would be heart in a patient with a bicuspid aortic valve?
Ejection Systolic Murmur
What syndrome is a common complication of infertility treatment? and how may it present?
Ovarian hyperstimulation syndrome.
Sudden onset (following egg retrieval) abdominal discomfort/distension, nausea and vomiting
Name 2 medications that may increase the risk of developing ovarian hypersensitivity syndrome
Gonadotropin
hCG
What forms of contraception are contraindicated in breast cancer? What should be offered instead?
All forms of hormonal contraception.
Offer Copper Intrauterine Device
Define Sheehan’s Syndrome
Aka Postpartum Hypopituitarism.
Describes decreased function of the pituitary gland following ischeamic necrosis due to hypovolaemic shock following birth.
Suspect in patients who suffered significant post-partum haemorrhage
Give 6 symptoms and 1 risk factor for Sheehan’s syndrome
Weight Gain
Hair Loss
Constipation
Feeling cold all the time
Amenorrhea
Struggle breast feeding
Risk factor ; Hypovolemia following severe post-partum haemorrhage
What form of HRT is the safest against Venous Thromboembolism?
Transdermal HRT
Give 3 common side effects of HRT
Nausea
Breast Tenderness
Fluid retention and weight gain
Give 3 possible complications of HRT
Increased risk of breast cancer
Increased risk of endometrial cancer
Increased risk of venous thromboembolism
When can the Combined Oral Contraceptive Pill be restarted after pregnancy? and why?
Restart after 3 weeks (21 days) due to increased risk of VTE post-partum
What 2 medications are present in the COCP
Ethinylestradiol and Levonorgestrel
Define premature ovarian failure (POF)
Cessation of menses for 1 year before the age of 40. May be preceded by irregular menstrual cycles
Give 3 strong risk factors for premature ovarian failure
Positive family history
Chemotherapy/radiation (breast cancer)
Autoimmune disease
What pathogen causes cervical cancer? (2)
HPV 16 and HPV 18
Describe 2 features of a threatened miscarriage
Painless vaginal bleeding before 24 weeks (typically occurs at 6-9 weeks)
Cervical os is closed
Describe 2 features of an inevitable miscarriage
Cervical os is open
Heavy bleeding with clots and pain
What investigation is used to identify placenta praevia?
Transvaginal Ultrasound Scan
Describe the management of post partum haemorrhage (1st, 2nd and 3rd line)
Immediate management - ABCDE and resuscitation
1st - Palpate uterus and catheterisation
2nd - IV oxytocin
3rd - Intrauterine balloon tamponade
What medication is given to facilitate the delivery of the placenta and prevent post partum haemorrhage?
Oxytocin/ergometrine
What 2 agents can be used to initiate labour?
Prostaglandin E1 (misoprostol)
Prostaglandin E2 (Dinoprostone)
What is a tocolytic? Give 3 examples
Agents used to suppress premature labour.
Indomethacin, Salbutamol and Terbutaline
What agent is used in medical abortion?
When is it’s use contraindicated? (2)
Mifepristone
Contraindicated in; Ectopic pregnancy and Acute Porphyria
How long after pregnancy can a patient restart the progestogen-only pill?
Immediately
When should a cervical smear be rescheduled to for pregnant women?
Until 12 weeks post-partum
Describe 3 stages of ovarian cancer
Stage 1 - Confined to the Ovaries
Stage 2 - Local Spread Within the Pelvis
Stage 3 - Spread beyond the pelvis to the abdomen
Give 3 tests used to Confirm Down’s Syndrome in Pregnancy (following a positive screen) and state when they can be used.
Cell Free Fetal DNA Testing (From <10 weeks gestation)
Chorionic Villous Sampling (from 13-15 weeks gestation)
Aminocentesis (from 15 weeks gestation - as dangerous in 1st trimester)
What pathogen is responsible for genital warts (aka condylomata acuminata)?
HPV 6 and HPV 11
What prophylaxis should a woman whom just experienced an inevitable miscarriage be given and why?
Anti-D immunoglobulin.
Due to potentially being exposed to fetal blood
What is the 1st line investigation for women presenting with menorrhagia with significant dysmenorrhoea (pain) or a bulky, tender uterus?
Transvaginal Ultrasound
(symptoms suggest adenomyosis)
What dose of folic acid should be given to low risk pregnancy women?
400mcg folic acid daily before conception to week 12
What dose of folic acid should be given to high risk pregnant women? and what constitutes high risk?
5mg folic acid daily before conception to week 12
MORE
M-Metabolic Disease (diabetes or Coeliac)
O- Obesity
R - Relative or personal Hx of Neural Tube Defects
E - Epilepsy (taking antiepileptic medications)
+Sickle Cell and Thalassaemia
In Cervical Smear testing, if a smear comes back hrHPV positive, what is the next step?
Cytology
In Cervical Smear testing, if a smear comes back hrHPV positive, but the cytology comes back negative, what is the next step?
Repeat smear test in 12 months
In Cervical Smear testing, if a positive smear is repeated in 12 months and it comes back hrHPV positive, and the cytology comes back positive, what is the next step?
Colposcopy
What is the 1st line investigation for women unable to conceive after 1 year of unprotected sex?
Day 21 progesterone test (conduct 7 days before period)
Tells us if the patient is actually ovulating
Hyperemesis Gravidarum treatment.
In which patients is cyclazine and promazine contraindicated? (4)
What should be used instead?
Hepatic impairment
Epilepsy
Urinary retention
Asthma, bronchitis or bronchiectasis (promethazine)
Prochlorperazine should be given instead
Hyperemesis Gravidarum treatment.
In which patients is metoclopromide and ondanstatron contraindicated? (3)
Long QT syndrome (ondanstatron)
Epilepsy (metoclopromide)
GI haemorrhage, obstruction or perforation (metoclopromide)
How long does it take for IUD (copper coil) to become an effective means of contraception?
Instantly?
How long does it take the Progesterone-only pill to become an effective means of contraception?
2 days
How long does it take for the combined oral contraceptive pill, implant and intrauterine system (hormonal coil) to become an effective means of contraception?
7 days
When is the booking appointment during pregnancy?
10 weeks
Define gestational diabetes and when it most commonly presents.
Gestational diabetes is defined as hyperglycaemia during pregnancy.
Most commonly occurs between weeks 24-28
What 2 assessments should diabetic patients be offered before/during pregnancy
Diabetic retinopathy assessment
Diabetic nephropathy assessment
What 3 nephrology results would suggest referral to a nephrologist before pregnancy?
Serum creatinine >120micromol/L
Urinary albumin:creatinine >30mg/mol
eGFR <45mil/min/1.73m2
What is the target blood glucose and HbA1c for a type 1 diabetic before pregnancy. (3)
Fasting plasma glucose - 5-7mmol/L on waking
Plasma glucose - 4-7mmol/L before meals at other times of day
HbA1c - <48mmol/mol
What is the 1st choice long acting insulin during pregnancy?
Isophane insulin (NPH insulin)
Give 5 risk factors for gestational diabetes
BMI >30kg
Previous macrosomic baby weighing >4.5kg
Previous gestational diabetes
Family history of diabetes (in 1st degree relative)
Afro/Caribbean ethnicity
On routine antenatal scan, what regent strip test results would warrant further testing to exclude gestational diabetes?
Glycosuria of 2+ or above on 1 occasion
Glycosuria of 1+ or above on 2 or more occasions
What test results are required to diagnose gestational diabetes? (2)
Fasting plasma glucose of >5.6mmol/L
OR
2 hour plasma glucose level of >7.8mmol/L
What investigations should be performed on a pregnant woman with risk factors for gestational diabetes?
