Obs and Gynae anki 2 Flashcards
What group is urinary incontinence most common in?
Elederly females
Name some risk factors for developing urinary incontinence
Advancing age
Previous pregnancy/childbirth
High BMI
Hysterectomy
Family history
Name the reversible causes of urinary incontinence
DIAPPERSD:
delirium
infection
atrophic vaginitis or urethritis
P-Pharmaceuticals-meds)
P-Psychiatric disorders
E-Endocrine disorders-diabetes etc
R-Restricted mobility
S-Stool impaction
What causes urge incontinence?
Detrusor overactivity
What is functional incontinence?
Comorbid physical conditions impair the patient’s ability to get to a bathroom in time
Causes: dementia, medications, injury/illness causing impaired mobility
What is a cystometry?
Investigation to measure bladder pressure whilst voiding
What is a cystogram?
Contrast instilled into the bladder and a radiological image is obtained to see if the contrast travels anywhere else
What are the surgical management options for treating urge incontinence?
Bladder instillation
botox injection to paralyse detrusor muscle
Sacral neuromodulation->only in tertiary centres where all other treatments have failed
What causes overflow incontinence?
Either:
1. Underactivity of the detrusor muscle e.g. from neurological damage OR
2. Urinary outlet pressures are too high e.g. constipation or prostatism
What is a genital or pelvic organ prolapse?
Descent of one or more pelvic structures from their normal anatomical position moving towards or through the vaginal opening
Name some risk factors for developing a genital prolapse
-Vaginal childbirth, especially with traumatic or complicated deliveries
-Increasing age
-Menopause
-Hysterectomy
-Obesity
-Chronic cough
-Heavy lifting
-Connective tissue disorders
-Spina bifida
What are the types of anterior vaginal wall prolapse?
Cystocele-bladder
Urethrocele-urethra
Cystourethrocele-both bladder and urethra
What is a cystocele? What condition can it lead to?
Bladder prolapse
Stress incontinence
Name the posterior wall prolapses
Enterocele-small intestine
Rectocele-rectum
Name the atypical vaginal wall prolapses?
Uterine prolapse-uterus
Vaginal vault prolapse-roof of the vagina
What are some differential diagnoses for a uterogential prolapse?
Gynecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain
Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain
Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass
Name some investigations to diagnose a genital prolapse
-Pelvic exam
Imaging if complex or required for surgical planning
Urodynamic studies if co-existing urinary symptoms
What is a vaginal fistula?
Unusual opening that connects your vagina to another organ
Can link vagina to bladder, ureters, urethra, rectum, intestines
Name some of the causes of a vaginal fistula?
Childbirth
Abdominal surgery
Pelvic, cervical or colon cancer
Radiation treatment
Bowel disease-Crohn’s or diverticulitis
Infection
Name some complications of a vaginal fistula
Vaginal/urinary tract infections that keep returning
Stool or gas that leaks through the vagina
Irritated/swollen skin around vagina/anus
Abscesses
What are fibroids?
Benign smooth muscle tumours originating from the myometrium of the uterus.
What do uterine fibroids develop in response to and how does incidence change with age?
Oestrogen
Increases with age until reaching menopause
In which group of people are uterine fibroids most common?
More common in Afro-Caribbean women
Name some symptoms of uterine fibroids
-Asymptomatic
-Menorrhagia and dysmenorrhoea-.can cause iron deficiency anaemia
-Bloating
-Lower abdominal pain, cramps
-Urinary symptoms
-Subfertility
Rare: polycythaemia
Name some differential diagnoses for uterine fibroids
Endometrial polyps: Present with irregular menstrual bleeding and spotting
Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility
Name some complications of uterine fibroids
-Subfertility
-Iron deficiency anaemia
-Red degeneration-> haemorrhage into tumour>commonly occurs during pregnancy
What are the types of uterine fibroids?
- Intramural
- Subserosal
- Submucosal
- Pedunculated
Where do intramural fibroids grow?
