Obs and Gynae Flashcards
Define primary amenorrhoea
Not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development
What is hypogonadism?
Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise before and during puberty. A lack of these hormones causes a delay in puberty.
What are the two types of hypogonadism?
Hypogonadotropic hypogonadism: a deficiency of LH and FSH
Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
Give three causes of hypogonadotropic hypogonadism.
Hypopituitarism (under production of pituitary hormones)
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome
Give three causes of hypergonadotropic hypogonadism
Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)
What causes congenital adrenal hyperplasia?
Congenital adrenal hyperplasia is caused by a congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth.
What is the pattern in congenital adrenal hyperplasia?
It is a genetic condition inherited in an autosomal recessive pattern.
How does congenital adrenal hyperplasia present?
In severe cases, the neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. In mild cases, female patients can present later in childhood or at puberty with typical features:
Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty
What is androgen insensitivity syndrome?
Androgen insensitivity syndrome is a condition where the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop.
How does androgen insensitivity syndrome present?
It results in a female phenotype, other than the internal pelvic organs. Patients have normal female external genitalia and breast tissue. Internally there are testes in the abdomen or inguinal canal, and an absent uterus, upper vagina, fallopian tubes and ovaries. Primary amenorrhoea
How do we investigate primary amenorrhoea?
Initial investigations assess for underlying medical conditions:
Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease
Hormonal blood tests assess for hormonal abnormalities:
FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
Thyroid function tests
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia
Genetic testing with a microarray test to assess for underlying genetic conditions:
Turner’s syndrome (XO)
Imaging can be useful:
Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
Pelvic ultrasound to assess the ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome
How do we manage hypogonadotropic hypogonadism?
Pulsatile GnRH can be used to induce ovulation and menstruation. This has the potential to induce fertility. Alternatively, where pregnancy is not wanted, replacement sex hormones in the form of the combined contraceptive pill may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency.
Define secondary amenorrhoea
Secondary amenorrhea is defined as no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.
Give three causes of secondary amenorrhoea
Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia
Give three stresses that could lead to secondary amenorrhoea
The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example:
Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress
Give two pituitary causes of secondary amenorrhoea
Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
How does high prolactin impact GnRH release, and what does this lead to?
High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism. Only 30% of women with a high prolactin level will have galactorrhea (breast milk production and secretion).
How do we investigate secondary amenorrhoea?
Detailed history and examination to assess for potential causes
Hormonal blood tests
Ultrasound of the pelvis to diagnose polycystic ovarian syndrome
Which hormone tests would we use in secondary amenorrhoea?
Beta human chorionic gonadotropin (HCG) urine or blood tests are required to diagnose or rule out pregnancy.
Luteinising hormone and follicle-stimulating hormone:
High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome
Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour.
Thyroid stimulating hormone (TSH) can screen for thyroid pathology. This is followed by T3 and T4 when the TSH is abnormal.
Raise TSH and low T3 and T4 indicate hypothyroidism
Low TSH and raised T3 and T4 indicate hyperthyroidism
Raise testosterone indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.
How do we reduce risk of endometrial cancer in PCOS patients?
Women with polycystic ovarian syndrome require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed.
What is premenstrual syndrome?
Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation. These symptoms can be distressing and significantly impact quality of life.
Give five symptoms of PMS
Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido
How do we manage PMS in primary care?
General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP)
SSRI antidepressants
Cognitive behavioural therapy (CBT)
How do we diagnose PMS?
Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation.
Which COCP is recommended first-line in PMS?
RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone (less breast swelling, water retention and bloating)
What is normal and excessive blood loss during menstruation?
On average, women lose 40 ml of blood during menstruation. Excessive menstrual blood loss involves more than an 80 ml loss.
How do we diagnose heavy menstrual bleeding?
The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. Heavy menstrual periods can have a significant impact on quality of life.
Give three causes of heavy menstrual bleeding
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
How do we investigate HMB?
Pelvic examination with a speculum and bimanual should be performed, mainly to assess for fibroids, ascites and cancers.
Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.
When should outpatient hysteroscopy be arranged for investigation of HMB?
Suspected submucosal fibroids
Suspected endometrial pathology, such as endometrial hyperplasia or cancer
Persistent intermenstrual bleeding
When should pelvic and tvs us be arranged for investigation of HMB?
Possible large fibroids (palpable pelvic mass)
Possible adenomyosis (associated pelvic pain or tenderness on examination)
Examination is difficult to interpret (e.g. obesity)
Hysteroscopy is declined
How do we treat HMB in a patient who does not want ocntraception?