75g 2 hour Oral Glucose Tolerance Test
Offer at 24-28 weeks
What investigations should be performed on a pregnant woman with a history of previous gestational diabetes?
Early self-monitoring of blood glucose
OR
OGTT asap after booking (whether in 1st or 2nd trimester) and further OGTT at 24-28 weeks if the first result is normal
What is the target fasting glucose level for pregnant women with any form of diabetes? (3)
Fasting <5.3mmol/L
AND
1 hour after meal = 7.8mmol/L
or
2 hours after meals = 6.4mmol/L
What is the plasma glucose target for a pregnant woman with diabetes on insulin?
> 4mmol/L
What should NOT be used to measure kidney function in pregnancy?
eGFR
How is fetal growth and wellbeing monitored for pregnant women with diabetes?
Ultrasound is used to measure fetal growth and amniotic fluid volume.
Conducted every 4 weeks from 28-36 weeks
What is the 1st, 2nd and 3rd line management for women with gestational diabetes with a fasting plasma glucose <7mmol/L
1st line - Lifestyle modification (improving diet, weight and exercise)
2nd line - Metformin (if blood glucose targets aren’t met in 1-2 weeks)
3rd line - Insulin (if blood glucose targets aren’t met with metformin)
What insulins are used during pregnancy? (2)
Long acting insulin - Isophane Insulin
Rapid acting insulin analogues - Aspart and Lispro
What prophylactic medication is given to pregnant women with diabetes to prevent NTDs?
5mg folic acid/day until 12 weeks gestation
What is the 1st line management for women with gestational diabetes with a fasting plasma glucose >7mmol/L
Insulin +/- metformin + lifestyle modification
What criteria must a pregnant woman with diabetes fulful to be offered Countinuous Subcutaneous Insulin Infusion (insulin pump)? (2)
Are using multiple daily injections of insulin
AND
Do not achieve blood glucose control without significant disabling hypoglycaemia
Give 5 complications of gestational diabetes
Fetal macrosomia
Shoulder dystocia
Fetal hypoglycaemia
Pre-eclampsia
Diabetic fetopathy
When should a retinal assessment be offered to pregnant women with pre-existing diabetes? When/why should it be repeated?
10 weeks
28 weeks
Repeat at 16-20 weeks if diabetic retinopathy is found at 10 weeks.
When is US monitoring of fetal growth and amniotic fluid volume offered to pregnant women with diabetes?
28 weeks (repeated every 4 weeks)
What type of deficiency can metformin cause? (what condition does it cause?)
Vitamin B12 deficiency
(macrocytic anaemia)
How long may a pregnancy test stay positive after a termination of pregnancy?
Up to 4 weeks
What does it suggest if a pregnancy test remains positive >4 weeks after a termination of pregnancy (2)
Incomplete abortion
Persistent trophoblast
What 3 findings on a combined screening test (12 weeks) would suggest a fetus has Down’s syndrome?
Raised beta-HCG
Low PAPP-A
Ultrasound - Shows thickened nuchal translucency
If a placenta previa (low lying) is found at the 20 week scan, what is the next point of action?
Rescan at 32 weeks
What grade placenta previa warrants C-section?
III/IV at 32 and 36-37 week scans
For how long is the Copper Intrauterine Device effective?
5-10 years
Describe the need for contraception after the menopause in >50 and <50 year olds
> 50 - Use contraception for 12 months after last period
<50 - Use contraception for 24 months after last period
What is HELLP Syndrome? and what are it’s features?
Severe form of pre-eclampsia.
H - Haemolysis
EL - Elevated liver enzymes
LP - Low platelets
Hypertension with proteinuria and epigastric/upper abdominal pain are also common
What is the gold standard investigation to diagnose placenta praevia?
Transvaginal Ultrasound
By when should most women feel their baby moving/kicking?
24 weeks
What medication is present in the implantable contraceptive?
Etonogestrel
Where is the implantable contraceptive usually implanted?
Subdermal, non-dominant arm
Why can the progestrogen only pill be started immediately post partum?
Because it doesn’t contain oestrogen, therefore doesn’t carry a risk of suppressing milk production or increasing risk of venous thromboembolism
Give 1 contraindication for epidural anaesthesia during labour
Coagulopathy
Define premature ovarian failure.
Results from what test (taken when) would suggest this diagnosis?
Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40
Elevated FHS levels (>30IL/U) in 2 samples taken 4-6 weeks apart
What ovarian pathology is associated with Meigs syndrome?
Ovarian fibroma
What symptoms are seen in Meigs syndrome?
Benign pelvic mass - Ovarian Fibroma
Ascites
Pleural effusion
What is the most common side effect of the progestogen only pill?
Irregular vaginal bleeding
Give 5 indications for the induction of labour
Prolonged pregnancy (>42 weeks)
Prelabour premature rupture of membranes after 34 weeks or at term
Diabetic mother >38 weeks
Pre-eclampsia, eclampsia or HELLP syndrome
Rhesus incompatibility
Give 7 contraindications for induction of labour
History of uterine rupture, previous high risk cesarean delivery
Placenta previa
Vasa previa
Transverse fetal lie
Cord prolapse
Active maternal genital herpes
Non-reassuring fetal heartbeat
What is the Bishops score and what are it’s interpretations?
Score used to assess whether induction of labour is required.
Score <5 indicates labour is unlikely to start without induction
Score >=8 indicates that the cervix is ripe so there is high chance of spontaneous labour or response to interventions that may induce labour.
What 5 parameters are used in the Bishop score?
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Fetal station
What stimulates the release of Oxytocin? (2)
Nipple stimulation
Stretching of cervix/vagina (i.e in membrane sweep)
What are the main effects of Oxytocin? (2)
Promotes uterine contractions during labour
Facilitates milk ejection reflex via myoepithelial cell contraction
What is misoprostol an analogue of?
Prostaglandin E1
Give 4 main effects of Misoprostol.
Relaxes vascular smooth muscle (vasodilation)
Increases uterine tone and softens the cervix (during labour)
Reduces gastric acid production
Stimulates production and secretion of mucous
Give 5 methods of inducing labour
Membrane sweep
Vaginal prostaglandin E1 - Misoprostol
Maternal oxytocin infusion
Amniotomy (‘breaking of waters’)
Cervical ripening balloon
What is the main complication of induction of labour and how is it defined?
Uterine hyperstimulation.
Defined as prolonged and frequent uterine contractions (tachysystole)
How is uterine hyperstimulation managed? (2)
Removing vaginal prostaglandins (misoprostol) and stopping oxytocin infusion
Use of Tocolytics - Terbutaline sulfate (Beta-mimetic)
What is Terbutaline Sulfate used for in pregnancy?
To manage uterine hyperstimulation
Give 5 contraindications of Terbutaline Sulfate use.
Placental Abruption
Antepartum haemorrhage
Eclampsia
History of cardiac disease
Hypertension
What is the main side effect of Terbytaline Sulfate?
Hypokalaemia (potentiated by theophylline use - think asthmatic)
Give 3 indications for forceps use in labour
Fetal/Maternal distress during second stage of labour
Failure to progress in second stage of labour
Breech presentation
Name 3 types of forceps and their uses
Piper - Used to deliver fetal head during breech delivery
Kielland - Enables rotation and traction of the fetal head
Simpson - Only enables traction of the fetal head
Describe stage 1 of labour
From the onset of true labour to when the cervix is fully dilated (10cm)
Describe stage 2 of labour
From full dilation to delivery of the fetus
Describe stage 3 of labour
From delivery of the fetus to when the placenta and membranes have been completely delivered
Describe the latent phase of stage 1 of labour (3)
Occurs during the onset of labour and ends at 6cm of cervical dilation
Characterised by mild, infrequent, irregular contractions
Change in cervical dilation <1cm/hour
Describe the active phase of stage 1 of labour
Occurs after the latent phase at >6cm cervical dilation.