Within the myometrium, -> can distort the uterus
Where do subserosal fibroids develop
Just below the outer layer of the uterus
Can fill the abdominal cavity
What is red degeneration of fibroids
-Ischemia, infarction, and necrosis of the fibroid due to disrupted blood supply
-MC in 2nd/3rd trimester of pregnancy
-fibroid rapidly enlarges during pregnancy-> outgrows blood supply, uterus changes shape and expands during pregnancy
What is an ovarian cyst?
Fluid filled sac that develops within or on the surface of an ovary.
What are some differential diagnoses for ovarian cysts?
Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.
Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.
Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.
What investigations are done into a suspected ovarian cyst?
Pregnancy test to exclude ectopic
Diagnostgic laparoscopy->especially if haemodynamically unstable
Ultrasound
Bloods: Ca125: tumour marker for ovarian cancer
LDH, AFP, HCG to assess for germ cell tumour
What are the main possible complications of an ovarian cyst?
Torsion
Haemorrhage into the cyst
Rupture with bleeding into the peritoneum
What are the types of physiological/functional cysts?
Follicular cysts
Corpus luteum cysts
What are serous cystadenomas?
Benign tumours of the epithelial cells
What are mucinous cystadenomas
Benign tumours of the epithelial space which can grow very large and take up lots of space in the pelvis and abdomen
What are sex cord stromal tumours?
Rare tumours that can be benign or malignant
Arise from stroma of connective tissue or sex cords (embryonic structures associated with the follicles)
Several types: Sertoli=-Leydig cell tumours and granulose cell tumours
Name some risk factors for ovarian malignancy
Age
Postmenopause
Increased number of ovulations
Obesity
Hormone replacement therapy
Smoking
Breastfeeding (protective)
Family history and BRCA1 and BRCA2 genes
Name some protective factors for ovarian cancer
Anything that will reduce the number of ovulations:
Later onset of periods (menarche)
Early menopause
Any pregnancies
Use of the combined contraceptive pill
Name some non-malignant causes of a raiserd CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
In women under 40 with a complex ovarian mass what tests should be done?
Tumour markers for a possible germ cell tumour:
Lactate dehydrogenase(LDH)
Alpha-fetoprotein;(α-FP)
Human chorionic gonadotropin(HCG)
What is ovarian torsion usually due to?
Ovarian mass >5cm-mc with benign tumours and in pregnancy
Name some risk factors for developing ovarian torsion?
Ovarian mass
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Name some complications of an ovarian torsion
Fertility not typically affected as other ovary can compensate
If only a functioning ovary removed->infertility and menopause
If necrotic ovary not removed:
Infection
Abscess
Sepsis
If it ruptures-> peritonitis and adhesions
What is lichen sclerosus?
Inflammatory dermatological condition
What is Koebner phenomenon?
When the signs and symptoms worsen with friction to the skin
Name a few things that cane make lichen sclerosus worse
Friction to the skin
Tight underwear
Sex
Urinary incontinence
Scratching the affected area
Name some differential diagnoses for lichen sclerosus
Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.
Name some complications of lichen sclerosus
5% risk of developing squamous cell carcinoma of the vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal/urethral openings
Name some risk factors for developing cervical cancer
HPV 16 and 18 infection or anything that increases the risk of this (early sexual activity, not suing condoms, increased number of sexual partners)
Smoking
Immunosuppression
Non engagement with cervical screening
Using COCP for >5yrs
Name some differential diagnoses of cervical cancer
Vaginitis: itching, burning, pain, and abnormal discharge
Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding
Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse
What characteristics of a cervix would be worrying and prompt an urgen colposcopy?
Ulceration
Inflammation
Bleeding
Visible tumour
What does cervical screening involve?
Speculum exam
Collection of cells from the cervix
Cells examined for precancerous changes(dyskaryosis)
Transporting the cells: liquid based cytology
Name some exceptions to the usual cervical screening programme
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
Name 3 infections that can be identified from smear testing for cervical cancer
Bacterial vaginosis
Candidiasis
Trichomoniasis
Describe the management of smear results
Inadequate: rpt in 3 months, then colposcopy
Positive with normal cytology: rpt in 12 months( x 2 then colposcopy)
Negative HPV: normal recall
What is a colposcopy?
