Obs and Gynae Flashcards
What is an ovarian cyst
A fluid filled sac in the ovary, may be benign or malignant
What are the risk factors for ovarian cyst
- Family Hx
- Obesity
- Smoking
- Early menarche/late menopause
- BRCA 1/2
- Nulliparity
- HRT- oestrogen only
What are protective factors for ovarian cyst
- Multiparity
- Breastfeeding
- Combined oral contraceptive
How you calculate risk of malignant ovarian cyst
- RMI (Risk of malignancy index) score
- 1 for pre-menopause, 3 for post-menopause
x - 0 for 0 features on USS, 1 for 1 and 3 for 2+
x - CA125 score
RM| 250+ NEEDS REFERRAL TO GYNAE
How might ovarian cysts present
- Chronic pelvic pain
- Deep dyspareunia
- Vaginal bleeding
- Frequency/constipation (cyst pressing on bladder/bowel)
- Weight loss/ malaise/ sweats
- Acute sudden onset severe pain in torsion/rupture
What investigations might you perform for ovarian cysts
- USS
- Bloods
- Biopsy
- CA125
How would you treat ovarian cysts
BENIGN - Watchful waiting - Cystectomy MALIGNANT - Hysterectomy + bilateral salpingo-oophorectomy + lymph nodes - Chemo/radiotherapy
What is polycystic ovarian syndrome (PCOS)
- PCOS is characterised by excessive androgen production and presence of multiple cysts on the ovaries
Describe the pathophysiology of PCOS
- Excess LH production causes excess ovarian production of androgens (testosterone)
- Insulin resistance also occurs
- Despite the increased levels of LH the raised androgens stop an LH surge occurring so ovulation is not triggered meaning follicles remain as cysts in the ovaries
How might PCOS present
- Excess weight gain
- Male pattern hair (alopecia + facial/chest/back hair)
- Amenorrhoea/oligomenorrhoea
- Chronic pelvic pain
- Acne/oily skin
- Infertility
What investigations might you do in PCOS
- USS of ovaries
- Bloods (testosterone and LH raised), TFTs to rule out thyroid
- ?cortisol
What is the diagnostic criteria for PCOS
- Rotterdam criteria (2 of 3)
1) Polycystic ovaries on USS
2) Clinical or biochemical signs of hyperandrogenism
3) Oligo/anovulation
How would you manage PCOS
Tailored to individual symptoms
Oligo/amenorrhoea (trigger ovulation to dec. cancer risk)
- Combined oral contraceptive or progesterone analogue
Obesity
- Lifestyle advice
- Orlistat / off licence metformin
Infertility (for people wanting to conceive)
- Clomifene +/- metformin
Hirsutism
- Anti-androgen medication
What are fibroids
- Benign tumour of the uterine smooth muscle
What are the risk factors for fibroids
- Prev. fibroids/ family Hx
- Early menarche/ late menopause (growth thought to be stimulated by oestrogen)
- Inc. age
- African-American
How might fibroids present
- Most are asymptomatic
- Heavy periods
- Pelvic pain/ deep dyspareunia
- Constipation/ frequency/ Abdo. distention
- Subfertility
What investigation might you do for fibroids
- USS
- Bloods
How might you manage fibroids
- Watch and wait
- Tranexamic acid
- GnRH analogues goserelin (not a long term option due to demineralisation of bone)
- Hysterectomy/ myomectomy/ Hysteroscopy + removal of fibroids
What is endometriosis
- Endometrial tissue growth in areas outside uterine cavity. Common areas include ovaries, peritoneum, bladder and pouch of Douglas.