Ends with complete (~10cm) cervical dilation.
Change in cervical dilation 1-4cm/hour
Give 2 methods of placental expulsion (3rd stage of labour)
Fundal massage (induces uterine contractions and stops bleeding)
Active management - Oxytocin (administered after cutting umbilical cord)
Define premature rupture of membranes (PROM)
Describes rupture of membranes occurring before the onset of labour at term
Give 5 risk factors for PROM
Ascending infection (common)
Smoking
Multiple pregnancy
Previous pre-term delivery
Previous PROM
List 3 complications of PROM
Pulmonary hypoplasia (underdevelopment of fetal lungs)
Chorioamnionitis (leading to premature labour/preterm birth, fetal distress and/or sepsis)
Umbilical cord prolapse
Describe the management of PROM (3)
Oral erythromycin - Given for 10 days
IM corticosteroids - To reduce risk of respiratory distress syndrome
Consider delivery at 34 weeks gestation
Define Preterm premature rupture of membranes (PPROM)
Describes rupture of membranes before onset of uterine contractions AND before 37 weeks gestation
Define pre-term labour
Describes regular uterine contractions with cervical effacement (thinning), dilation or both, before 37 weeks gestation
Define pre-term birth
Describes live birth between 20 - 36+6 weeks gestation
What prophylaxis is given to women at risk of preterm labour/birth? (2)
Vaginal progesterone
Prophylactic cervical cerclage
Premature labour prophylaxis is given to women who have both what?
A history of spontaneous preterm birth (up to 34 weeks pregnancy) or loss (from 16 weeks)
AND
Transvaginal ultrasound scan (between 16-24 weeks) showing cervical length of <25mm
Give 1 clinical feature of PPROM
Sudden ‘gush’ of pale yellow/clear fluid from the vagina (pooling)
How is PPROM diagnosed?
Speculum examination
PPROM - On speculum examination pooling is present, what is the appropriate management?
Offer erythromycin (prophylaxis for intrauterine infection)
Consider oral penicillin if erythromycin contraindicated
PPROM - On speculum examination NO pooling is present, what is the appropriate management?
Perform IGF-1 or Placental Alpha Macroglobulin 1 testing of vaginal fluid
Factors normally present in amniotic fluid
What combination of tests are used to diagnose intrauterine infection in PPROM (3)
CRP
White Cell Count
Measure Fetal Heart Rate - Cardiotocography
Define tocolysis
Tocolysis describes using medications to delay the delivery of a fetus in a woman presenting with pre-term contractions
What is the 1st line tocolytic and at what stage gestation is it offered?
Nifedipine (calcium channel blocker)
Offered for women between 24-26 weeks with intact membranes whom are suspected pre-term labor
What tocolytic is offered if Nifedipine is contraindicated?
Atosiban (Oxytocin receptor antagonists)
Nifedipine may be contraindicated in cardiac disease
Give 4 contraindications for tocolysis
Maternal drug interactions (i.e Myasthenia Gravis for Magnesium Sulphate or Aortic insufficiency for calcium channel blockers)
Chorioamnionitis
Antepartum haemorrhage with hemodynamic instability
Severe pre-eclampsia/eclampsia
If a woman has PPROM after 34 weeks and is positive for Group B Streptococcus, what should be offered?
Immediate induction of labour or C-Section
What is the most effective method of emergency contraception?
Copper IUD
When can the copper IUD be offered as emergency contraception? (2)
Up to 5 days after unprotected sex OR up to 5 days after estimated ovulation
How do urlipristal and levonorgestrel work as contraceptions?
Inhibit ovulation
What biomarker is raised in neural tube defects?
Alpha Feto protein
Define grade 1 (minor) placenta praevia
Placenta does not cover internal cervical os but ilying low
Define grade 2 (marginal) placenta praevia
Lower edge of placenta reaches the internal os
Define grade 3 (partial) placenta praevia
Lower edge of the placenta partially covers the internal cervical os
Define grade 4 (complete) placenta praevia
Placenta lies completely over the internal cervical os
In PPROM what should be administered antenatally to reduce the risk of respiratory distress syndrome?
IM corticosteroids
How long before elective surgery should the COCP be stopped? What should be offered instead?
4 weeks before
Switch to Progestogen only pill
What 1st line treatment for hyperemesis gravidarum is contraindicated in asthma? What should you give instead?
Promazine
Give Prochlorperazine instead
Between what ages does cervical cancer most commonly present?
25-29
What is the most common type of cervical cancer?
Squamous Cell Carcinoma (80%)
Give 6 risk factors for cervical cancer
Early onset of sexual activity (before 18)
HPV infection
Multiple sexual partners
History of STDs
Immunosuppression
Smoking
How is cervical cancer classified? Describe each classification (3)
Classified as CIN I-III (cervical intraepithelial neoplasia)
o CIN-I – Mild dysplasia (involves 1/3 of the basal epithelium)
o CIN-II – Moderate dysplasia (involves <2/3 of the basal epithelium)
o CIN -III – Severe irreversible dysplasia (involves >2/3 of the basal epithelium)
What term is used to describe the pre-malignant epithelial dysplasia seen in the early stages of cervical cancer?
Cervical intraepithelial neoplasia (CIN)
Where does cervical cancer most commonly arise?
Transformation zone - Location between the endocervix and ectocervix
Give 4 early symptoms of cervical cancer
Abnormal vaginal bleeding (post coital spotting)
Abnormal vaginal discharge (blood-stained or purulent malodorous discharge)
Dyspareunia
Pelvic pain
Give 3 late symptoms of cervical cancer (Stage 4)
Hydronephrosis (flank pain)
Bladder/Bowel obstruction
Fistula formation
Screening for cervical cancer is offered to all women between what ages?
25-64
How often is cervical cancer screening performed? (2)
25-49 - 3 yearly screening
50-64 - 5 yearly screening
Give 2 special considerations for cervical screening
Pregnancy - Screening is delayed until 3 months post-partum, unless missed screening or previous abnormal smears
Never been sexually active - Considered very low risk
What is the HPV first system?
Means that a cervical smear sample is first tested for HPV. If this is positive only then is a cytological examination performed.
If a cervical smear returns positive, what should be arranged?
Cytology
If cytology returns abnormal (following positive smear test), what should be arranged>
Colposcopy
Describe the Test of Cure (TOC) process for cervical cancer.
Patients being treated for CINI-III should be invited for a smear test 6 months after treatment
What staging is used to stage Cervical Cancer?
FIGO staging
Describe FIGO Stage IA cervical cancer (3)
o Confined to cervix
o Only visible on microscopy
o <7mm wide
Describe FIGO Stage IB cervical cancer (3)
o Confined to cervix
o Clinically visible
o >7mm wide
Describe FIGO Stage II cervical cancer (3)
o Extension of tumour beyond cervix but not to pelvic wall
o A = Upper 2/3 of vagina
o B = Parametrial involvement
Describe FIGO Stage III cervical cancer (4)
o Extension of tumour beyond cervix to the pelvic wall
o A = lower 1/3 of vagina
o B = Pelvic side wall
o Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III
Describe FIGO Stage IV cervical cancer
o Extension of tumour beyond pelvis or involvement of bladder or rectum
o A = Involves bladder or rectum
o B = Involves distant sites outside the pelvis
If cervical cancer is causing hydronephrosis or a non-functioning kidney, what FIGO stage is it considered?