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)
How do we treat HMB in a pt who wants contraception?
Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)
Progesterone only contraception may also be tried, as it can suppress menstruation. This could be the progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant).
How do we treat HMB when medical management hasn’t worked?
The final options when medical management has failed are endometrial ablation and hysterectomy.
Endometrial ablation involves destroying the endometrium. The first generation of ablative techniques involved a hysteroscopy and direct destruction of the endometrium. This has been replaced by second generation, non-hysteroscopic techniques that are safer and faster. A typical example of one of these techniques involves passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining. This is called balloon thermal ablation.
What are fibroids?
Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas. Oestrogen sensitive
How do we investigate fibroids?
Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
Pelvic ultrasound is the investigation of choice for larger fibroids.
MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
How do we manage fibroids?
For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding:
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens
More than 3cm = referral to gynaecology
Give three surgical options for larger fibroids
Uterine artery embolisation
Myomectomy (surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.)
Hysterectomy
What might we give to reduce the size of fibroids before surgery?
GnRH agonists, such as goserelin or leuprorelin. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.
What is red degeneration of fibroids?
Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
When is red degeneration of fibroids most likely to occur?
Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.
How does red degeneration of fibroids present? How do we manage it?
Severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
How does endometriosis present?
Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria
There can also be cyclical symptoms relating to other areas affected by the endometriosis:
Urinary symptoms
Bowel symptoms
How do we diagnose endometriosis?
Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.
What is endometriosis?
Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma.
Why do we use COCP in the treatment of endometriosis?
Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.
What is adenomyosis?
Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall.
How does adenomyosis present?
Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
How do we investigate adenomyosis?
Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis.
MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.
How do we manage adenomyosis?
Same as HMB
How do we diagnose menopause
Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation.
What is perimenopause?
Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.
What is premature menopause?
Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
What causes the menopause?
Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
What are the perimenopausal symptoms?
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
Which conditions does a lack of oestrogen increase the risk of?
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Give two side effects of the progesterone depot injection
Weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.
Define premature ovarian insufficiency
Premature ovarian insufficiency is defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.
What will hormonal analysis in premature ovarian insufficiency show?
Premature ovarian insufficiency is characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show:
Raised LH and FSH levels (gonadotropins)
Low oestradiol levels
How does premature ovarian insufficiency present?
Premature ovarian insufficiency presents with irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness.
How do we diagnose primary ovarian insufficiency?
NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in women younger than 40 years with typical menopausal symptoms plus elevated FSH.
The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.
How do we manage primary ovarian insufficiency?
Management involves hormone replacement therapy (HRT) until at least the age at which women typically go through menopause. HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required.
How do we reduce VTE risk in pts taking HRT?
There may be an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches).
What must you prescribe as HRT for a woman with a uterus?
Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT.
What must you prescribe as HRT for a woman still having periods?
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.
What should you prescribe as HRT for a woman with a uterus and more than 12 months without periods?
Continuous combined HRT
What is clonidine? What is it used for?
Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
Give three side effects of clonidine
Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.
Give four indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
Give four risks of HRT
Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
Increased risk of endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
Give the oestrogenic SEs of HRT
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
Give the progestogenic SEs of HRT
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
What is the best way of delivering oestrogen as HRT?
Patches, due to the reduced risk of VTE
What’s the best way of delivering progesterone as HRT?
IUD, e.g. the Mirena coil
What is oligoovulation?
irregular, infrequent ovulation
What is oligomenorrhoea?
Irregular, infrequent menstrual periods
What are androgens?
Male sex hormones, e.g. testosterone
What is hirtuism?
The growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
What are the Rotterdam criteria?
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
Give two symptoms of PCOS not in the Rotterdam criteria
Infertility
Obesity
Hair loss in a male pattern
Insulin resistance
Where do you see acanthosis nigricans?
Insulin resistance
Give four causes of hirtuism.
Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
What do hormonal blood tests show in PCOS?
Raised luteinising hormone **
Raised LH to FSH ratio (high LH compared with FSH) **
Raised testosterone
Raised insulin
Normal or raised oestrogen levels
How does a polycystic ovary present on TVS?
The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.
What are the diagnostic criteria for PCOS on TVS?
The diagnostic criteria are either:
12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3
What is an impaired fasting glucose =?
7mmol/l or higher
What is an impaired glucose tolerance?
Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
How do we diagnose diabetes using an oral glucose tolerance test?
Plasma glucose at 2hrs above 11.1mmol/l
What is the best way to manage PCOS?
Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.
Why are women with PCOS more likely to develop endometrial cancer?
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
How do we manage the risk of endometrial cancer in PCOS?
Options for reducing the risk of endometrial hyperplasia and endometrial cancer are:
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill
When do we assess female patients endometrial thickness?
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
How do we manage acne in PCOS?
The combined oral contraceptive pill is first-line for acne in PCOS. Co-cyprindiol may be the best option as it has anti-androgen effects; however, there is a significantly increased risk of venous thromboembolism. Also treat hirtuism.
What is a tumour marker for ovarian cancer?
CA125
Give the tumour markers for possible germ cell tumours (? ovarian ca in under 40 y.o.)
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
What is the risk of malignancy index?
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
What is Meig’s syndrome? How is it managed?
Meig’s syndrome involves a triad of:
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
How does ovarian torsion present?
The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting.
The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.
What is seen O/E with ovarian torsion?
On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.
How do we diagnose ovarian torsion?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow.
Laparoscopic surgery
What is Asherman’s syndrome?
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.
How does Asherman’s syndrome present?
Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with:
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
It may also present with infertility.
How do we diagnose Asherman’s syndrome?
There are several options for establishing a diagnosis of intrauterine adhesions:
Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan
What is cervical ectropion?
Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.
How does cervical ectropion present?
Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests.
Ectropion may present with increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding.
How do we manage cervical ectropion?
Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
How do nabothian cysts present?
Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis.
How do we manage nabothian cysts?
Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously.
If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.
What is a vault prolapse?
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagin
What is a rectocele? How does it present?
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.
How does pelvic organ prolapse present?
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
How do we manage pelvic organ prolapse?
Conservative management
Vaginal pessary
Surgery
How does urge incontinence present?
The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.
What causes urge incontinence?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder.
What causes stress incontinence?
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles
What is overflow incontinence?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine.
What is the post-void residual bladder volume used to identify?
Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
What is atrophic vaginitis?
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. It occurs in women entering the menopause
How does atrophic vaginitis present?
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
How do we manage atrophic vaginitis?
Vaginal lubricants can help symptoms of dryness.
Topical oestrogen can make a big difference in symptoms. Options include:
Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months
What are the Bartholin’s glands?
The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.
How do we manage Bartholin’s cysts?
Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).
How do we manage Bartholin’s abscesses?
A Bartholin’s abscess will require antibiotics. A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. E. coli is the most common cause. Send specific swabs for chlamydia and gonorrhoea.
What is lichen sclerosus?
An autoimmune condition, a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.
What is lichen simplex?
Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.
What is Lichen planus?
Lichen planus is an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
How does Lichen sclerosus present?
The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
What is the Koebner phenomenon?
The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.
How do we manage lichen sclerosus’/
Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist.
Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.
Emollients
Give the main complication of lichen sclerosus
The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.
Who must we inform when we see a patient with FGM?
The police if the patient is under 18
Why don’t the female internal organs develop in androgen insensitivity syndrome?
The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
What is the common presentation for androgen insensitivity syndrome?
Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.
How do we manage androgen insensitivity syndrome?
Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
What develops from the Mullerian ducts?
The upper vagina, cervix, uterus and fallopian tubes
Who is given the HPV vaccine? What is it for?
HPV type 16 and 18, as they are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine.
Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer and genital warts.
How does HPV promote the development of cancer?
P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
What increases risk of catching HPV?
Increased risk of catching HPV occurs with:
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Non-engagement with cervical screening is a significant risk factor. Many cases of cervical cancer are preventable with early detection and treatment of precancerous changes.
How does cervical cancer present?
Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)
How does cervical cancer present OE?
Ulceration
Inflammation
Bleeding
Visible tumour
What is cervical intraepithelial neoplasia?
Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are:
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
CIN III is sometimes called cervical carcinoma in situ.
Describe the cervical screening program
Every three years aged 25 – 49
Every five years aged 50 – 64
What is the most common endometrial cancer?
Adenocarcinoma
What is endometrial cancer?
Endometrial cancer is cancer of the endometrium, the lining of the uterus
What does PCOS lead to increased risk of endometrial cancer
Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation. Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg. It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle). Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum. Without developing a corpus luteum during the menstrual cycle, progesterone is not produced, and the endometrial lining has more exposure to unopposed oestrogen.
Why is obesity a risk factor for endometrial cancer?
Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen. Adipose tissue is the primary source of oestrogen in postmenopausal women. Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen. Androgens are produced mainly by the adrenal glands. In women with more adipose tissue, and therefore more aromatase enzyme, more of these androgens are converted to oestrogen. This extra oestrogen is unopposed in women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.
