Obs and Gynae Flashcards
What drug surprisingly is a risk factor for endometrial carcinoma
Tamoxifen (oestrogen antagonist in the breast but agonist in the postmenopausal uterus)
What is the principal risk for endometrial carcinoma?
High ratio of oestrogen to progesterone
What are the clinical features of endometrial cancer?
Post menopausal bleeding
Intermenstrual bleeding
What is the staging for endometrial carcinoma?
Stage 1 - Lesions confined to uterus: 1A (less than half of myometrial invasion, 1B more than half)
Stage 2 - also in cervix
Stage 3 - Tumour invades through the uterus:
3a: invades serosa or adnexae
3b: vaginal and/or [arametrial involvement
3Ci: pelvic node involvement
3C ii: para-aortic involvement
Stage 4: further spread
4a: in bowel or bladder
4b: distant mets.
What are the majority of ovarian tumours?
Epithelial carcinomas
What gene is called Lynch’s syndrome?
HNPCC gene mutations (hereditary non-polyposis colorectal cancer gene)
What are the clinical features of ovarian cancer?
Vague:
Bloating
Early satiety
Loss of appetite
Pelvic or abdominal pain
Increased urinary urgency and/or frequency
Many similar symptoms to IBS
What investigations for ovarian cancer
CA 125 in women over 50 with many abdo symptoms - if above >35 IU/mL then need US abdo and pelvis
Alpha fetoprotein and hCG are measured in under 40 year olds to identify germ cell tumours
Management of ovarian cancer
Surgery
Chemo: Carboplatin +/- paclitaxel
What are the majority of vulval cancers
Squamous cell carcinomas
What are the features of vulval cancer?
Pruritus, bleeding or discharge, mass
What is adenomyosis
When the endometrium grows into the myometrium
What is androgen insensitivity syndrome?
Genetic male who appears to be female: amenorrhoea and absent uterus with rudimentary testes.
What can endometrial polyps cause
abnormal uterine bleeding
What are women with uterine malformations likely to also have
renal malformations
What is Asherman’s syndrome
Scarring/adhesions in the uterus or cervix, often following D&C
What does hyperprolactinaemia cause
Anovulation (prolactin reduced GnRH release
Often caused by a benign adenoma but also seen with PCOS, hypothyroidism and psychotropic drugs
What is the treatment for hyperprolactinaemia
Bromocriptine or Cabergoline (dopamine agonists)
(dopamine inhibits prolactin release)
What are the hallmark symptoms of PID?
Bilateral lower abdominal pain with deep dyspareunia, usually with abnormal vaginal bleeding or discharge
Clinical features of placental abruption
Pallor
Hypotension
Tender, hard uterus
Foetal distress or absent heart sounds
Tachycardia
Abdominal pain
Vaginal bleeding
What type of antibiotic is used to treat gonorrhoea?
Cephalosporins (because of resistance to penicillin being common)
What are chlamydia and gonorrhoea infections associated with in pregnancy
Preterm labour
Neonatal conjunctivitis
What causes oligohydramnios
Impairment of placental function (and decreased blood flow to foetal kidneys means decreased production of urine)
Congenital abnormalities of kidneys
What causes polyhydramnios
Anencephaly
Congenital abnormalities which prevent ingestion of amniotic fluid (E.g. oesophageal atresia)
Renal diseases which cause increased urine production
Hydrocephaly
Diaphragmatic hernia
Complications of polyhydramnios
Unstable lie
Cord prolapse or limb prolapse
Placental abruption if there is sudden release of amniotic fluid
Postpartum haemorrhage associated with over distension of the uterus
Maternal discomfort and dyspnoea
How do you prevent sickle cell crises in pregnancy?
Infection prophylaxis
Avoid dehydration
What is hydrops fetalis
Oedema in at least two foetal departments (e.g. scalp, peritoneum)
Pre-natal form of heart disease
What causes foetal hydrops?
Severe anaemia (heart tries to compensate)
Rhesus disease
Parvovirus in the mum is the most common cause
What are the clinical features in maternal rubella infection?
Mild fever
Fine macular rash
Lymphadenopathy
What can cytomegalovirus in pregnancy cause in the foetus?
Hearing loss
Visual impairment
Learning disability
Microcephaly
Affect growth
Liver problems
What can toxoplasmosis in pregnancy cause in the foetus?
Hydrocephalus
Mental retardation
Retinochoroiditis
Drug treatment for pre-term labour
Beta-adrenergic agonists
Prostaglandin synthesise inhibitors
Magnesium sulphate
Slow calcium-channel clockers
Corticosteroids
Oxytocin antagonists
NOTE: these have lots of side effects so use cautiously.
What is the main purpose of trying to delay preterm labour?
To give corticosteroids before delivery to help foetal surfactant production
What is the decidual reaction in placental development?
When the endometrial stroll cells become large and pale in response to contact with the syncytiotrophoblast
What score 0 in the Bishop’s score
Firm cervix
Posterior
0cm dilated
3cm length
Station < -3
What score 1 on Bishop’s score
Medium firmness
Mid position
1-2cm dilated
2cm length
Station < -2
What score 2 points on Bishops score
Soft cervix
Anterior
3-4cm dilated
1 cm length
Station -1
Lower limits for semen analysis
1ml semen
15-20 million sperm/ml (sperm concentration)
50 million per ejaculate (total sperm count)
Motility: in 60% at 1 hr.