Stage III
What treatment is offered for patients with IA cervical cancer desiring fertility?
Cone biopsy with negative margins
Give 2 complications of surgery for cervical cancer
Cone biopsies and radical trachelectomies can increase risk of pre-term birth in future pregnancies
Radical hysterectomies can cause ureteral fistulas
Give 4 short term complications of cervical cancer radiotherapy
Diarrhoea
Vaginal bleeding
Radiation burns
Pain on micturition
Give 3 long term complications of cervical cancer radiotherapy
Ovarian failure
Fibrosis of bowel/skin/bladder/vagina
Lymphoedema
What type of epithelial cell develops after HPV infection? (Cervical cancer)
Koilocytes
Give 4 characteristics of Koilocytes (HPV infection)
Enlarged nucleus
Irregular nuclear membrane contour
Nucleus stains darker than normal (hyperchromasia)
A perinuclear halo may be seen
Give 8 risk factors for Endometrial Cancer
- Obesity
- Nulliparity
- Early menarche
- Late menopause
- Unopposed oestrogen (HRT)
- Diabetes mellitus
- Tamoxifen
- PCOS
What histological type of endometrial cancer is most common?
Adenocarcinoma
Give 4 clinical features of endometrial cancer
Painless vaginal bleeding (early stage)
Post-menopausal bleeding
Pelvic pain
Palpable mass (uterine, fixed uterus, adnexal ect)
What is the 1st line investigation for endometrial cancer? What subsequent test is used to confirm the diagnosis?
Transvaginal ultrasound (>4mm thickness)
Hysteroscopy with endometrial biopsy
What is the treatment for endometrial cancer (women whom can tolerate surgery)?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
What is the treatment for endometrial cancer (women whom cannot tolerate surgery)?
Progestogen
Give 2 factors that are protective against endometrial cancer
Smoking
Combined Oral Contraceptive Pill
Give 1 complication of endometrial cancer.
Pyometra (accumulation of pus in the uterine cavity)
Anatomically, where is ovarian cancer most likely to present?
Distal end of the fallopian tube
What type of cancer are the majority of ovarian cancers?
Serous carcinomas (epithelial in origin)
Give 4 risk factors for ovarian cancer
Positive family history (BRCA1 or BRCA2 genes)
Many ovulations (early menarche, late menopause, nulliparity)
Have never used the COCP
Increasing age
Give 4 clinical features of ovarian cancer
Pelvic bloating/distension
Non-specific pelvic pain
Urinary frequency or urgency
Early satiety or diarrhoea
Give 3 extra-pelvic symptoms of ovarian cancer
Pleural effusion (right sided)
Ascites
Bowel Obstruction
What biomarker is usually raised in ovarian cancer?
CA-125
What should be arranged if CA-125 is >35IU/mL in suspected ovarian cancer?
Urgent ultrasound of abdomen and pelvis
Give 2 factors that are protective against ovarian cancer
Combined Oral Contraceptive Pill (fewer ovulations)
Many pregnancies
What is the most common type of breast cancer?
Invasive ductal carcinomas
What is Ductal Carcinoma In situ (DCIS)? (3)
Describes a non-invasive ductal carcinoma of breast tissue.
Characterised by no penetration of the basement membrane and the absence of stromal invasion.
Is preceded by ductal atypia.
Give 1 subtype of DCIS and describe how it’s characterised
Comedocarcinoma
Characterised by central necrosis
Name 4 types of breast cancer
Invasive Ductal Carcinoma (most common)
Invasive lobular carcinoma
Ductal carcinoma in-situ (DCIS)
Lobular carcinoma in situ (LCIS)
What may be seen on mammography in DCIS?
Grouped microcalcifications
Give 4 clinical features of breast cancer
Lumps (Hard, irregular, painless or fixed in place)
Nipple retraction, inversion or blood tinged discharge
Skin dimpling or oedema (Peau d’orange)
Axillary Lymphadenopathy
Give 5 risk factors for breast cancer
Female
Increased oestrogen exposure
Family history (BRCA1/2 genes)
Smoking
Obesity
What chromosome is BRCA1 located?
Chromosome 17
What chromosome is BRCA2 located?
Chromosome 13
Between what ages is breast cancer screening (mammography) offered and repeated for women?
Offered between ages of 50-70. Mammography is offered every 3 years
What is the referral wait time and criteria for suspected breast cancer? (2)
2 week wait
Unexplained breast lump in patients >30
Unexplained nipple changes in patients >50 (discharge, retractions ect)
What criteria would make a patient high risk for breast cancer? (4)
1st degree relative with breast cancer <40 years old
1st degree male relative with breast cancer
1st degree relative with bilateral breast cancer, first diagnosed <50 years old
2 1st degree relatives with breast cancer
Give 2 medications used for breast cancer chemoprevention (in high risk patients) and state whom they are offered to.
Tamoxifen - Offered to premenopausal women
Anastrozole (aromatase inhibitor) - Offered to postmenopausal women
Give 1 contraindication for Anastrozole use as a chemopreventant.
Severe osteoporosis
What 3 factors make up the triple diagnostic assessment in breast cancer?
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Biopsy (fine needle aspiration or core biopsy)
What 3 receptors are sampled for in all invasive breast cancers?
Oestrogen receptors (ER)
Progesterone Receptors (PR)
Human Epidermal Growth Factor 2 (HER2)
Describe lymph node assessment in breast cancer (imagining used (2) and management offered (2)) (4)
Ultrasound of the axilla (looking for abnormal lymph nodes)
If abnormal lymph nodes are found, an Ultrasound guided needle biopsy is performed
If -ve then sentinel node biopsy is performed during surgery
If +ve then axillary clearance is performed during surgery
Give 1 common complication of axillary clearance
Chronic lymphoedema in affected arm
How is chronic lymphoedema managed following axillary clearance? (3)
Massage techniques (manual lymphatic drainage)
Compression bandages
Weight loss (if overweight)
Name 2 tools used to predict prognosis/survival in Breast Cancer
PREDICT
Nottingham Prognostic Index (NPI)
What 10 factors does PREDICT measure (breast cancer)
o DCIS or LCIS
o Age at diagnosis
o Post menopausal
o ER status
o HER2/ERRB2 status
o Ki-67 status
o Invasive tumour size (mm)
o Tumour grade
o Detected by
o Positive nodes
In what individuals is PREDICT (breast cancer) less accurate? (3)
Women <30 with ER positive breast cancer
Women >70
Women with tumours >50mm
How is the Notingham Prognostic Index (NPI) calculated?
Uses tumour size x 0.2 + lymph node score + grade score
How is the lymph node score (NPI) calculated? (3)
Lymph nodes involved 0 = score 1 (grade 1)
Lymph nodes involved 1-3 = score 2 (grade 2)
Lymph nodes involved >3 = score 3 (grade 3)
What is the % 5 year survival for an NPI Score 2.0-2.4? (lowest)
93%
What is the % 5 year survival for an NPI Score 2.5-3.4?
85%
What is the % 5 year survival for an NPI Score 3.5-5.4
70%
What is the % 5 year survival for an NPI Score >5.4 (highest)
50%
What 4 organs does breast cancer commonly metastasize?
2Ls 2Bs
Lungs
Liver
Bones
Brain
What criteria would suggest having a mastectomy over breast conserving surgery (wide local excision) (5)
Multifocal tumour
Central Tumour
Large Lesion in a small breast
DCIS >4cm
Patient choice
What criteria would suggest having Breast Conserving Surgery (wide local excision) over a mastectomy? (5)
Solitary lesion
Peripheral tumour
Small lesion in a large breast
DCIS <4cm
Patient choice
In breast cancer, who may tamoxifen therapy be offered to? (2)
Men and post-menopausal women with ER positive invasive breast cancer
Women at low risk of disease recurrence or when aromatase inhibitors aren’t tolerated
In breast cancer, who may aromatase inhibitors (anastrozole) be offered to?