- Most common in 25-40
What are the risk factors for endometriosis
- Early menarche
- Family Hx
- Heavy periods/ short cycles
- Uterine defects
How might endometriosis present
- Cyclical pelvic pain (may be constant)
- Heavy, painful periods (dysmenorrhoea)
- Subfertility
- Painful bowels
- Deep dyspareunia
What investigations might you do for endometriosis
- USS
- Laproscopy (gold standard)
How might you manage endometriosis
- Pain - Analgesic ladder
- Periods - COCP or merina coil
- Surgical excision
- Hysterectomy + bilateral salpingo-oophorectomy
What is Pelvic inflammatory disease (PID)
- An infection of the female upper genital tract
- Mostly caused by STIs (chlamydia/gonorrhoea)
What are the risk factors for PID
- Sexually active
- IUD/pelvic surgery
- Prev. PID/STI
- Unprotected sex
- Recent partner change
How might PID present
- Pelvic/lower abdo. pain
- Deep dyspareunia
- Post- coital bleeding
- Abnormal offensive discharge
- Menstrual abnormalities
- Dysuria
- Fever/ N+V/ severe abdo pain (advanced)
What investigations might you do for PID
- Endocervical swab
- STI screen
- Urine dip (rule out UTI)
- Pregnancy test (rule out ectopic)
How might you manage PID
- Broad spectrum antibiotics
- Analgesia
- Avoid sex
- Contact tracing
What complications can arise from PID
- Ectopic pregnancy (scarring of fallopian tubes)
- Infertility
- Chronic pelvic pain
What is a Bartholin’s cyst
- A fluid filled sac within one of the Bartholin’s glands in the vagina
- They secrete mucus to help lubricate vagina, can get blocked leading to a cyst or abscess
What are the risk factors for Bartholin’s cyst
- Vulvar surgery
- Previous cyst
- STIs can cause cysts/ abscess
How might Bartholin’s cyst present
- Mostly asymptomatic
- Cyst- Soft, non-tender vulval lump
- Abscess - Hard, painful, vulval lump (may be cellulitis)
- Superficial dyspareunia
- Vulvar Pain
What investigations might you do for Bartholin’s cyst
- Clinical diagnosis
- Biopsy in suspicious/ over 40
- STI screen if indicated
What is the management of Bartholin’s cyst
- Watch + wait
- Drainage with word catheter
- Antibiotics if systemically unwell
What is bacterial vaginosis
- An infection of the lower genital tract, occurring due to disturbance of the normal vaginal flora causing an increase in pH
What are the risk factors for bacterial vaginosis
- Sexually active
- Douching/ overwashing vagina
- Antibiotics
- IUD
- Black
How might bacterial vaginosis present
- White thin, fishy smelling discharge
- Usually no pain or itchiness
What investigations might you do for bacterial vaginosis
- Clinical diagnosis
- High vaginal smear
How might you manage bacterial vaginosis
- Metronidazole oral or vaginal gel
What is vulvovaginal candidiasis
- A fungal infection of the lower genital tract (aka. thrush/yeast infection)
What are the risk factors for vulvovaginal candidiasis
- Pregnancy
- Diabetes
- Antibiotics
- Steroids/immunosuppression
How might vulvovaginal candidiasis present
- Itchiness/ pain
- White curd like discharge usually inoffensive
- Satellite lesions/ redness
- Dysuria
What investigations might you do for vulvovaginal candidiasis
- Usually clinical diagnosis
- Urine dip to rule out UTI
- Smear in recurrent/ complicated
How might you manage vulvovaginal candidiasis
- Vaginal clotrimazole
- Oral fluconazole
What is urinary incontinence
- The involuntary leakage of urine
What are the two main types of urinary incontinence
1) Stress
- Involuntary leakage of urine due to increases in intra-abdominal pressure
2) Urge
- Aka. over-active bladder syndrome. Presence of urgency without UTI or other obvious pathology
How might stress incontinence present
- Leakage of urine on exertion eg. Laughing Coughing Sneezing Exercise
How might urge incontinence present
- Patient will complain of urgency resulting in leakage
- May also be frequency and nocturia
What investigations might you do for urinary incontinence
- Urine dip to exclude UTI
- Frequency volume chart
- In stress is normal, in urge frequency is raised
How do you manage stress incontinence
- Lifestyle changes
- Pelvic floor exercises/ physio
- Surgery- tension free vaginal tape
- Duloxetine (if surgery fails/contra-indicated)
How do you manage urge incontinence
- Lifestyle changes
- Bladder re-training
- Anti-cholinergics- oxybutynin
- botulinum toxin A (botox)
- Surgery
What is the menopause
- Cessation of menstruation
- Average age is 51
When can menopause be diagnosed
- After 12 months amenorrhoea
- If hysterectomy diagnosed at onset of menopausal symptoms
What is the perimenopause
- Period leading up to menopause
- Characterised by irregular periods, hot flushes, mood swings and urogenital atrophy
What are the symptoms of the menopause
- Hot flushes
- Mood swings/ irritability
- Decreased sex drive
- Aches/pains
- Dry vagina
What are the long term consequences of the menopause
- Stroke/ CVD
- Dementia
- Osteoporosis
What does HRT cause increased risk of
- Stroke
- Breast cancer
- Venous thromboembolism
- Must weigh up risks vs benefits and be wary when giving to patients at inc. risk of these conditions
What are the types of HRT
- Combined sequential (oestrogen + progesterone 12-14 days per 28 - causes a bleed)
- Combined continuous (Oestrogen + progesterone daily - bleed free)
- Mirena coil
- Tibolone (synthetic Oestrogen + progesterone, equivalent to combined cont.)