High levels of LH with low levels of testosterone are characteristic of what syndrome?
Klinefelter’s
What are the 5 things APGAR uses in scoring?
Appearance
Pulse
Grimace
Activity
Respiration
How does Mifepristone work?
A progesterone antagonist, blocks the progesterone required for continuation of the pregnancy - termination of pregnancy
What score on Bishops’s score means successful vaginal delivery is likely, and would be a favourable candidate for induction?
9
What are the two things that 1 point is added for in Bishops’ score apart from the main categories?
Pre-eclampia
1 point for each previous vaginal delivery
What are the three things that 1 point is subtracted in Bishops’ score apart from the main categories?
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
Molar pregnancy is a rare cause of what
Thyrotoxicosis
What does bleeding look like in an ectopic pregnancy?
Scant dark brown vaginal bleeding
What is the most likely complication of BV in pregnancy?
Pre-term labour or late miscarriage
What are the symptoms of acute fatty liver of pregnancy
Jaundice
RUQ abdo pain
DIC
Nausea and vomiting
Malaise
Fatigue
Oliguria
Tachycardia
Fever
Requires immediate delivery
When can women stop contraception after amenorrheoa
After 12 months of amenorrhoea if over 50 yr old
After 2 year if under 50 years old
What is the difference between fibroadenoma and fibrocystic disease of the breast?
Fibroadenoma is a discrete, well defined firm lump with smooth mobile edges
Fibrocystic changes is bilateral nodularity which worsens in relation to their menstrual cycle
Is hypotension more profound in spinal anaesthesia or epidural anaesthesia?
Spinal
Spinal anaesthesia can wear off after how long?
2 hours
Which meningeal space does spinal anaesthesia go into
Subarachnoid
What hypertensives are used in gestational hypertension?
Labetalol
Or nifedipine (e.g. if they have asthma and labetalol is contraindicated)
What should you do if a lady presents with PROM at term?
- Blood cultures
- Broad spectrum antibiotics (likely has chorioamnionitis)
- Assess for signs of infection
- Monitor foetal heart and wait for 24 hrs to see if labour starts spontaneously
- If labour hasn’t started after 24hrs - induce
What are the different times and types of emergency contraception following UPSI?
Levonelle pill (up to 3 days post UPSI)
ellaOne (up to 5 days post UPSI)
Copper IUD (up to 5 days post UPSI)
What cancer can a hydratiform molar pregnancy lead to?
Choriocarcinoma
Often bhCG levels continue to rise after treatment for the molar pregnancy
What are thee causes of post partum haemorrhage (4 T’s)
Tone (atony)
Trauma
Tissue (retained tissue)
Thrombin
What is a contraindication for ECV
Previous C-section
Recent antepartum haemorrhage
What is the investigation of choice for placenta praevia?
Transvaginal ultrasound
Fraser guidelines for prescribing contraception to under 16s
1) she demonstrates understanding
2) they cannot be persuaded to discuss things with their parents first
3) they are likely to have sex anyway, with or without contraception
4) their physical or mental health may suffer without contraception
5) it is in their best interests
What medication can be used to suppress lactation?
Cabergoline - dopamine agonist which inhibits prolactin production
What, apart from ovarian cancer can cause a raised Ca-125?
Pelvic inflammatory disease
Weight gain is a possible side effect of which method of contraception?
POP
What hormone does a Mirena coil release?
Progesterone
What are the features of congenital VZV syndrome?
Low birth weight
Limb hypoplasia
Skin scarring
Microcephaly
Eye defects
How does vasa praevia present usually?
Painless vaginal bleeding in the third trimester or vaginal bleeding after membrane rupture
What are Nabothian cysts?
Cysts around the cervix, common in women who have had children
How do Nabothian cysts form?
Squamous cell epithelium coves columnar epithelium, so when the columnar epithelium secretes mucus, it gets trapped
If lichen sclerosis is left untreated, what is there a small but serious risk of?
Vulval cancer
When can chorionic villus sampling happen in gestation?
Between 11 weeks-13 weeks (before 11 weeks may result in foetal limb abnormalities)
Wehn can amniocentesis happen in gestation?
After 15 weeks
What is the biggest risk factor for stillbirth?
IUGR
What are some risk factors for stillbirth?
Obesity
IUGR
Grand multiparity (7+)
Malpresentation
Maternal age over 40
What are fibromas
Benign, stromal ovarian tumours
What syndrome are fibromas commonly associated with?
Meig’s syndrome (pleural effusions and ascites in a patient with a benign ovarian tumour)
How many pulls should be attempted with Ventouse?
3 pulls - then lower segment C-section if unsuccessful
How does misoprostol work?