Offered to women at medium-high risk of disease recurrence
When should tamoxifen be switched to an aromatase inhibitor?
After 5 years of treatment
Give 4 complications of endocrine therapy in breast cancer (tamoxifen/aromatase inhibitors) (4)
Endometrial cancer
Osteoporosis
Toxicity
Phlebitis (inflammaiton of a vein)
Name 2 types of breast reconstruction
Latissimus dorsi myocutaneous flap
Sub perctoral implants
What are the 1st and 2nd line investigations for breast cancer during pregnancy?
1st line - Ultrasound
2nd line - Mammography (if ultrasound indicates cancer)
Why is ultrasound guided biopsy favoured over cytology in breast cancer diagnosis during pregnancy?
Proliferative changes during pregnancy render cytology inconclusive
Why should breast reconstruction be delayed in pregnancy (breast cancer)
To avoid prolonged anaesthesia
In breast cancer, if pre-operative axillary ultrasound is negative, what should be offered?
Sentinel node biopsy
In breast cancer, if pre-operative axillary ultrasound is positive, what should be offered?
Axillary node clearance
Radiotherapy is contraindicated in pregnancy (until delivery of the fetus), unless? (2)
Life saving
To preserve organ function (spinal cord compression)
What 2 breast cancer medications are contraindicated in pregnancy?
Tamoxifen
Trastuzumab (MAB against HER2/neu receptor)
What type of drug is Trastuzumab? (breast cancer)
MAB against HER2/neu
When can women start breast feeding after tamoxifen/trastuzumab treatment?
14 days after stopping the drug
Describe a missed (delayed) miscarriage (3)
Light vaginal bleeding/discharge symptoms which disappear
Closed cervical os
Gestational sac containing dead fetus <20 weeks without symptoms of expulsion
Describe features of an incomplete miscarriage (3)
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open
What triad of symptoms is typically seen in Shaken Baby Syndrome?
Retinal Haemorrhages
Subdural haematoma
Encephalopathy
What are the requirements for forceps use in pregnancy? (FORCEPS)
Fully dilated (in 2nd stage of labour)
Occiput Anterior Position
Ruptured Membranes
Cephalic presentation
Engaged presenting part (i.e head at or below ischial spines)
Pain relief
Sphincter (bladded) empty
Women taking hepatic enzyme anti-epileptic drugs (e.g carbamazepine, phenytoin ect) during pregnancy should be offered what?
Vitamin K (10mg daily) in last 4 weeks of pregnancy.
Should also be given to the baby post natally to reduce haemorrhagic disease`
What normal physiological respiratory changes occur in pregnancy? (4)
Tidal volume increase > respiratory rate
Arterial pO2 increases
pCO2 + bicarbonate decreases (compensatory respiratory alkalosis)
PEFR/FEV remain normal
Describe NSAID use during pregnancy (2)
Safe during 1st and 2nd trimester
Should be avoided during 3rd trimester as can cause premature closure of Ductus Arteriosus
How does pregnancy increase VTE risk? (2)
Increased levels of Factor X, VII and fibrinogen
Decreased levels of protein S activity
Give 4 high risk factors for VTE during pregnancy. How is this managed?
Management - LMWH prophylaxis (Enoxaparin) + 6 weeks post-partum
High risk factors;
History of >1 VTE
Unprovoked or oestrogen related VTE
Thrombophillia + VTE or Family History
Antithrombin III deficiency
What investigations should be arranged in a pregnant women with suspected VTE? (4)
ABG
ECG
CXR
Duplex US of deep veins
If a pregnant women >20 weeks presents within 24 hours of chicken pox symptoms (rash), what should be given?
Oral acyclovir
Give 2 LMWHs used for VTE prophylaxis in pregnancy
Dalteparin
Enoxaparin
If a pregnant woman presents with >4 VTE risk factors, what is the most appropriate management?
Immediate treatment with LMWH continued for 6 weeks post-partum
If a woman presents with <3 VTE risk factors, what is the most appropriate management?
Begin LMWH prophylaxis from 28 weeks pregnancy and continue for 6 weeks post partum
Define antepartum haemorrhage
Describes bleeding from or in the genital tract occurring from 24 weeks pregnancy and prior to birth of the baby.
Define placental abruption
Describes the premature separation of a normally located placenta from the uterine wall, before the delivery of a fetus
Name and describe 2 forms of placental abruption
Revealed- Blood tracks between the membranes and escapes through the vaginal and cervix
Concealed - Blood collects behind the placenta, providing no evidence of vaginal bleeding
Describe 3 clinical features distinguishing between placental abruption vs praevia
Abruption;
Shock out of keeping with visible blood loss
Pain constant
Tender, tense uterus
Praevia;
Shock in proportion to visible blood loss
No pain
Uterus not tender
What should women with antepartum haemorrhage be given on admission (non-acute)
If shocked - Give fresh ABO Rh compatible or o Rh -ve blood until systolic BP >100mmHg
Describe the acute management of placental abruption (severe bleeding) (3)
Intravenous Insertion (fluids)
Take bloods and lift legs
Give supplemental oxygen
Describe Disseminated Intravascular Coagulation
Describes a dysregulation in coagulation (clot formation) and fibrinolysis (clot breakdown) resulting in widespread clotting with bleeding
What factor is a key mediator of DIC?
Tissue factor
What blood results would you expect to see in DIC? (4)
Thrombocytopenia (low platelets)
Increased PT and aPTT (takes longer for blood to clot)
Low Fibrinogen
Increased D-Dimer
Name 1 complication of concealed placental abruption
DIC - Due to release of coagulation factors
Give 9 risk factors for placental abruption (ABRUPTION)
A - Abruption previously
B - Blood pressure (hypertension/pre-eclampsia)
R - Ruptured membranes (premature or prolonged)
U - Uterine injury (trauma to abdomen)
P - Polyhydraminos
T - Twins/multiple gestation)
I - Infection (chorioamnionitis)
O - Older age (>35)
N - Narcotic use (cocaine/amphetamines/smoking)
How are minor, major and massive antepartum haemorrhages defined?
Minor - Blood loss <50ml and has settled
Major - Blood loss 50-1000ml with no signs of clinical shock
Massive - Blood loss >1000ml and/or signs of clinical shock
Give 5 risk factors for placenta previa
Prior Placenta Previa
IVF treatment
Advanced maternal age
Caesarean section (uterine scarring)
Miscarriages/induced abortions
Define placenta succenturia
Separate (succenturiate) lobe away from the main placenta. Can fail and separate normally and cause PPH
Define placenta accreta, increta and percreta
Describes abnormal adherence of the placenta to the uterus.
Accreta - When placenta attaches too deeply to uterine awall, attaching to superficial layer of the myometrium
Increta - If myometrium is infiltrated
Percreta - If penetration reaches the serosa
How is placenta accreta diagnosed?
Doppler US
What is vasa praeva
When umbilical cord vessels that usually run in the fetal membranes cross the internal os of the cervix and rupture spontaneously during early labour
If vasa praeva is suspected, what test should be conducted?
Test blood for fetal haemoglobin
How is post-partum haemorrhage defined?
Defined as blood loss of >500ml from genital tract after delivery of the fetus
What is the Obstetric Shock index and how is it calculated? What is normal?