How does endometrial cancer present?
The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding.
How would you manage a 55 F patient presenting with unexplained vaginal discharge and haematuria?
Transvaginal ultrasound
Which biopsy do we use to diagnose endometrial cancer?
A pipelle biopsy can be taken in the outpatient clinic. It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer. Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.
How do we manage endometrial cancer?
The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
How does ovarian cancer present?
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
How do we investigate ovarian cancer?
The initial investigations in primary or secondary care are:
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
What is the risk of malignancy index?
Menopausal status
Ultrasound findings
CA125 level
What is the most common form of vulval cancer?
Around 90% are squamous cell carcinomas.
What is VIN?
Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).
How does vulval cancer present symptomatically?
Vulval cancer may present with symptoms of:
Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
How does vulval cancer present O/E?
Irregular mass
Fungating lesion
Ulceration
Bleeding
How does bacterial vaginosis present?
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
Give four risk factors of bacterial vaginosis
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
What is the normal vaginal pH? What is the pH in BV?
Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
What do you see on microscopy in bacterial vaginosis?
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
How do we manage BV?
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.
What must a patient avoid when on metronidazole and why?
Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
How does candidiasis present?
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
How do we manage candidiasis?
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.
What must you warn patients about who use antifungal creams and pessaries?
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
What is chlamydia trachomatis?
Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.
What tests are performed on a patient attending a GUM clinic for STI screening?
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
What is the National Chlamydia Screening Programme?
This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again, rather than to check the treatment has worked.
What is NAAT used for?
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism. NAAT testing is used to test specifically for chlamydia and gonorrhoea. In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample. The order of preference is endocervical, vulvovaginal, and then urine. In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.
How does chlamydia present in women?
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
How does chlamydia present in men?
Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis
How do we manage chlamydia?
First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days. Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:
Azithromycin 1g stat then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
When do we use a test of cure in cases of chlamydia?
A test of cure is not routinely recommended. However, a test of cure should be used for rectal cases of chlamydia, in pregnancy and where symptoms persist.
Give three complications of chlamydia
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
What is gonorrhoea?
Neisseria gonorrhoeae is a gram-negative diplococcus bacteria.
How does gonorrhoea present in men?
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)
How does gonorrhoea present in women?
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Why do we also use charcoal swabs as well as NAAT in cases of gonorrhoea?
NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.
How do we manage gonococcal infections?
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
When do we use a test of cure in gonococcal infection?
All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:
72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
What is ophthalmia neonatorum?
A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.
What is disseminated gonococcal infection?
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue
What is mycoplasma genitalium?
Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin.
Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.
How do we test for mycoplasma genitalium?
Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA if the bacteria.
What is pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.
How does PID present symptomatically?
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
How does PID present OE?
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Patients may have a fever and other signs of sepsis.
What is seen on microscopy in PID?
A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.
What is Fitz-Hugh-Curtis syndrome?
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
How does Fitz-Hugh-Curtis syndrome present?
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
What is trichomonas vaginalis?
Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella.
How does TV present/
Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
How does the discharge appear in trichomonas vaginalis?
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
What is seen OE in TV?
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.
How do we treat TV?
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
How does HSV-1 present?
HSV-1 is most associated with cold sores. It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress. Genital herpes caused by HSV-1 is usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection.
How does HSV-2 present?
HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection. It can also cause lesions in the mouth.
How does genital herpes present?
Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy
How do we manage genital herpes?
Where appropriate, patients should be referred to a genitourinary medicine (GUM) specialist service.
Aciclovir is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances.
How do we manage genital herpes in pregnancy?
Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection. This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery. Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection). Caesarean section is recommended when symptoms are present.
Primary genital herpes contracted after 28 weeks gestation is treated with aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection.
Recurrent genital herpes in pregnancy, where the woman is known to have genital herpes before the pregnancy, carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery. - After an initial infection with genital herpes, the woman will develop antibodies to the virus. During pregnancy, these antibodies can cross the placenta into the fetus. This gives the fetus passive immunity to the virus, and protects the baby during labour and delivery.
What is vertical transmission?
Mother to child at any stage of pregnancy, birth or breastfeeding
How do we test people for HIV in general?
Antibody testing is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.
What is the benefit of testing for the p24 antigen in HIV?
Testing for the p24 antigen, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.
Why do we use PCR testing in HIV?
PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.
What is a normal range for the CD4 count?
500-1200 cells/mm3
What is considered an end-stage HIV CD4 count?
Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections
What do we need to protect against in patients with a CD4 under 200/mm3?
Prophylactic co-trimoxazole (Septrin) is given to patients with a CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).
Do we recommend breastfeeding in patients with HIV?
No. HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is not recommended for mothers with HIV. However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.
What causes syphilis?
Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body.
How does primary syphilis present?
Primary syphilis can present with:
A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy
How does secondary syphilis present?
Secondary syphilis typically starts after the chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
How does neurosyphilis present?
Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of:
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
What is Argyll-Robertson pupil?
Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
What is the screening test for syphilis?
Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.
How do we treat syphilis?
All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.
What general advice do we give those trying to conceive?
The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse
What might a high FSH show in an infertile female?
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
Why do we measure anti-Mullerian hormone in infertile patients?
Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
What is a hysterosalpingogram used for?
A hysterosalpingogram is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes. Not only does it help with diagnosis, but it also has therapeutic benefit. It seems to increase the rate of conception without any other intervention.
What is clomifene? How does it work?
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
What is ovarian drilling? What is it used for?
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
How does ectopic pregnancy present?
Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain.
The classic features of an ectopic pregnancy include:
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
What is seen on TVUS in an ectopic pregnancy?
A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance).
A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.
Features that may also indicate an ectopic pregnancy are:
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
What is a PUL?
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
How do we monitor PUL?
The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.
A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.
Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.
How do we manage ectopic pregnancies?
All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy.
There are three options for terminating an ectopic pregnancy:
Expectant management (awaiting natural termination)
Medical management (IM methotrexate)
Surgical management (salpingectomy or salpingotomy)
What is important to tell the patient with methotrexate use?
Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long.
What is a threatened miscarriage?
Vaginal bleeding with a closed cervix and a fetus that is alive
What is an inevitable miscarriage?
Vaginal bleeding with an open cervix
What is an incomplete miscarriage?
Retained products of conception remain in the uterus after the miscarriage
What is a missed miscarriage?
The fetus is no longer alive, but no symptoms have occurred
How do we diagnose miscarriage?
TVUS
How do we manage a pregnancy less than 6 weeks gestation presenting with bleeding?
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
How do we manage a miscarriage and bleeding after 6 weeks gestation?
The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.
There are three options for managing a miscarriage:
Expectant management (do nothing and await a spontaneous miscarriage)
Medical management (misoprostol)
Surgical management
What is misoprostol?
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
Give a key complication of evacuation of retained products of conception (ERPC)
A key complication is endometritis (infection of the endometrium) following the procedure.
How do we treat antiphospholipid syndrome?
Low dose aspirin
Low molecular weight heparin (LMWH)
What is mifepristone? What is it used for?
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
Which hormone is thought to cause N&V in pregnancy?
hCG
What are the diagnostic criteria for hyperemesis gravidarum?
Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
What is the PUQE used for?
The severity of N&V during pregnancy can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 – 12: Moderate
> 12: Severe
Which anti-emetics are used in pregnancy?
Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide
Ranitidine or omeprazole can be used if acid reflux is a problem.
What is a hydatidiform mole?
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy.
What is the difference between a complete mole and a partial mole?
A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
How does molar pregnancy present?
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
How do we diagnose molar pregnancy?
Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.
Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.
Gravidity and parity: a pregnant woman with three previous deliveries at term
G4 P3
Gravidity and parity: a pregnant woman with a previous birth of healthy twins
G1 P1
Gravidity and parity: a non-pregnant woman with a previous miscarriage
G1 P0 +1
A non-pregnant woman with a previous stillbirth (after 24wks gestation)
G1 P1
What is the second trimester?
The second trimester is from 13 weeks until 26 weeks gestation.
When do fetal movements start?
It is worth noting that fetal movements start from around 20 weeks gestation, and continue until birth.
Which two vaccines are offered to all pregnant women?
There are two vaccines offered to all pregnant women:
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
Why are NSAIDs avoided in pregnancy?
NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis). They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.
What is neonatal abstinence syndrome? How does it present?
The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth. This is called neonatal abstinence syndrome (NAS). NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.
Which congenital abnormality can lithium cause?
Lithium is particularly avoided in the first trimester, as this is linked with congenital cardiac abnormalities. In particular, it is associated with Ebstein’s anomaly, where the tricuspid valve is set lower on the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle.
What is isotretinoin? What is it used for? Is it given in pregnancy?
Isotretinoin is a retinoid medication (relating to vitamin A) that is used to treat severe acne. It should be prescribed and monitored by a specialist dermatologist.
