Obs and Gynae Flashcards
Endometriosis Ix
laparoscopy with biopsy
TVS/TAS
Endometriosis examination findings
fixed retroverted uterus
adnexal mass
tender
sometimes normal
RF for PID
- STI (chlam and gono)
- unprotected sex
- multiple sexual partners
- IUD
- termination
Presentation of PID
asymptomatic (subfert)
- lower abdo pain
- deep dyspareunia
- PCB
- dysuria
- vaginal discharge
PID investigations
gold standard - laparoscopy with fimbrial biopsy
- endocervical swabs
- high vaginal swabs (TV, BV)
- full STI screen
- urine dip
- preg test
- pelvic USS
PID O/E
cervical excitation
severe - tachycardia and fever
Ix for incontinence
cystometry
stress: when pt coughs increased BP, AP, UF but no increase in DP
Urge: detrusor contractions on filling
urine dip to exclude infections
urinary diary can be helpful for urge
Pharmaceutical and surgical management of stress incontinence
Autologous rectus fascial sling
colposuspension (neck of bladder lifted and sutured back into place)
duloxetine (enhances urethral sphincter activity: 2nd line to surgery)
Management of urge incontinence
Lifestyle: caffeine, weight
bladder training: 6 weeks
Drugs: Oxybutynin, relax SM, increase bladder capacity -> Mirabegron if CI
Intravaginal oestrogens for post meno women
Secondary care
- Botulinum toxin A injection: blocks neuromuscular trasmission, worry about retension
- Sacral nerve stimulation
- Cystoplasty
USS findings for PCO
multiple (>12) small (2-8mm) follicles in an enlarged (>10mL) ovary
Describe the pathology of PCOS
disordered LH production
- increased ovarian androgens
- folliculogenesis disrupted -> XS small ovarian follicles, irregular/abscent ovulation
Compensatory insulin production (increased weight)
- increased adrenal androgen production and decreased hepatic sex hormone binding globulin production
- increased free androgen levels -> hirsutism
Investigations for ?PCOS
aim: find other causes
Testosterone and LH increased
FSH normal (increased in ovarian failure, decreased hypothalamic disease)
prolactin (increased prolactinoma)
PCOS management
lifestyle
Co-cyprindrol: hirsutism and acne
COCP - oligomenorrhoea, acne, hirsutism
eflornithine/lazer therapy - facial hirsutism
endometrial hyperplasia prevention(bleed once every 4 months)
- cyclical progestogen (medroxyprogesterone)
- COCP
- IUS
Describe the degrees of prolapse
1st - lowest part halfway down vaginal
2nd - lowest part to introutus
3rd - lowest part outside vagina without straining
4th - uterus lies outside vagina
Specific prolapse symptoms
cystocoele - urgency, frequency, incomplete emptying (retension -> infection)
enterocoele - gurging sound when sitting
rectocoele - constipation, digitation
Prolapse causes
- pregnancy and vaginal delivery
- menopause (oestrong withdrawal reduced collagen)
- increased abdo pressure
- iatrogenic (pelvic surgery)
- congential (abnormal collagen)
Management of prolapse
Lifestyle: weight, managing constipation
PFME: 16 week course
Vaginal oestrogen creams if atrophy
Pessary: ring or shelf - affects intercourse, changed every 6m
surgery: mesh repair, colposuspension, hysterectomy
Causes of menorrhagia
- fibroids
- polyps
- adenomyosis
- chronic pelvic infection
- tumour - ovarian, endometrial, cervical
Investigations for menorrhagia
Hb
TVUS (endometrial thickness, fibrods, polyps, masses)
if thickness >10mm -> biopsy
hysteroscopy
What is a fibroid and what are causes and presentation
Benign tumour of myometrium
ax: oestrogen and progesterone dependent
sx: asymptomatic, menorrhagia, IMB, dysmenorrhoea, frequency and retension, impaired fert
Fibroid investigations
USS
Hysteroscopy
Hb (increased bc fibroids secrete erythropoietin)
Fibroid management
- NSAIDS, tranexamic acid, progestodens
- GnRH agonist for women near menopause only used 6/12 bc done density loss + HRT can use longer
- resection, hysterectomy, myomectomy, ablation or embolization
Polyp RF, presentation, IX and Mx
-pt on tamoxifen for breast cancer
Sx: asy, menorrhagia, IMB
Ix: USS, hysteroscopy
Mx: resection or avulsion
Menorrhagia management
1st: IUS
2nd: COCP, NSAIDS, tranexamic acid