Medical management of an incomplete miscarriage
Synthetic prostoglandin
Post natal thromboprophylaxis indicators (4 or more = 6 week prophylaxis)
Previous VTE
Thrombophilia
Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions)
Age >35
BMI >30
Parity >3
Smoking
Multiple pregnancy
Pre-eclampsia
Caesarean section
Prolonged labour
Operative delivery
Preterm birth
Stillbirth
Postpartum haemorrhage >1000mL
Other surgical procedure carried out
Immobility
Systemic infection
What are the modifying factors in the Bishops score that cause points to be added?
1 point in the presence of pre-eclampsia
1 point for each previous vaginal delivery
What are the modifying factors in the Bishop’s score that cause points to be subtracted?
1 point subtracted in a post-dates pregnancy
1 point subtracted if primiparous
1 point subtracted if pre-mature pre-term rupture of membranes
What is medroxyprogesterone acetate used for?
Regulate menstrual cycles in women who have PCOS who don’t want to conceive
What is Clomiphene Citrate for?
An antioestrogene which induces endogenous FSH production and induces ovulation. Helps with fertility
When is Clomiphene Citrate taken?
Day 2-6 of cycle, with progesterone level taken on day 21 to confirm ovulation
What apart from breastfeeding can cause mastitis?
Smoking
Eczema
Breast implant
Nipple piercing
Weak immune system (e.g. diabetes)
Shaving or plucking hairs from around nipple
What are the different types of breech presentation?
Footling breech: one or both of the legs are fully extended into the pelvic inlet, with foot or leg as presenting part
Complete breech: presenting part is buttocks, with hips and knees flexed
Frank breech: presenting part is buttocks, with legs fully extended up to shoulders
Incomplete: One or both hips are completely extended with knee or foot as presenting part
What class of drug is mefenamic acid
NSAID
What should you do if a patient over 55 presents with post-menopausal bleeding?
2 week wait referral to gynae
What can improve fertility in endometriosis?
Laparoscopic diathermy and adhesiolysis
In most patients with endometriosis, what does a transvaginal ultrasound show?
nothing - usually normal
What is seen on transvaginal ultrasound in adenomyosis?
Endometrial deposits in the myometrium
What are the risk factors for ectopic pregnancy?
Previous ectopic
PID
IUD/S
IVF
Endometriosis
Pelvic surgery
Smoking
Age older than 35
What types of HPV are most at risk of cervical cancer?
HPV 16 and 18
What other symptoms can fibroids cause?
Compression symptoms
Constipation
Pedal oedema
Urinary frequency
What is Naegele’s rule in estimating date of delivery?
Ad one year and seven days to the last menstrual period date and then subtract 3 months
What is Ovarian hyper stimulation syndrome?
Known side effect of fertility treatment.
Can often present with ascites or pleural effusions
Increase in ovarian size
Hypercoagulable state - think VTE prophylaxis
What is prochlorperazine?
Anti-emetic - often IM
How does amniotic fluid embolism present?
Extremely rare but causes hypoxic respiratory and cardiovascular arrest, as well as DIC - often fatal
What is on offer to all women at 40 weeks gestation?
Vaginal examination and membrane sweep
What is the most common type of ovarian cyst?
Follicular cyst
What is the first line investigation for fibroids?
Transvaginal ultrasound
What is Fitz-Hugh-Curtis syndrome?
A complication of pelvic inflammatory disease where the liver capsule becomes inflames, leading to the development of adhesions between the capsule and the surrounding peritoneum.
Causes RUQ pain, radiating up to shoulder with PID symptoms such as vaginal discharge and fever
What is Asherman syndrome?
When adhesions form within the uterus.
Causes dysmenorrhoea, secondary amenorrhoea and sub fertility
What is Ebstein’s anomaly?
Congenital heart defect caused by Lithium in mother.
Large right atrium, small right ventricle, usually due to low insertion of the tricuspid valve, which also causes tricuspid incompetence
What is Phyllodes tumour?
Similar to fibro-adenoma but faster growing and usually in women aged 40-60
What is the management for anti-phospholipid syndrome to prevent miscarriage?
Aspirin and LMWH
What is the recommended HRT for women who are still menstruating?
Monthly cyclical HRT
What is monthly cyclical HRT?
Oestrogen is taken daily and progestogen is given for the last 10-14 days of each cycle
What is a serious side effect of Trastuzumab (Herceptin) that you must keep an eye out for?
Cardiotoxicity resulting in heart failure
In what part of the pregnancy can parvovirus B19 cause hydrops fetalis?
during the first 20 weeks
What womans health cancer does diabetes mellitus put you at risk for?
Endometrial cancer- high insulin levels may cause proliferation of endometrial stromal cells
What is a Chandelier sign?
informal name for cervical excitation
What is a radial scar on the breast?
Benign breast condition which can mimic a breast carcinoma
Idiopathic sclerosing hyperplasia of the breast ducts
Usually picked up incidentally on mammogram
How long does it take for fertility to return to normal with the COCP?
6 months
What is the first line investigation for suspected endometrial cancer?
Trans-vaginal USS
If lining less than 5mm uniformly then risk is less than 1%
Bleeding likely to be due to atrophic vaginitis
What is first line management for strong opioid analgesia in the latent first stage of labour?
Diamorphine IM