Isotretinoin is highly teratogenic, causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.
Describe rhesus incompatibility in pregnancy
When a woman that is rhesus-D negative becomes pregnant, we have to consider the possibility that her child will be rhesus positive. It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens.
Usually, this sensitisation process does not cause problems during the first pregnancy. During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.
How do we manage rhesus incompatibility?
Prevention of sensitisation is the mainstay of management. This involves giving intramuscular anti-D injections to rhesus-D negative women. There is no way to reverse the sensitisation process once it has occurred, which is why prophylaxis is so essential.
The anti-D medication works by attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen. It acts as a prevention for the mother becoming sensitised to the rhesus-D antigen.
Anti-D injections are given routinely on two occasions:
28 weeks gestation
Birth (if the baby’s blood group is found to be rhesus-positive)
Anti-D injections should also be given at any time where sensitisation may occur, such as:
Antepartum haemorrhage
Amniocentesis procedures
Abdominal trauma
What is the Kleihauer test?
The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
What is fetal growth restriction?
Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.
What are the two types of FGR?
Placenta mediated growth restriction
Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
Define macrosomia
Babies are defined as being large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth. During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.
What is the main risk with a large for gestational age baby?
Shoulder dystocia
How does infection present on urine dipstick?
Nitrites are a more accurate indication of infection than leukocytes.
How do we test for pernicious anaemia?
Check for intrinsic factor antibodies
What dose of folate do we give to pregnant women?
All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily.
How do we manage eclampsia?
Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.
How does HELLP syndrome present?
Haemolysis
Elevated Liver enzymes
Low Platelets
How do we diagnose pre-eclampsia?
The NICE guidelines (2019) advise a diagnosis can be made with a:
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
How do we quantify proteinuria?
Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)
What can be used as prophylaxis for pre-eclamspia?
Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with:
A single high-risk factor
Two or more moderate-risk factors
How do we diagnose gestational diabetes?
OGTT
Normal results are:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
How do we manage gestational diabetes?
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Which screening is important in patients with gestational diabetes?
Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.
How do we manage type 1 diabetes in pregnancy?
Women with existing type 1 and type 2 diabetes should aim for the same target insulin levels as with gestational diabetes. A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol.
Give two complications of gestational diabetes
If you remember two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia. Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.
What is obstetric cholestasis?
Obstetric cholestasis is also known as intrahepatic cholestasis of pregnancy. Chole- relates to the bile and bile ducts. Stasis refers to inactivity. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby.
How does obstetric cholestasis present?
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
Fatigue
Dark urine
Pale, greasy stools
Jaundice
How do we investigate obstetric cholestasis?
Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
Raised bile acids
How do we manage obstetric cholestasis?
Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
Emollients (i.e. calamine lotion) to soothe the skin
Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
Delivery at 37 weeks to reduce risk of stillbirth
What causes acute fatty liver of pregnancy?
Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. Autosomal recessive condition
How does acute fatty liver of pregnancy present?
The presentation is with vague symptoms associated with hepatitis :
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
How do we manage acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.
Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.
What is the difference between low-lying placenta and placenta previa?
Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os
Give three causes of antepartum haemorrhage
The three causes of antepartum haemorrhage (painless vaginal bleeding in pregnancy) to remember are placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality.
Give three causes of spotting or minor bleeding in pregnancy
Causes of spotting or minor bleeding in pregnancy include cervical ectropion, infection and vaginal abrasions from intercourse or procedures.
Give three risk factors for placenta praevia
Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
How do we diagnose placenta praevia?
The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.
How do we manage placenta praevia?
For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), the RCOG guideline (2018) recommends a repeat transvaginal ultrasound scan at:
32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.
Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).
Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta.
Emergency caesarean section may be required with premature labour or antenatal bleeding.
What makes up the fetal vessels?
The fetal vessels consist of the two umbilical arteries and single umbilical vein.
What is vasa praevia?
In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.
How do we diagnose vasa praevia?
Vasa praevia may be diagnosed by ultrasound during pregnancy. This is the ideal scenario, as it allows a planned caesarean section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally.
It may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy.
It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix.
Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.
How do we manage vasa praevia?
For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend:
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs.
After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.
What is placental abruption?
Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.
What is the pain like in placental abruption/
Sudden onset severe abdominal pain that is continuous
What is felt on examination in placental abruption?
Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
What are the three types of placenta accreta?
Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
Placenta increta is where the placenta attaches deeply into the myometrium
Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
Why do we give antenatal steroids before delivery in high risk patients?
Antenatal steroids are given to mature the fetal lungs before delivery.