Used to detect haemodynamic instability and hypovolemia.
Calculated by; heart rate/systolic blood pressure
Normal = 0.7-0.9
Define primary and secondary post-partum haemorrhage
Primary - Haemorrhage within the first 24 hours of delivery
Secondary - Haemorrhage between 24 hours to 12 weeks after delivery
Give 4 causes of primary post-partum haemorrhage
Poor uterine tone
Tears or trauma
Retained tissue
Coagulopathy
Give 3 causes of secondary post-partum haemorrhage
Endometritis
Pseudo-aneyrusm, uterine artery
Retained tissue
What are the 1st and 2nd line drugs used to manage post-partum haemorrhage?
1st line - Oxytocin/ergometrine infusion
2nd line - Tranexamic acid
What is the 1st line surgical management for post-partum haemorrhage caused by uterine atony?
Intrauterine balloon tamponade
Give 5 major risk factors for Sudden Infant Death Syndrome
Putting the baby to sleep prone
Parental smoking
Prematurity
Bed sharing
Hyperthermia (over-wrapping) or head covering
Give 3 protective factors for Sudden Infant Death Syndrome
Breastfeeding
Room sharing
The use of dummies
What term is used to describe the fetal head in relation to the ischial spine?
Station
Neonatal respiratory distress syndrome occurs due to a deficiency in what product?
Surfactant
What cell type produces surfactant?
Type II pneumocytes
Give 2 risk factors for neonatal respiratory distress syndrome and explain why they are risk factors.
Prematurity - Because surfactant production begins at 20 weeks and it’s distribution begins at 28-32 weeks.
Maternal diabetes mellitus - Because this leads to increased fetal insulin which inhibits surfactant synthesis.
Give 5 clinical features of neonatal respiratory distress syndrome
Maternal history of premature birth
Symptoms presenting shortly after birth
Signs of respiratory distress (tachypnea, nasal flaring, intercostal recessions)
Cyanosis
Hypoxia (+/- respiratory acidosis)
What appearance may be seen on X-ray in neonatal respiratory distress syndrome?
Ground glass appearance
Give 2 complications of neonatal respiratory distress syndrome
Bronchopulmonary dysplasia
Pneumothorax
What 5 reflexes are tested in a NIPE?
Moro reflex
Suckling reflex
Rooting reflex
Grasp reflex
Stepping reflex
What 4 domains are screened during the NIPE?
Eyes
Heart
Hips
Testes
What is the primary purpose of examining the eyes in a NIPE?
To screen for congenital cataracts (Opacity within the lens of the eye)
Give 5 risk factors for eye/visual problems in a newborn
First degree relative with ocular condition (i.e aniridia (absent iris), coloboma (malformation of the eye) or retinoblastoma (malignant retinal tumour)
Prematurity
Genetic syndromes (trisomy 21)
Port wine stain involving eyelids (can lead to glaucoma)
Maternal exposure to viruses during pregnancy (rubella and cytomegalovirus)
What examination finding would be present in congenital cataracts?
Completely or partially obstructed red reflex (causes leukocoria - white reflection)
When (in weeks) is the anomaly performed?
20 weeks
What conditions are screened for in the anomaly scan? (7)
Edwards’(T18) and Patau’s (T13)
Anencephaly
Spina bifida
Cleft lip
Congenital diaphragmatic hernia
Congenital heart disease
Exomphalos
Give 3 NIPE hip risk factors
1st degree relative with hip problems in early life
Breech presentation at or after 36 weeks, irrespective of presentation at birth or mode of delivery (inc successful ECV)
Breech presentation at time of birth between 28 weeks and term
What is the proimary purpose of examining the testes in NIPE?
Screening for bilateral/unilateral undescended testes
What cancer is associated with undescended testes?
Seminoma (germ cell tumour of testicle)
What condition is associated with bilateral undescended testes?
Congenital adrenal hyperplasia (ambiguous genitalia)
What are the components of the Apgar score?
Quick way of evaluating health of newborn
Pulse
Respiratory effort
Colour
Muscle tone
Reflex irritability
What is the most common liver disease of pregnancy? When does it typically present?
Obstetric cholestasis
Presents in 3rd trimester
Give 3 clinical features of obstetric cholestasis?
Pruritis (on palms and soles)
No rash
Raised bilirubin
What investigations should be arranged in suspected obstetric cholestasis? (4)
Test for viral hepatitis
Liver Function Tests
Autoimmune screen
Ultrasound of liver
How is obstetric cholestasis managed? (3)
Ursodeoxycholic acid (for itchiness)
Weekly liver function tests
Women are induced at 37 weeks
What is the most common cause of early onset severe infection in neonatal period?
Group B streptococcus infection
Give 4 risk factors for group B streptococcus infection
Prematurity
Prolonged rupture of membranes
Previous sibling GBS infection
Maternal pyrexia (secondary to chorioamnionitis)
How can GBS infection present in neonates?
Pneumonia
Meningitis
Septicaemia
What is given for GBS prophylaxis? (1st line, 2nd line)
1st line - Benzylpenicillin
2nd line - Clindamycin
Define acute fatty liver of pregnancy. When does it commonly arise?
Describes a rare-life threatening obstetric emergency characterised by extensive fatty infiltration of the liver, resulting in acute liver failure.
Commonly arises in 3rd trimester
Give 5 clinical features of acute fatty liver of pregnancy
Sudden onset of jaundice
Right upper quadrant pain, nausea and vomiting
Headache
Hypoalbuminemia > ascites
Concurrent pre-eclampsia
What test is used to diagnose acute fatty liver of pregnancy? What will it show?
Liver ultrasound. Shows hepatic steatosis
Give 4 blood results for acute fatty liver of pregnancy
Hypoglycaemia
Uraemia
Raised WBC
Raised LFTs (ALT/AST)
What is used to assess severity of nausea and vomiting in pregnancy?
Pregnancy-Unique Quanitification of Emesis (PUQE) score
oDefine complex ovarian cyst. How should the be treated? What tests should be performed? (3)
Describes a cyst containing a solid mass or which is multi-loculated.
Should be treated as malignant until proven otherwise.
Test for serum CA-125, aFP and bHCG
What is the 1st line antibiotic for Group B streptococcal prophylaxis?
Benzylpenicillin
What is the 2nd line antibiotic for group be streptococcal prophylaxis? (Non penicillin allergy and penicillin allergy allergy)
Non-penicillin allergy - Cephalosporin
Penicillin allergy - Vancomycin
When should bacteriological testing be performed in high risk GBS women?
35-37 weeks gestation or 3-5 weeks prior to expected delivery date
What is the 1st line medical therapy for IBS? (2)
Loperamide (decreases frequency of diarrhoea) and Buscopan (manages stomach cramps)
Give 3 contraindications for Buscopan (IBS treatment)
Glaucoma
Myasthenia gravia
Bowel obstruction
Where does vulval carcinoma tend to present?
Labium majora (with ulceration)
Name 4 sex cord stromal tumours (hormone related)
Thecoma (stromal)
Fibroma (stromal)
Sertoli cell tumour (sex cord)
Granulosa cell tumour (sex cord)
What ovarian tumour is associated with the development of endometrial hyperplasia?
Granulosa cell tumours
(remember, granulosa cells produce oestrogen, oestorgen promotes endometrial thickening)
Adding what to HRT increases risk of breast cancer?
Progesterone
In cervical cancer screening, if 2 consecutive inadequate samples are acquired then what is the next step?
Colposcopy
In cervical cancer screening, if one inadequate sample is acquired, what is the next step?
Repeat sample in 3 months
What is the Pearl Index?