What is premature ovarian insufficiency
- Menopause at less than 40 years old
- Can be natural or iatrogenic causes
- Mostly idiopathic
How do you manage premature ovarian insufficiency
- Hormone replacement
- Dec. symptoms and risk of oestrogen deficiency
- Continue until at least 51 yrs
What is the aetiology of cervical cancer
- 3rd most common in world, 12th in uk
- Primarily of younger people - peak at 25-29
- Strong association with HPV, hence vaccination scheme in schools
What are the risk factors for cervical cancer
- HPV!!!!! IMPORTANT
- Smoking
- Family Hx
- Oral contraceptive pill long term
- STIs
How might cervical cancer present
- Abnormal vaginal bleeding
- Dyspareunia
- Pelvic pain
- Vaginal discharge
- B- symptoms
- Often are picked up on cervical cancer screen
What investigations might you do for cervical cancer
- If pre-menopausal then do a chlamydia screen, if negative then colposcopy + biopsy
- If post-menopausal then colposcopy + biopsy
- CT/MRI
How might you manage cervical cancer
- Surgical - may preserve fertility, or hysterectomy - Hysterectomy + bilateral salpingo-oopherectomy (full pelvic clearance)
- Chemo/radiotherapy
What are the risk factors for endometrial cancer
- Early menarche/ late menopause (inc. proliferation)
- Low parity
- HRT (only oestrogen)
- Tamoxifen
- Inc. age
- PCOS
- Obesity
How might endometrial cancer present
- Post menopausal bleeding (most common)
- Vaginal discharge
- B-symptoms
What investigations might you do for endometrial cancer
- Transvaginal USS
- Biopsy/ hysteroscopy + biopsy
- CT/MRI for staging
How do you stage endometrial cancer
FIGO staging
Stage I – Carcinoma confined to within uterine body.
Stage II – Carcinoma may extend to cervix but is not beyond the uterus.
Stage III – Carcinoma extends beyond uterus but is confined to the pelvis.
Stage IV – Carcinoma involves bladder or bowel, or has metastasised to distant sites.
How might you manage endometrial cancer
- Hysterectomy + bilateral salpingo-oopherectomy
- Chemo/radiotherapy
What is an ectopic pregnancy
- Any pregnancy which has implanted outside the uterine cavity
- Common sites include fallopian tubes (most common), ovaries, cervix and peritoneum
What are the risk factors for ectopic pregnancy
- PID
- Past ectopic
- Endometriosis
- Pelvic surgery
- IUD
- IVF
How might an ectopic pregnancy present
- Recent onset lower abdo./ pelvic pain
- Vaginal bleeding
- Shoulder tip pain
- Vaginal discharge
What investigations might you do for ectopic pregnancy
- Urine B-HCG
- USS
- If no pregnancy seen on USS and urine B-HCG >1500 then offer laparoscopy for diagnosis
- Blood B-HCG
How might you manage ectopic pregnancy
1) Expectant (rare)
- Monitor blood B-HCG
2) Medical
- IM methotrexate
- Monitor bloods, if not falling then repeat dose
3) Surgical
- Salpingectomy
- Salpingotomy if need to preserve fertility
What is a miscarriage
- A loss of a pregnancy at less than 24 weeks gestation
- More common less than 12 weeks than 12-24 weeks
What are the risk factors for miscarriage
- Previous miscarriage
- Maternal age >30-35
- Uterine abnormalities/surgery
- Obesity
- Smoking
How might a miscarriage present
- Vaginal bleeding
- Crampy pain (like period pains)
What investigation might you do for miscarriage
- Transvaginal USS
- Serum B-HCG
How might you manage miscarriage
1) Expectant
- Allow POC to pass naturally
2) Medical
- Give mifepristone followed by vaginal misoprostol (prostaglandin analogue) 24-48 hours later
3) Surgical
- Removal via. vacuum or excavation
Describe a threatened miscarriage
CLINICAL - Small bleed +/- pain, cervix is closed TV USS - Viable pregnancy MANAGEMENT - Reassure/ treat bleeding if required
Describe an inevitable miscarriage
CLINICAL - Heavy bleed/ clots, pain, cervix open TV USS - Viable or non-viable pregnancy MANAGEMENT - Medical/ surgical/ expectant
Describe a missed miscarriage
CLINICAL - Usually asymptomatic TV USS - No foetal heartbeat MANAGEMENT - Medical/ surgical/ expectant
Describe an incomplete miscarriage
CLINICAL - Bleed/ clots, pain, TV USS - Partially expelled POC MANAGEMENT - Medical/ surgical/ expectant
Describe a complete miscarriage