3rd: progestins(norethisterone), GnRH (6/12 only)
surgery: endometrial ablation(uterus <10 weeks), uterine artery embolisation (uterus >10 weeks), hysterectomy
causes of PCB
- Infection
- carcinoma (cervical vaginal)
- cervical ectropion (cervix epi columnar instead of squamous)
- atropic vagina
- cervititis, vaginitis
- trauma
Candidiasis
cottage cheese dischange and itching
Tx: clotrimazole PO fluconazole
Bacterial Vaginosis
grey/white discharge, fishy odor
1) increased pH
2) +ve whiff (fishy when 10% pot hydroxide)
3) Clue cells
Mx: metronidazole or clindamycin cream
Chalmydia
asyp, Reiters, abnormal
ECS, NAAT
Mx: azithromycin 2nd doxycycline
Gonorrhoea
asym, urethritis, cervicitis, bartholinitis
ECS NAAT
Mx: IM ceftriaxone, azithromycin
Genital warts
HPV (16/18)
Tiny flat patches-> papilloform swellings
Mx: podophyllin or imiquimod topical
Herpes
HSV type 2
painful vesicles and ulcers around introitus. local lymphadenopathy, dysuria, systemic features
VE/swabs
Mx: aciclovir or valaciclovir
Syphilis
- chancre
- > rash and flu symptmos
- gential warts or oral growths
Syphilis EIA, VDRL
Mx: benpen IM
Trichomoniasis
offensive grey/green discharge , itching, cervicitis, dyspareunia
Polymorphonuclear lymphocytes on wet firm microscopy
Mx: metronidazole
Lichen infections presentations
Planus: plain, purple papules
Simple: pruritis, hypo/hyper pigmented labia majora
Sclerosis: pruritits, pink/while papules-> parchment
Lichen infections management
Planus/Sclerosis: high potency steriod cream
Simplex: Avoid, Steriod (betamethasone), Anti hist (hydroxyzine) Emollient
Lichen infections diagnosis
planus: clinical
simplex and sclerosis: biopsy
Gestational Diabetes RF
History: Person or family
Mum: overweight(>30), smoker
Previous births: still birth, macrosomia (>4.5kg)
Complications of gestational diabetes
fetal: congenital abnormalities, preterm labour, macrosomia/polyhydramnios
Maternal: UTI, Pre E, CS, db retinopathy
Ix and Mx for gestational diabetes
fasting glucose >5.6 or OGTT >7.8
Mx: increase insulin <6.0 in previous db
Diet->metformin -> insulin
aspirin to reduce pre-eclampsia risk
Pre - eclampsia pathology
incomplete trophoblastic invasion, reduced uteroplacental blood flow, endothelial damage
increased vascular perm (proteinuria)
vasocontriction (HTN, eclampsia)
Risk factors for pre-eclampsia
Mod
- BMI >35
- age>40
- fam Hx
- nulliparity
High
- personal Hx
- HTN
- CKD
- db
- autoimmune
1 high or 2 mod = aspirin
Pre eclampsia presentation and examination findings
systolic BP >140 or diastolic BP >90 in the 2nd half of pregnancy
with ≥1+ proteinuria on reagent stick testing.
Asymptomatic
- headache
- N&V
- visual disturbances
- upper epi pain
O/E - oedema, hyper-reflexia
Pre-eclampsia complications
- eclampsia (tx- mg sulphate)
- Pulmonary oedema (Tx - 02, frusemide)
Baby: IUGR, abruption
Mum: Renal failure, HELLP,
Pre eclampsia investigations
Urine >30mg protein
fetal wellbeing: USS for growth, doppler artery, amniotic fluid volume
Monitor: LFT, U&E, FBC to guide delivery time
Pre-eclampsia management
<150/109
- BP QDS
- bloods 2 times weekly
>150/109
- BP QDS
- bloods 3 times weekly
- labetalol or nifedipine
Mg Sulphate reduces eclampsia risk
Symptoms of RBC isoimmunization
mild: neonatal jaundice ± anaemia
severe: in utero anaemia (cardiac failure, ascites, oedema, fetal death)
worse with successive pregs
Rhesus management
Booking at 28 weeks check all women for antibodies
- <10 = sig problems unlikely check 2/4 weeks
- >10 = further investigations
Doppler US every 2 weeks
Anti D at 28 weeks and within 72 hours of a sensitising event or delivery
Blood transfusion or delivery >36 weeks
What to look at on CTG
DR C BRAVADO
Define Risk
Contractions
Baseline RAte
Variability
Accel
Decel
Overall impression
Combined test
10-14 weeks
- nuchal translucency
- B-HCG
- PAPPA
Downs, Edwards, Pataus
Risk >1 in 150 -> more testing
Quad test
14-20 weeks
- alpha feto protein
- B- HCG
- oestriol
- inhibin A
Amniocentesis what and risk
needle (US guided) into amniotic sack to remove fluid sample. Pt given anaesthic.