Describes the number of pregnancies that happen for one method of contraception per 100 women over a year.
i.e Pearl Index of 0.2 = 2/1000 women/year become pregnant using this form of contraception.
How may imperforate hymen present?
Primary amenorrhoea (no periods <14 years old)
Cyclical pain (in absence of periods)
Bluish bulging membrane on physical examination
What pathogen commonly causes thrush?
Candida albicans
Give 4 clinical features of thrush (vaginal candidiasis)
Cottage cheese, non-offensive discharge
Vulvitis (superficial dyspareunia, dysuria)
Itch
Vulval erythema, fissuring, satellite lesions
How is vaginal candidiasis managed?
1st line - Oral fluconazole (single dose)
2nd line - Clotrimazole intravaginal pessary
Vulval symptoms? - Add Topical imidazole
How is vaginal candidiasis managed in pregnancy?
Oral treatments are contrindicated
Clotrimazole pessary (Only use local treatments (cream/pessaries)
How is vaginal candidiasis diagnosed?
High vaginal swab for microscopy and culture
What should be excluded in patients with vaginal candidiasis?
Diabetes - Blood glucose test
How is fetal hypoxia defined on CTG? (6)
One of more of the following;
Baseline bradycardia (<110)
Baseline tachycardia (>160)
Loss of variability (<5bom)
Early decelerations
Late decelerations
Variable decelerations
Describe category 1 C-section. Give 3 indications. When should delivery occur?
Conducted if there is an immediate threat to maternal/fetal life.
Indications include
- Suspected uterine rupture
- Major placental abruption
- Fetal hypoxia
Baby should be delivered within 30 minutes
Describe category 2 C-section. When should delivery occur?
Maternal or fetal compromise that is not immediately life threatening
Delivery should occur within 75 minutes
What term is used to describe post-partum bleeding?
Lochia
What period of time would continued lochia warrant further investigation with ultrasound?
6 weeks
What form of contraception is associated with weight gain?
Injectable contraceptive (Depo-provera)
What type of ovarian cysts is referred to as a chocolate cyst?
Endometriotic cyst
What is the most common type of ovarian cancer?
Serous carcinoma
What is the most appropriate management of umbilical cord prolapse?
Avoid touching the cord and keep it warm
Define polyhydraminos
Excess amniotic fluid volume for gestational age. Results in uterine distention.
Give 3 fetal causes of polyhydraminos
Gastrointestinal - Oesophageal atresia, duodenal atresia/stenosis
CNS - anencephaly (due to defective fetal swallowing centre), Fetal ADH deficiency (leading to reduced urination)
Multiple pregnancy
Give 2 maternal causes of polyhydraminos
Diabetes mellitus
Rh incompatibility
How is polyhydraminos managed?
Amnioreduction (drainage of excess amniotic fluid)
Define oligohydramnios?
Amount of amniotic fluid is less than expected for gestational age
Give 4 fetal causes of oligohydraminos
Urethral obstruction
Bilateral renal agenesis (congenital absence of one or both kidneys)
Edwards syndrome (trisomy 18)
TORCH infections
Give 4 maternal causes of oligohydraminos
Placental insufficiency
Late/post-term pregnancy (>42 weeks)
PROM
Pre-eclampsia
What investigation is used to assess oligohydraminos?
Ultrasound (determines amniotic fluid volume/fetal abnormalities)
How is oligohydraminos managed?
Amnioinfusion (infusion of fluid into amniotic cavity through amniocentesis)
Define chorioamnionitis
Describes infection of the amniotic fluid, fetal membranes and placenta
Name 2 bacteria that most commonly cause chorioamnionitis
Ureaplasma urealyticum (50%)
Mycoplasma hominis (30%)
Give 3 risk factors for chorioamnionitis
Prolonged labor
Premature rupture of membranes (PROM)
STDs/Frequent UTIs
Give 4 clinical features of chorioamnionitis (maternal/fetal)
Maternal;
Fever
Tachycardia
Uterine tenderness
Malodorous/purulent amniotic fluid/discharge
Fetal;
Fetal tachycardia (>60/min on CTG)
Describe the difference between primary and secondary dyspmenorrhoea
Primary - Describes painful menstruation in the absence of underlying pelvic pathology. Pain occurs with onset of menstruation
Secondary - Describes painful menstruation secondary to underlying pelvic pathology (such as endometriosis, fibroids or polyps). Pain typically occurs before the start of menstruation
How should hypothyroidism be managed in pregnancy (early i.e 7 weeks)?
Increase levothyroxine levels (even if euthyroid) by 25mcg and repeat thyroid function tests in 4 weeks.
Conducted as there is a physiological increase in serum free thyroxine until weel 12 of pregnancy.
Define overactive bladder/urge incontinence
Describes detrusor overactivity.
Patients haver the urge to urinate quickly followed by leakage (may be a few drops to complete bladder emptying)
Describe stress incontinence
Describes leaking small amounts of urine when coughing or laughing
What 4 investigations would you conduct in a patient presenting with urinary incontinence?
Bladder diary (minimum of 3 days)
Vaginal examination (to exclude pelvic organ prolapse)
Urine dipstick/culture
Urodynamic studies
How is urge incontinence managed? (1st and 2nd lines)
Bladder retraining (minimum of 6 weeks)
Bladder stabilising drugs (anti-muscainics)
1st line - Oxybutynin
2nd line - Tolterodine (antimuscarinic) or Mirabegron (beta 3 agonist) - consider in frail old patients
In whom may oxybutynin be contraindicated? What can be given instead (for urge incontinence)
Frail old patients
Mirabegron (beta 3 agonist)
What is the 1st and 2nd line treatment for stress incontinence?
1st - Pelvic floor muscle training (8 contractions, 3 times per day for 3 months)
2nd line - Duloxetine (SNRI)
Give 4 side effects of Oxybutynin
Antimuscarinic;
Dry mouth
Constipation
Flushing
Dizziness/drowsiness
What pathogen causes vaginal thrush?
Candida albicans
Name 4 factors that increase the risk of developing vaginal thrush
Diabetes mellitus
Drugs (antibiotics/steroids)
Pregnancy
Immunosuppression (HIV)
Give 4 clinical features of vaginal thrush
‘cottage cheese’ (non-offensive discharge)
Vulvitis (superficial dyspareunia, dysuria)
Itch
Vulval erythema, fissuring, satellite lesions
What are the 1st and 2nd line treatments for vaginal thrush?
1st - Fluconazole (oral)
2nd - Clotrimazole pessary (if oral is contraindicated)
What is used to treat vulval symptoms in vaginal thrush?
Topical imidazole
How is thrush treated in pregnancy?
Oral treatments are contraindicated.
Offer local cream or pessaries
Define recurrent vaginal candidiasis
Defined as 4 or more episodes per year
Describe the induction-maintenance regime for recurrent vaginal candidiasis
Induction - Oral fluconazole every 3 days for 3 doses
Maintenance - Oral fluconazole weekly for 6 months
How may ovarian torsion appear on US scan?
Whirlpool sign
How may chronic salpingitis appear on US scan?
Beads-on-string sign
How may fibroids appear on US scan?
Hypoechoic mass
How may hydatifiform mole present on US scan?
Snow storm appearance
What are the NICE guidelines on contraception use in post-menopausal women?