Inserting a speculum and using a colposcope to magnify the cervix.
Allows epithelial lining of cervix to be examined
What tests are used in a colposcopy
- Acetic acid: abnormal cells appear white-CIN and cervical cancer
- Schiller’s iodine test: stain cells of cervix: healthy cells brown, abnormal cells won’t stain
- Punch biopsy, Large loop excision of transformation zone
What is a Large Loop Excision of the Transformation Zone (LLETZ)
-Loop biopsy with local anaesthetic during colposcopy
-Loop of wire with electrical current to remove abnormal epithelial tissue on cervix
-May increase risk fo preterm labour
-SE: bleeding and discharge-avoid intercourse and tampons to reduce infection risk
What are the main risks associated with a cone biopsy?
Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
Describe the cervical cancer staging
FIGO: Federation of gynae and obstetrics staging:
Stage 1: confined to cervix
Stage 2: Invades uterus or upper 2/3 of vagina
Stage 3: Invades pelvic wall or lower 1/3 of vagina
Stage 4: Invades bladder, rectum or beyond pevlis
Describe the management of cervical cancer and cervical intraepithelial neoplasia
Stage 1A: LLETZ or cone biopsy
1B-2A: Radical hysterectomy and removal of local lymph nodes with chemo and radiotherapy
2B-4A: Chemo and radiotherapy
4B: Surgery, chemo and palliative care
What do HPV strains 6 and 11 cause?
Genital warts
Name some risk factors for developing endometrial cancer
Nulliparity
Obesity
Early menarche
Late menopause
Polycystic ovary syndrome
Oestrogen-only hormone replacement therapy
Tamoxifen
Name some protective factors against endometrial cancer
multiparity
combined oral contraceptive pill
smoking;(the reasons for this are unclear)
Name some symptoms of endometrial cancer
Postmenopausal bleeding(usually slight and intermittent then becomes heavier)
Abnormal vaginal bleeding, such as intermenstrual bleeding
Dyspareunia
Pelvic pain-uncommon apart from in later stages
Abdominal discomfort or bloating
Weight loss
Anaemia
Name some differentials for endometrial cancer
Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.
Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.
Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.
What is endometrial hyperplasia?
Precancerous thickening of the endometrium
What are the 2 types of endometrial hyperplasia
Hyperplasia without atypia
Atypical hyperplasia
How does Type 2 diabetes increase the risk of endometrial cancer
Increased production of insulin-> stimulates endometrial cells and increases risk of endometrial hyperplasia and cancer
How does tamoxifen affect the risk of endometrial cancer
Anti oestrogenic effect on breast tissue but eostrogenic effect on endometrium-> increased risk
What are the NICE suspected cancer referral guidelines concerning endometrial cancer?
Urgent 2 week wait: women with postmenopausal bleeding
Transvaginal US in women >55yrs with:
Unexplained vaginal discharge
Visible haematuria+raised platelets, anaemia or elevated glucose levels
Describe endometrial cancer staging
FIGO staging:
Stage 1: confined to uterus
Stage 2: Invades the cervix
Stage 3: Invades ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond pelvis
What are the different types of ovarian cancers?
Epithelial-mc
Germ cell
Sex cord
What group of people do ovarian germ cell tumours typically arise from?
Young women-mc
atypical for most cases of ovarian cancer
What are the tumour markers for ovarian germ cell tumours?
Alpha fetoprotein and B-HCG
What is a Krukenbery tumour?
‘Signet ring’ sub-type of tumour typically GI in origin whcih has metastasised to the ovary
Name some risk factors for developing ovarian cancer
Advanced age
Smoking
Increased number of ovulations
(early menarche, late menopause)
Obesity
HRT
Genetics: BRCA1&BRCA2
Name some protective factors against ovarian cancer
Childbearing
Breastfeeding
Early menopause
Use of COCP
Name some differentials for developing ovarian cancer
Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits
Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation
Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating
Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms
What investigations are done to diagnose ovarian cancer?