CLINICAL - Hx bleed/ clots, pain TV USS - No POC MANAGEMENT - Refer to GP
What are the moderate risk factors for pre-eclampsia
- Nulliparity
- BMI >35
- Multiple pregnancy (twins+)
- Family Hx pre-eclampsia
- Maternal age 40+
- Pregnancy interval 10+ years apart
What are the high risk factors for pre-eclampsia
- Prev. pre-eclampsia
- Autoimmune disease
- CKD
- Diabetes
- Hypertension
If 2+ moderate or 1+ high then give 75mg aspirin
How might pre-eclampsia present
- Headache
- Oedema
- Visual changes
- Epigastric pain
- Hyper-reflexia
What is the diagnostic criteria for pre-eclampsia
- B.P >140/90
- Proteinuria
- > 20 wks. gestation
What investigations might you do for pre-eclampsia
- B.P
- Bloods - FBC, LFT, U&E
How might you manage pre-eclampsia
- Inc. monitoring
- Anti-hypertensives - 1st line labetalol, 2nd line nifedipine
- Delivery
What is Eclampsia
- Occurrence of one or more convulsions in a pre-ecplamptic woman
How might eclampsia present
- Seizure/ convulsions
- Jaundice
- Headache
- Oedema
- Visual changes
- N+V
How might you manage eclampsia
1) Stop seizure
- Magnesium sulphate
2) IV Anti-hypertensives
- Labetalol
3) Deliver baby when mother is stable via. C-section
What are the definitions for small for gestational age (SGA) and foetal growth restriction (FGR)
- <10th centile of estimated foetal weight or <10th centile of abdominal circumference
- A pathological process in which the foetus’ growth is restricted, commonly by genetic abnormalities or placental insufficiency
What investigations might you do for FGR
- USS - plot growth on growth chart
- Uterine artery doppler (absent/reversed end-diastolic flow)
- Karyotyping
How would you manage FGR
1) Surveillance
- UAD every 14 days
- Change modifiable risk factors
2) Delivery
- Absent/reversed EDF on UAD = urgent C-section
What are some of the complications of FGR
- Still birth
- Cancer
- Hypothermia
- Obesity
- Birth asphyxia
What is an Antepartum haemorrhage (APH)
- > 50mls of bleeding at >24 weeks before birth
What are the common and important causes of APH
Common - Cervical ectropion - Unexplained Important - Placental abruption - Placenta previa
What is placental abruption
- Premature separation of the placenta from the uterine wall
What are the risk factors for placental abruption
- Previous abruption
- Pre-eclampsia
- Polyhydramnios
- Smoking/drug use
- Multiple pregnancy
How might placental abruption present
- Painful vaginal bleeding
- Woody uterus
What investigations might you do for placental abruption
- FBC/clotting
- Foetal CTG
- USS
How do you manage placental abruption
- Maternal resuscitation
- C-section
What is placenta previa
- Where the placenta is partially or fully attached to the lower part of the uterus
Minor - Not covering the cervical Os
Major - Covering cervical Os
What are the risk factors for placenta previa
- Previous placenta previa
- Maternal age >40 yrs
- Multiple pregnancy (eg. twins)
- High parity
What investigations might you do for placenta previa
- FBC/Clotting
- Foetal CTG
- USS
How do you mange placenta previa
- Maternal resuscitation
- C-section
What is primary PPH
- A loss of >500mls of blood within 24hrs of delivery
- Minor = 500-1000mls
- Major >1000mls
What are the 4 Ts for causing PPH
Tone - Uterine atony (most common)
- Failure of uterus to contract following delivery
Tissue - retained placental tissue
Tears - episiotomy, instrumental delivery, C-section all inc. risk
Thrombin - Clotting abormalities
How might you manage PPH
- Fluids/blood/resuscitation
- Bimanual compression to stimulate uterine contractions
- Drugs to stimulate uterine contractions eg. syntocinon
- Repair trauma/manually evacuate tissue
What is cord prolapse
- When the umbilical cord descends through the cervix alongside or before the presenting part of the foetus
- This causes foetal hypoxia due to compression of the cord and arterial vasospasm when exposed to cold atmosphere
What are the risk factors for cord prolapse
- Prematurity
- Breech presentation
- Abnormal/unstable lie
- AROM
Why might you suspect cord prolapse
- Always considered in non-reassuring foetal heart and absent membranes