Risks
- miscarriage 1%
- infection
- repeat procedure
- punctured placenta
- Rhesus
- club foot (<15w)
14 days after period unilateral pain
Mittelschmerz
Whirlpool sign on pelvic USS?
Ovarian torsion
Management for vaginal vault prolapse?
sacrocolpoplexy
Endometriosis management
COCP
GnRH agonist
IUS
pain relief: naproxen
PID management
Abx
IM ceftriaxone + PO doxy and metronidazole BD 14 days
Severe: doxy + IV ceft and metron -> PO doxy and mentron as above
Types of incontinence
Functional incontinence: Can’t reach toilet bc poor mobility
Stress incontinence: leaking on effort or exertion, coughing sneezing, bc incompletely sphincter
Urge incontinence: leakage with or after urgency. destrusor instability or hyperreflexia -> contraction
PCOS diagnostic criteria
- Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
- Oligo-ovulation or anovulation.
- Clinical and/or biochemical signs of hyperandrogenism.
PCOS complications
- Infert
- Endometrial hyperplasia and cancer
- CVD
- T2DM
- Gestational db
when to induce in pre-eclampsia
When to induce
- Gestational HTN >40w
- mild >37 w
- mod/severe 34-36
- monitor for 24 hours
- discharge on BB
What increases a womans risk of developing cervical cancer?
Younger women, associated with HPV 16+18
Increased risk of getting HPV
- earler intercourse
- multiple partners
- STIs
General: smoking, CIN, OCP
what is CIN?
Cervial intraepithelial neoplasia
most common type of abnormal cell found on colposcopy
2 and 3 are higher risk of cervical cancer
What are the symptoms of cervical cancer?
- bleeding
- discharge
- vaginal discomfort
- urinary symptoms
How do you manage cervical cancer?
stage 1: tachelectomy or hysterectomy
stage 2: radio, chemo, palliative
What increases a womans risk of developing endometrial cancer
Menopausal women
unopposed oestrogen
- early menarche
- late menopause
- nulli
- HRT
- obese
- smoking
- PCOS, db
How does endometrial cancer present?
PMB
How do you investigate PMB
TVUS if thickness >3mm -> biopsy
How do you manage endometrial cancer?
- hysterectomy ± node biopsy
- radiotherapy (SE ulceration, bladder issues)
What increases a womans risk of developing ovarian cancer?
increased ovulation
- early menarche
- late menopause
- nulli
- HRT
- obese
- smoking
- BRCA 1/2
How does ovarian cancer present?
vague GI symptoms
- bloating/IBS
- bowel habit change
- urinary frequency
- pelvic/abdo mass
How do you investigate ?ovarian cancer
*if >50 with vague GI symptoms refer for USS*
- CA 125
- pelvic and abdo USS
- CT
Risk assessment by Risk Malignancy index 1
How do you manage confirmed ovarian cancer?
- hysterectomy +chemo
- palliative debulking
What increases a womans chance of developing vulval cancer?
- VIN
- HPV
- lichen sclerosis
What is VIN?
vulval intraepithelial neoplasm
premalignant state occuring independently or in lichen sclerosus
px: pruritic lesions
ix: examination and biopsy
mx: wide local excision with life long follow up (HPV association)
How does vulval cancer present?
- non healing lesion/ulcer
- lump
- itching
- soreness
- bleeding
- dysuria
How would you investigate potenital vulval cancer?
Examination and biopsy
what is the management of vulval cancer
surgery
what types are each of the gynae cancers?
Cervical: Squamous
Endometrial: adenocarinoma
Ovarian: epithelial origin
When is cervical cancer screening?
every 3 years from 25-49 then every 5 years until 65
What does a -ve cervical cancer screening result mean and what action would then be taken?
normal cells
next smear in 3/5 years
What does an inadequate cervical cancer screening result mean and what action would then be taken?
insufficient/unsuitable material
redo within 3 months
What does a borderline cervical cancer screening result mean and what action would then be taken?