How do we diagnose placenta accreta?
Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth.
MRI scans may be used to assess the depth and width of the invasion.
How do we treat placenta accreta surgically??
The options during caesarean are:
Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time
Expectant management comes with significant risks, particularly bleeding and infection.
What is complete breech?
The legs are fully flexed at the hips and knees
What is incomplete breech?
One leg flexed at the hip and extended at the knee
What is extended breech?
Also known as frank breech, with both legs flexed at the hip and extended at the knee
What is footling breech?
With a foot is presenting through the cervix with the leg extended
How do we manage breech presentation?
Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus.
Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required.
Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.
When is ECV offered?
External cephalic version is used in babies that are breech:
After 36 weeks for nulliparous women (women that have not previously given birth)
After 37 weeks in women that have given birth previously
What do we give to patients prior to ECV?
Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn.
Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.
Define stillbirth
Stillbirth is defined as the birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD). It occurs in approximately 1 in 200 pregnancies.
How do we diagnose intrauterine fetal death?
US - visualises the fetal heartbeat
What are the 4 Ts for reversible causes of cardiac arrest?
Thrombosis (i.e. PE or MI)
Tension pneumothorax
Toxins
Tamponade (cardiac)
What are the 4 Hs for reversible causes of cardiac arrest?
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities
What are the three main causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock
Give three causes of massive obstetric haemorrhage
Ectopic pregnancy (early pregnancy)
Placental abruption (including concealed haemorrhage)
Placenta praevia
Placenta accreta
Uterine rupture
What is aortocaval compression?
After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). This reduces the cardiac output, leading to hypotension. In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest.
How do we manage aortocaval compression?
The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.
How do we adapt ALS for pregnant women?
A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
Early intubation to protect the airway
Early supplementary oxygen
Aggressive fluid resuscitation (caution in pre-eclampsia)
Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR - to improve the survival of the mother
What are the three stages of labour?
First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta
What are the three stages of the first stage of labour?
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
What is a Braxton-Hicks contraction?
Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.
Define prematurity
Prematurity is defined as birth before 37 weeks gestation.
How do we prevent preterm labour?
Vaginal Progesterone
Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.
Cervical Cerclage
Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.
What is preterm prelabour rupture of membranes?
Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).
How do we manage premature labour?
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.
Induction of labour may be offered from 34 weeks to initiate the onset of labour.
What is tocolysis?
Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.
Which antenatal steroids might we give for babies less than 36 weeks of gestation at risk of preterm birth?
An example regime would be two doses of intramuscular betamethasone, 24 hours apart.
When do we give IV magnesium sulphate in pregnancy?
Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.
Give three key signs of magnesium toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
What is the Bishop score?
The Bishop score is a scoring system used to determine whether to induce labour. A score of 8 or more predicts a successful induction of labour.
How do we induce labour?
Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.
Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.
Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).
Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.
What are the criteria for uterine hyperstimulation?
Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes
What can uterine hyperstimulation lead to?
Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture
How do we manage uterine hyperstimulation?
Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline
When would a CTG be reassuring?
It is worth remembering that the CTG is reassuring when there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.
What causes early decelerations?
Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.
What causes late decelerations?
Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
What causes prolonged decelerations?
Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.
What is oxytocin used for?
Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding.
Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
When ir ergometrine used and why?
Ergometrine is derived from ergot plants. It stimulates smooth muscle contraction, both in the uterus and blood vessels. This makes it useful for delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.
When is ergometrine contraindicated?
Due to the action on the smooth muscle in blood vessels and gastrointestinal tract, it can cause several side effects, including hypertension, diarrhoea, vomiting and angina. It needs to be avoided in eclampsia, and used only with significant caution in patients with hypertension.
What is dinoprostone used for?
A PGE2. This is used for induction of labour, and can come in one of three forms:
Vaginal pessaries (Propess)
Vaginal tablets (Prostin tablets)
Vaginal gel (Prostin gel)
How do NSAIDs impact prostaglandin action?
Prostaglandins act as vasodilators, and lower blood pressure. NSAIDs such as ibuprofen and naproxen inhibit the action of prostaglandins. As a result, NSAIDs can increase blood pressure. NSAIDs are generally avoided in pregnancy, and also after delivery in women with raised blood pressure (although research has shed doubt on whether the effects on blood pressure is significant enough to justify avoiding them). NSAIDs (e.g. ibuprofen and mefenamic acid) are useful in treating dysmenorrhoea (painful periods), as they reduce the painful cramping of the uterus during menstruation.
What is terbutaline?
Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.