CA125 blood test
Pelvic and abdominal US scan
CT scans for staging
AFP and B-HCG in younger women-germ cell tumours
Laparotomy for tissue biopsy
Name some conditions aside from ovarian cancer that can raise the CA125 level
Endometriosis
Menstruation
Benign ovarian cysts
Describe ovarian cancer staging
Stage 1: limited to ovaries
Stage 2: One or both ovaries with pelvic extension and/or implants
Stage 3: One or both ovaries microscopically confirmed peritoneal implants outside the pelvis
Stage 4: One or both ovaries with distant metastasis
What are the NICE suspected cancer guidelines relating to ovarian cancer?
2 week wait if:
Ascites
Pelvic mass
Abdominal mass
Further investigations includng CA125 if:
New symptoms of IBS/change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency/urgency
Weight loss
What does the risk of malignancy index relating to ovarian cancer take into account?
Estimates the risk of an ovarian mass being malignant
Menopausal status
Ultrasound findings
CA125 level
Name some risk factors for developing vulval cancer
Advancing age
HPV infeciton
Vulval intraepithelial neoplasia(VIN)
Immunosuppression
Lichen sclerosus
Name some differential diagnoses for vulval cancer
Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
Lichen sclerosus: itching, pain, and white patches on the vulva.
Bartholin’s cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.
What investigations might be done to diagnose vulval cancer?
Thorough exam of vulva
Biopsy
Imaging/blood tests to assess extent of disease and staging
What are the treatment options for VIN
Watch and wait;with close followup
Wide local excision(surgery) to remove the lesion
Imiquimod cream
Laser ablation
What age group(s) are most at risk of developing a molar pregnancy?
Extreme ends of the fertility age range<16yrs&>45yrs
What is a complete molar pregnancy?
Formation from a single sperm and empty egg with no genetic material
Sperm replicates to provide a normal number of chromosomes-all paternal
foetal tissue, only proliferation of swollen chorionic villi
What is a partial molar paregnancy?
Formed from 2 sperm and a normal egg
Both paternal and maternal genetic materials present
Variable evidence of foetal parts
Name some differential diagnoses for a molar pregnancy
Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.
Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.
Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.
Name 2 complications of molar pregnancies
Choriocarcinoma
Mole can metastasise->patient may require systemic chemotherapy
What is endometriosis?
Growth of ectopic endometrial tissue outside of the uterine cavity
Name some theories thought to explain the cause of endometriosis
Retrograde menstruation
Coelomic metaplasia
Lymphatic/vascular dissemination of endometrial cells
Name some differential diagnoses for endometriosis
Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.
Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.
Adhesions: pelvic pain and possible bowel obstruction.
Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.
What investigations are used to diagnose endometriosis?
Transvaginal US-> Often normal but may ID an ovarian endometrioma
GS: Diagnostic laparoscopy
Name a complication of endometriosis
Infertility
Poor quality of life due to chronic pain
Describe the staging of endometriosis
Stage 1: small superficial lesions
Stage 2: Mild but deeper lesions
Stage 3: Deeper lesion with lesions on ovaries and mild adhesions
Stage 4: Deep and large lesions affecting ovaries with extensive adhesions
What is adenomyosis?
Presence of endometrial tissue within the myometrium
In which group of people is adenomyosis most common in?
Multiparous women towards the end of their reproductive years
What conditions can adenomyosis occur with?
Endometriosis
Fibroids
What investigations are done to diagnose adenomyosis?
1st line: transvaginal US of pelvis
If unsuitable: MRI and transabdominal USGS:
Histological exam of the uterus after a hysterectomy(mostly unsuitable)
What complications relating to pregnancy can adenomyosis cause?