Women using non-hormonal methods can be advised to stop contraception after 1 year of amenorrhoea if aged >50, or 2 years in women aged <50
Give 7 absolute contraindications to COCP use (UKMEC4)
Known or suspected pregnancy
Smoker >35 who smokes >15/day
Obesity
Breastfeeding <6 weeks post-partum
Fx of thrombosis before 45
Breast cancer or cancer within last few years
BRCA genes
Give 5 situations where the disadvantages of contraceptive use outweigh the advantages (UKMEC3)
Breast feeding > 6 weeks post-partum
Previous arterial or venous clots
Continued use after heart disease or stroke
Migraine with aura
Active disease of liver or gallbladder
Give 2 situations where the advantages of contraceptive use outweigh the disadvantages (UKMEC2)
Initiation after current or previous MI/stroke
Multiple risk factors for cardiovascular disease
Describe the management of post-natal depression (with symptoms)
Seek advice from specialist perinatal mentalhealth team
1st line - Paroxetine or sertraline (SSRIs) for breastfeeding women
Describe the 3 stages of post-partum thyroiditis
Thyrotoxicosis > Hypothyroidism > Normal thyroid function
How is the thyrotoxic phase of postpartum thyroiditis managed?
Propranolol
How is the hypothyroid phase of post-partum thyroiditis managed?
Thyroxine
Where is the most common site of an ctopic pregnancy?
Ampulla of the fallopian tube
Name 6 drugs contraindicated in breast feeding
Antibiotics - Ciprofloxacin, tetracycline, sulphonamides
Psychiatric drugs - Lithium, Benzodiazepines
Aspirin
Carbimazole
Methotrexate
Amiodarone
What tests are routinely performed in the 10 week booking appointment? (4)
4 3 2 1
4 - Blood (FBC, Rhesus, Blood group, Alloantibodies)
3 - Virus (hepB, HIV, syphilis)
2 - UTI (dipstick, urine culture)
1 - Full physical examination (Pelvicm breast, BMI, BP)
What is the 1st investigation to order in a pregnant women presenting with reduced fetal movements?
Handheld doppler (auscultate fetal heart rate)
Used to confirm fetal heartbeat
If a handheld doppler doesn’t find a foetal heart beat, what investigation should be performed?
Ultrasound
What is the 1st line non-hormonal treatment for menorrhagia (for women trying for a family)
Tranexamic acid
If a woman positive for Hepatitis B gives birth, what treatment should be given to the baby?
Hep B vaccine + 0.5ml HBIG within 12 hours + Further hep B vaccine at 1-2 months and 6 months
What tests are important to conduct in patients with urinary incontinence? (stress incontinence) (3)
Urine dipstick and culture
Diabetes - HbA1c
3 day bladder diary
Use of ulipristal should be used with caution in which patients?
Patients with severe asthma (controlled by oral steroids)
What normally happens to blood pressure during pregnancy?
Falls in the first half of pregnancy before rising to pre-pregnancy levels before term
When can the injectable implant be adminsitered in post-partum women? (breastfeeding and non breastfeeding)
Non breastfeeding - Immediately
Breastfeeding - After 4 weeks
What anti-diabetic medication should be avoided in breastfeeding? What is safe?
Sulphonylureas (Gliclazide)- can cause neonatal hypoglycemia
Metformin is safe
If 1 COCP pill is missed (any time in the cycle) what should occur?
Take the last pill, even if it means taking 2 pills in one day, then continue taking pills daily, one each day.
No additional contraception needed
If 2 COCP pills are missed in the 1st week 1 of menstrual cycle, what should happen?
Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)
Emergency contraception should be considered if woman has unprotected sex in the pill free interval/week 1
If 2 COCP pills are missed in week 2 of the menstrual cycle, what should happen?
Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)
After 7 days of taking COCP, no emergency contraception needed
If 2 COCP pills are missed in week 3 of the menstrual cycle, what should happen?
Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)
Woman should finish pills in current pack, and start a new pack the next day (omitting the pill free interval).
Ondanstetron use during pregnancy is associated with an increased risk of what?
Fetus developing cleft palate/lip
What may increase risk of developing cervical ectropion?
COCP due to increased oestrogen levels.
Rectoceles are caused by a defect in what?
Posterior vaginal wall
Cystoceles are caused by a defect in what?
Anterior abdominal wall
A patient with a history of neonatal sepsis (caused by group B strep) asks what can be given to prevent this happening again in a 2nd pregnancy? How sis this managed?
Maternal IV antibiotics (benzylpenicillin) during labour
Define PPH
500ml of blood loss 24 hours since delivery of the baby
Describe the biosynthesis of estradiol
Cholesterol > Pregnenolone > Androstenedione
Then splits into 2;
Androstenedione > Testosterone > Estradiol (catalysed by aromatase - stage 2)
or
Androstenedione > Estrone (1) > Estradiol (E2)
(catalysed by aromatase - stage 1)
What enzyme catalyses the conversion of androstenedione to testosterone?
17 HDS3
What enzyme catalyses conversion of estrone to estradiol?
17 HSD1
What enzyme catalyses the conversion of testosterone to estradiol?
Aromatase (CYP19)
What enzyme catalyses the conversion of androstenedione to estrone?
Aromatase (CYP19)
Name 5 criteria that would warrant expectant management of an ectopic pregnancy
An unruptured embryo
Size <35mm
Have no heart beat
Be asymptomatic
Have a B-hCG of <10000IU/L and declining
If a patient suddenly collapses after rupture of membranes, what is the most likely diagnosis?
Amniotic fluid embolism
Define amniotic fluid embolism
Describes when fetal cells/amniotic fluid enters the mothers blood stream, causing an adverse reaction
Give 4 clinical features of amniotic fluid embolism
Majority of cases occur in labour
Chills, shivering, sweating
Coughing
Hypotension, cyanosis and tachycardia
In whom does atrophic vaginitis commonly present?
Post-menopausal women
Give 3 clinical features of atrophic vaginitis
Vaginal dryness
Dyspareunia
Occasional spotting
What are the 1st and 2nd line treatments for atrophic vaginitis?
1st line - Topical oestrogen
Adjuncts - Lubricants and moisturizers
Woman presents with continuous dribbling incontinence after prolonged labour, what is the most likely diagnosis?
Vesicovaginal fistula
Name 4 ways to assess foetal growth
Measure femur length on US
Measure foetal abdominal circumference (AC) on US
Measurement of size of uterus on abdominal examination
Palpation of the foetal head on abdominal examination
Give 5 benign/malignant causes of a raised CA-125
Adenomyosis
Ascites
Endometriosis
Menstruation
Cancer (ovarian, breast, endometrial)
Give 4 risk factors for ectopic pregnancy
Age <18 at first sexual intercourse
Black race
Smoking
Use of Contraceptive Intrauterine Device
Give 4 consequences of androgen insensitivity syndrome
AMH is secreted by the fetal testes
Development of the testes does not require presence of androgens
In the embryo the testes develop normally
Regression of mullerian structures occurs
Descruibe the physiology of testes development
Testes develop under the influence of the SRY gene on Y chromosome. Does not require presence of androgens.
What does the Wolffian duct develop into during embryogenesis?
Male differentiation occurs when Wolffian duct is exposed to testosterone.
Develops into;
Ejaculation ducts, Epididymis, Rete testes, Ductus deferens and seminal vesicles
What is the most common type of vaginal cancer?
Secondary (metastatic) vaginal cancer
Commonly metastasizing from the cervix or endometrium
What amniotic fluid index (AFI) would diagnose polyhydraminos?
> 24cm (or 2000ml)
What amniotic fluid index would diagnose oligohydraminos?
<5cm (or <200ml)
Give 4 roles of metformin in PCOS treatment
Reduces appetite
Decreases androgen production
Decreases LH from anterior pituitary
Decreases sex-hormone binding globulin in the liver
What is the most important treatable cause of recurrent miscarriage?
SLE associated with Antiphospholipid syndrome