What is carboprost? What is it used for?
Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate. Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.
What is TXA?
Tranexamic acid is an antifibrinolytic medication that reduces bleeding. It binds to plasminogen and prevents it from converting to plasmin. Plasmin is an enzyme that works to dissolve the fibrin within blood clots. Fibrin is a protein that helps hold blood clots together. Therefore, by decreasing the activity of the enzyme plasmin, tranexamic acid helps prevent the breakdown of blood clots.
Give three SEs of entonox
Nausea, lightheadedness and sleepiness
When might a patient need an urgent anaesthetic review when they have an epidural in-situ?
Women need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise). The catheter may be incorrectly sited in the subarachnoid space (within the spinal cord), rather than the epidural space.
Give three SEs of epidural
Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
What is umbilical cord prolapse?
Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
How do we manage umbilical cord prolapse?
Emergency caesarean section. Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
How do we manage shoulder dystocia?
Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary.
McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.
What are the four degrees of perineal tear?
First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
Second-degree – including the perineal muscles, but not affecting the anal sphincter
Third-degree – including the anal sphincter, but not affecting the rectal mucosa
Fourth-degree – including the rectal mucosa
How do we subcategorise third-degree tears?
3A – less than 50% of the external anal sphincter affected
3B – more than 50% of the external anal sphincter affected
3C – external and internal anal sphincter affected
How do we manage perineal tears?
First-degree tears usually do not require any sutures. When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury. A third or fourth-degree tear is likely to need repairing in theatre.
How can we prevent perineal tears
Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
How do we actively manage the third stage of labour?
Active management of the third stage is where the midwife or doctor assist in delivering of the placenta. It involves a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.
Define PPH
500ml after a vaginal delivery
1000ml after a caesarean section
How do we classify PPH?
Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss
–> Moderate PPH – 1000 – 2000ml blood loss
–> Severe PPH – over 2000ml blood loss
What are the four causes of PPH?
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
Why do women give birth with an empty bladder?
a full bladder reduces uterine contraction and can increase risk of PPH
How can we mechanically attempt to stop PPH?
Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
Catheterisation (bladder distention prevents uterus contractions)
What is the most likely cause of secondary postpartum haemorrhage?
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
What is a Category 1 caesarean section?
There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
What is a Category 2 caesarean section?
There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
What is chorioamnionitis?
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.
Give two causes of sepsis in pregnancy
Chorioamnionitis
UTI
How does amniotic fluid embolisation present?
Amniotic fluid embolisation usually presents around the time of labour and delivery, but can be postpartum. It can present similarly to sepsis, pulmonary embolism or anaphylaxis, with an acute onset of symptoms of:
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
What are the two types of uterine rupture?
Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
How does uterine rupture present?
Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of:
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
How do we manage uterine rupture?
Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
What might be covered at the six week postnatal check?
General wellbeing
Mood and depression
Bleeding and menstruation
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Fasting blood glucose (after gestational diabetes)
Blood pressure (after hypertension or pre-eclampsia)
Urine dipstick for protein (after pre-eclampsia)
When do women become fertile again postnatally?
After 21 days
How effective is lactational amenorrhoea?
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
When can we give the combined pill after childbirth?
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
What is Asherman’s syndrome?
Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus. Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.
What is ERPC? What can it lead to?
The standard management of postpartum retained products of conception is to remove them surgically.
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”. Two key complications are:
Endometritis
Asherman’s syndrome
Give a contraindication to an iron infusion.
Active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.
How do we treat anaemia postnatally?
Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron
When does postnatal depression peak in women?
Around three months after birth
What is the triad in postnatal depression?
Low mood, anhedonia (lack of pleasure in activities), low energy
Give a screening tool for postnatal depression
The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.
There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.
What is puerperal psychosis? How does it present?
Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
What is neonatal abstinence syndrome?
SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome). It presents in the first few days after birth with symptoms such as irritability and poor feeding. Neonates are monitored for this after delivery. Supportive management is usually all that is required.
How do we treat candida of the nipple?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)
How do we manage postpartum thyroiditis?
Patients with abnormal thyroid function tests in the postpartum period require referral to an endocrinologist for specialist management. Typical treatment is with:
Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
Hypothyroidism: levothyroxine
What is Sheehan’s syndrome/
Sheehan’s syndrome is a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland. Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death.
Sheehan’s syndrome only affects the anterior pituitary gland. Therefore, hormones produced by the posterior pituitary are spared.
Which hormones are affected in Sheehan’s syndrome?
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin
How does Sheehan’s syndrome present?
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)