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm rupture of membranes
Malpresentation
Need for C section
Postpartum haemorrhage
What is atrophic vaginitis?
Inflammation and thinning of the genital tissues due to a decrease in oestrogen levels
What causes atophic vaginitis?
Decline in oestrogen levels, typically post-menopause
On examination, what might you find in a patient with atrophic vaginitis?
Pale and dry vagina
Loss of pubic hair
Thinning of vaginal mucosa
Narrowed introitus
Loss of vaginal rugae
Name some differentials for atrophic vaginitis
For postmenopausal bleeding:
malignancy, endometrial hyperplasia
For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes
For narrowed introitus: female genital mutilation
For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis
For dyspareunia: malignancy, vaginismus
What investigations should be done in a patient presenting with likely atrophic vaginitis?
Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy
Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer
An infection screen if itching or discharge is present
A biopsy of any abnormal skin lesions, if needed
What is a miscarriage?
Loss of pregnancy <24 weeks gestation
Name some risk factors for having a miscarriage
Maternal age >30
Previous miscarriage
Obesity
Smoking
APS
Uterina abnormalities
Coagulopathies
Previous uterine surgeries
Chromosomal abnormalities
Name some symptoms of a miscarriage
Often found incidentally on US
Vaginal bleeding-clots/conception products
If lots of bleeding: signs of haemodynamic instability: pallor, dizziness, SOB
suprapubic, cramping pain
Name some signs of a miscarriage
Haemodynamic instability: tachy, hypotension, tachycardia
Abdo exam: distended, local areas of tenderness
Speculum: cervical os, POC, bleeding
Bimanual exam: uterine tenderness, adnexal masses/collections
Name some differentials for a miscarriage
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine cancer
What blood might be done in a patient suspected of having a miscarriage?
b-HCG-
important to also assess the possibility of an ectopic pregnancy
What are the different kinds of miscarriage?
Threatened
Inevitable
Missed/delayed
Incomplete
Complete
Septic
What is an ectopic pregnancy?
Embryo implants and beigns to grow outside fo the uterine cavity, usually in the fallopian tuubes
Name some of the causes/risk factors for having an ectopic pregnancy
Pelvic inflammatory disease
Endometriosis
Genital infections
Previous ectopic pregnancies
Having an IUD/coil in situ
Assissted reproduction like IVF
Name some differentials for an ectopic pregnancy
Miscarriage
UTI
Appendicitis
Diverticulitis
PID
Ovarian accident
What investigations should be done in a patient with a suspected ectopic pregnancy?
B-HCG-POSITIVE
Pelvic US
Transvaginal US
Can’t find evidence of pregnancy on any scans
Serum B-HCG
Describe the level of serum B-HCG in suspected ectopic pregnancy:
> 1500iU: ectopic-diagnostic laparoscopy
<1500iU: if stable, can repeat in 48 hours
Using B-HCG monitoring how can you tell if a patient is having a miscarriage or has a viable pregnancy?
Viable pregnancy: will double every 48 hours
Miscarriage: halves every 48 hours
What complications can arise from an ectopic pregnancy
Fallopian tube rupture->hypovolaemic shock->organ failure>death
Name some causes of oligohydramnios
Pre-term rupture of membranes
Non-functional kidneys
Renal agenesis(Potter’s)
Obstructive uropathy
Placental insufficiency
Chromosomal abnormalities
Viral infections
What are the most common causes of oligohydramnios?
Pre-term rupture of membranes
Placental insufficiency
What causes symptoms in patients with oligohydramnios?
Decreased space around fetus
Lack of amniotic fluid for fetal growth and development
What investigations are typically done to diagnose oligohydramnios?
USS:Reduced amniotic fluid index
Reduced max pool depth(MPD) or single deepest pocket(SDP)
To ID underlying cause:Maternal bloods
KaryotypingIf membrane rupture suspecteD:IGFBP-1 or PAMG-1(usually in amniotic fluid)
What is important to remember if delivering a baby early via C-section due to oligohydramnios?