How might you manage cord prolapse
- AVOID HANDLING THE CORD
- Elevate foetus pressing on cord
- Encourage into left lateral position
- Emergency C-section
What are the stages of labour
Stage 1 - Latent/active Stage 2 - Passive/active Stage 3 - Delivery of placenta
Describe stage 1 of labour
Latent - Cervix <4cm dilated - Contractions every 5-20 mins - Do not encourage pushing Active - Cervix dilated 4-9cm - Contractions every 2-10 mins - Do not encourage pushing Management - V.E every 4 hrs - If failing to progress (should progress 1cm every two hours) then AROM/oxytocin/membrane sweep
Describe stage 2 of labour
Passive - not pushing Active - Encourage pushing - Cervix 9cm+/ fully dilated - Contractions every 2-5 mins Management - May need episiotomy/ forceps/ ventouse
Describe stage 3 of labour
- Delivery of placenta
- Cord clamp
- May need traction/ oxytocin
What are the 4 Ps for successful labour
Power - Adequate contractions Passage - Pelvic abnormalities Passenger - Lie/position - Size of baby Psychology - Support
How might chlamydia present
50% of men and 70% of men are asymptomatic - Dysuria - Abnormal discharge Women - Deep dyspareunia - Lower abdo pain Men - Testicular pain
What investigations might you do for chlamydia
- Full STI screen Women - First catch urine, vulvo-vaginal or endocervical swab Men - First catch urine or urethral swab
How do you treat chlamydia
- Doxycycline 100mg 2x daily
- IM azathioprine 1g single dose
- Sexual abstinence/contact tracing
How might gonorrhoea present
- Abnormal discharge
- Dysuria
- Dyspareunia
- Lower abdo pain
What investigations might you do for gonorrhoea
- Endocervical/vaginal swab
- First catch urine sample
How do you treat gonorrhoea
- IM ceftriaxone 1g
What are the potential complications of gonorrhoea and chlamydia
Women - PID - Ectopic/infertility Men - Epididymo-orchitis - Infertility Chlamydia can cause reactive arthritis
How might primary syphilis present
- Papule on genitals which develops into a painless ulcer (chancre)
- Usually a singular painless, non itchy and hard ulcer
How might secondary (if left untreated) syphilis present
- Skin rash (on hands and soles of feet)
- Fever
- Malaise/arthralgia
- Weight loss
- Painless lymphadenopathy
- Elevated plaque like lesions on moist skin (axilla, inner thighs, genitalia)
How do you investigate syphilis
- Swab from and active lesion
- Serology
How do you treat syphilis
Early - Penicillin IM x1 dose Late - Penicillin IM weekly for 3 weeks Contact tracing/sexual abstinence
How might Trichomonas vaginalis present
- Many cases asymptomatic
- Offensive vaginal odour
- Abnormal discharge
- Itchy vulva/foreskin
- Dysuria
- Dyspareunia
- Strawberry cervix
How might you investigate Trichomonas vaginalis
- High vaginal swab
- First void urine sample/urethral swab
How might you treat Trichomonas vaginalis
- Metronidazole 2g x1
- Sexual abstinence/contact tracing
What is hyperemesis gravidarum
- Persistent vomiting in pregnancy that causes weight loss in excess of 5% of pre-pregnancy weight and ketosis
How might hyperemesis gravidarum present
- Can’t keep food/fluids down
- Weight loss
- Malnutrition
- Dehydration
- Tachycardia
What investigations might you do in hyperemesis gravidarum
- Urine dip to check for UTI and ketones
- U&Es to check electrolyte levels
How might you manage hyperemesis gravidarum
- Hospital admission for fluid resuscitation and electrolyte balancing
- Anti-emetics
What are the types of FGM
Type 1
- Partial or full removal of the clitoris
Type 2
- Partial or full removal of clitoris and labia
Type 3
- Narrowing of vagina via cutting/stitching of labia, with or without removal of clitoris
Type 4
- Any other non-medical procedures that harm female genitalia
What is primary amenorrhoea
- Failure to start periods, need investigation at 16, or 14 if no breast development
What is secondary amenorrhoea
- Stopping of periods for >6 months, other than for pregnancy
What is menorrhagia
- Excessive bleeding during periods
What is primary dysmenorrhoea
- Painful periods with no underlying pathological cause
What is secondary dysmenorrhoea
- Painful periods caused by pathology