-abnormal nuclei but not definitely dyskaryosis
-> HPV DNA test
-: normal smear routine
+: colposcopy
?: smear/HPV in 6 months
What does a mild dyskaryosis cervical cancer screening result mean and what action would then be taken?
CIN1
-> HPV DNA test
-: normal smear routine
+: colposcopy
?: smear/HPV in 6 months
What does a moderate cervical cancer screening result mean and what action would then be taken?
CIN 2
-> colposcopy
What does a severe cervical cancer screening result mean and what action would then be taken?
CIN 3
-> colposcopy
What does a glandular neoplasia cervical cancer screening result mean and what action would then be taken?
adenocarcinoma
->cancer management
Average age of menopause?
51
what counts as early meno pause?
40-45 years old
what are the most common menopause symptoms
Menstrual irregularity
hot flushes/sweats
Urinary symptoms: UTIs incontinence
Vaginal symptoms: dyspareunia, dryness
Disturbed sleep
Mood: anxiety, depression, memory loss, difficulty concentrating
loss of libido
which diseases are associated with menopause?
- Cardiovascular: stroke, coronary artery disease
- osteoporosis
- Alzheimers
What management is availble for menopause?
Healthy lifestyle
HRT
What are the risks of HRT?
- VTE
- stroke
- breast cancer
- endometrial cancer
What is antepartum haemorrhage?
bleeding from 24w - birth
How do you classify APH?
- minor <50mls
- major 50-1000 mls
- massive >1000mls and/or shock
What are the common causes of APH?
Placenta praevia
Placental abruption
Cervical Ectropion
Trauma
Infection
What is placenta praevia and what are the risk factors?
Placental implatned low in uterus ± covering the OS
- Previous CS
- Hx
- increased parity
- increased age
Presentation of placenta praevia?
Intermittent painless bleeding
investigations in placenta praevia
DONT VE
USS- baby breech and transverse lie
fetal well being: CTG
What is the management of placenta praevia?
C-section
What is placental abruption and what are the risk factors ?
separation of the placenta
- Hx
- Pres E, HTN
- IUGR, twins
- smoking, cocaine
How does placental abruption present?
abdo pain and bleeding (can be underestimated)
Examination findings in placental abruption?
woody tender uterus
Management of placental abruption
- ABCDE
- IV fluids
- bloods, G&S
- delivery if fetal distress or >37
Cervical ectropion
what, presentation and management
Columnar epithelium present outside cervix, oestrogen related
Px: PCB
Mx: cautery
What are desensitising events?
- Abortion, miscarriage, ectopic
- Aminocentesis
Symptoms of Turners by age
newborn: SFD, cardiac stuff
infancy: feeding diffs, poor weight gain
Pre-school: short stature, OME
School: obesity, impaired puberty, learning diffs
adult: infertility, obesity, autoimmune disorders
Physical features of Turners
- low set ears
- short webbed neck
- wide spaced nipples
- pectus excavatum
Investigations for Turners
Chromosomal analysis
LH/FSH: decreased ages 4-10, increased otherwise
Management of Turners
MDT: paeds, ophthal, ENT, dentist, cardio, urology
rhGH - increase growth
oestrogen and progesterone
Cardiovascular problems associated with Turners
Coarctation of the aorta.
Bicuspid aortic valve; aortic stenosis.
Aortic aneurysms.
Mitral valve prolapse.
What is HELLP syndrome?
Haemolysis Elevated Liver enzymes Low Platelets
How does HELLP present?
Worse at night, non specific
- headache
- abdo pain
- eye blurr
OE: oedema, HTN, proteinuria
What increases risk of HELLP
History, nulli, >35 gestational HTN history, APS
Investigations for HELLP
- Haemolysis: blood film and high LDH
- Elevated Liver: high AST or ALT
- Low Platelets
Management of HELLP
>34 weeks: delivery
<34weeks: corticosteriods
RC, platelets, FFP, cryoprecipitate, as needed
What is a PPH
loss of >500ml blood <24 hours after delivery
What are the causes of PPH?
Tone - most common
Tissue: retained placenta
Trauma: tears
Thrombin: DIC
How do you manage PPH?
ABCDE
Group and save
Oxytocin - ergometrine - tranexamic acid
Uterine massage
B Lynch sutures if above not effective
PPH risk factors?
Large Baby
Multip
Long Labour