Give a course of steroids for fetal lung development and antibtiotics to lower risk of infection
What complications can arise from oligohydramnios and why?
Amniotic fluid allows fetus to move in utero
No fluid-> no exercise-> muscle contractures-> disability after birth
What investigations might be done in a patient with polyhydramnios?
USS-diagnostic
To look for cause:Maternal glucose tolerance test
Fetal anaemia
Karyotyping
Fetal anatomy for structural cause
Viral screen(TORCH)
What si the pregnancy viral screen-TORCH
Toxoplasmosis
Parvovirus
Rubella
CMV
Hepatitis
What are the 2 stages of labour?
Latent phase: 0-3cm cervical dilation
Active phase: 3-10cm cervical dilation
Name some differentials for the first stage of labour
Braxton Hicks
Preterm labour
What investigations might be done if a woman is in the first stage of labour?
Regular assessment of maternal and foetal vital signs
Frequent exam to determine cervical dilation and effacement
Palpation to assess position and descent of foetus
Name some signs and symptoms of the second stage of labour
Foetal head flexion, descent and ngagement into the pelvis
Foetal internal rotation to face maternal back
Foetal head extension to deliver head
Foetal external rotation after delivery of head, positioning of shoulders in AP position
Delivery of anterior shoulder first then rest of foetus
Maternal desire to push
Name some signs indicative of the 3rd stage of labour
Gush of blood from vagina
Lengthening of umbilical cord
Ascension of uterus in abdomen
Name some indications for inducing labour
Post dates:>41 weeks gestationPreterm prelabour rupture of membranes
Intrauterine foetal death
Abnormal CTG
Maternal conditions like pre-eclampsia, diabetes, cholestasis
Name some contrainidctaions for inducing labour
Previous classical/vertical incision during C-section
Multiple lower uterine segment C-sections
Transmissible infections
Placenta praevia
Malpresentations
Severe fetal compromise
Cord prolapse
Vasa Previa
What investigations might be carried out prior to starting inductino of labour?
US: confirm gestational age, foetal position and placental location
Bloods: Check mother’s health status-pre-eclampsia/diabetes
Name some differentials for pre-term labour
Braxton Hicks
UTI
Placental abruption
Uterine rupture
What investigations might be done in a patient presentign with pre term labour
Foetal fibroenctin tes(fFN)- assesss risk of pre term elivery after onset of pre-term labour
What age does menopause usually happen?
45-55Average in UK: 52yrs
Name some symptoms of menopause
Vasomotor: hot flushes, night sweats
Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm
Psychological: depression, anxiety, brain fog
Name some differentials for menopause
Hyperthyroidism
Depression
premature ovarian insufficiency
What are the types of HRT
Oestrogens-can be oral, transdermal or topical
Progestogens-oral, transdermal, intrauterine
Name some benefits of HRT
Relief of vasomotor sx
Relief of urogential sc
Reduced risk of osteoporosis
Name some things HRT can increase the risk of?
Breast cancer
Endometrial cancer(especially if given alone)VTE
Name some contraindications for prescribing HRT
Breast cancer
Oestrogen dependednt cancer
Vaginal bleeding of unknown cause
Pregnancy
Untreated endometrial hyperplasia
VTE
Liver disease with abnormal LFTs
Name some complications of menopause
Osteoporosis
Cardiovascular disease
Dyspareunia
Urinary incontinence
What does GnRH do for the menstrual cycle?
Released from the hypothalamus and stimulates LH and FSH release from anterior pituitary
What are the phases of the ovarian cycle?
Follicular
Ovulation
Luteal
What happens during the follicular phase of the ovarian cycle?
Follicles begin to mature and prepare to release an oocyte
At the start: low ovarian hormone production: little negative feedback at HPG axis so increase in FSH and LH
Only 1 follicle can reach maturity, other follicles form polar bodies
Oestrogen becomes high enough to initiate positive feedback, increases everything, especially LH but increased inhibin means FSH doesn’t surge(inhibin selectively inhibits FSH)
Granulosa cells express LH receptors
What happens during the ovulaton stage of the ovarian cycle
Response to LH surge: follicle ruptures and oocyte assisted to fallopian tube by fimbria->viable for fertilisation for 24 hours
After ovulation, follicle remains luteinised, secreting oestrogen and progesterone
What happens in the luteal phase of the ovarian cycle?
In absence of fertilisation: corpus luteum regresses after 14 days, fall in hormones relieving negative feedback
What happens to the corpus luteum if fertilisation occurs?
HCG is produced exerting a luteinising effect to maintain the corpus luteum
What are the stages of the uterine cycle?
Proliferative
Secretory
Menses
What happens in the proliferative phase of the uterine cycle?
Runs alongside follicular phase
Prepares reproductive tract for fertilisation and implantation
Oestrogen initiates fallopian tube formation->endometrium thickening->increased growth and motility of myometrium and productive of thin alkaline cervical mucus
What happens during the secretory phase of the uterine cycle?
Runs alongside luteal phase
Progesterone stimulates thickening of endometrium into glandular secretory form, thickening of myometrium, reduction of motility in myometrium, thick acidic cervical mucus production(prevent polyspermy)
What are the main hormones involved in:a)proliferative phaseb)secretory phase?
a)oestrogen
b)progesterone
Name some differentials for PCOS
Menopause
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen secreting tumour
Cushing’s
What investigations might be done to diagnose PCOS?
Bedside: clinical exam to look for features of hyperandrogenism/insulin resistance
Bloods: LH:FSH ratio, total testosterone, fasting/oral glucose tolerance, TFT, prolactin, cortisol
Imaging: transabdominal/transvaginal USS
What diagnostic criteria is used for PCOS?
Rotterdam diagnostic criteria
Name some complications of PCOS
Infertility
Metabolic syndrome and dyslipidaemia
T2DM
CVD
Hypertension
Obstructive sleep apnoea
What is Asherman’s syndrome?
Adhesions(synechiae) form within uterus following damage to the uterus
Name some common causes of Asherman’s syndrome
Pregnancy related dilatation and curettage procedure
Post uterine surgery
Pelvic infections
Name some complications of Asherman’s syndrome
Menstruation abnormalities
Infertility
Recurrent miscarriages
What are congenital malformations of the female genital tract?
Deviations form normal anatomy resulting from embryonic maldevelopment of Mullerian or paramesonephric ducts
What are the most common types of congenital uterine abnormalities caused by?
Incomplete fusion of mullerian or paramesonephric ducts
Name some complications of congenital uteirne abnormalities
Dysmenorrhoea
Haematoemtra
Complicaitons during pregnancy and labour
Congenital renal abnormalities often co-exist
What are endometrial polyps?
Benign growths of endometrial lining of the uterus, consisting of glandular epithelium, stroma and blood vessels
What age groups are endometrial polyps found in?
Reproductive age women
Can occur post menopausal
Name some risk factors for polyps
Obesity
Htn
Tamoxifen
HRT
Name some differentials for a polyp
Fibroid
Adenomyoma
Endometrial carcinoma
Gestation trophoblastic disease
Name some complications fo endometrial polyps
Small percentage may have atypical hyperplasia/endometrial carcinoma
Anaemia due to chronic blood loss in those with heavy menstrual bleeding
Name the causative organisms of PID
Chlamydia trachomatis-most common cause
Gonnorhoea
Mycoplasma genitalium
Mycoplasma hominis
Sometimes no pathogen isolates
What is Fitz Hugh Curtis syndrome?
Adhesions form between anterior liver capsule and anterior wall/diaphragm in context of PIC
Name some differential diagnoses for PID
Appendicitis
Ectopic
Endometriosis
Ovarian cyst
UTI
What investigations are used to diagnose PID
Pregnancy test to exclude ectopic
Swabs for gonorrhoea and chlamydia or urine NAAT
Bimanual exam: cervical motion tenderness
Bloods: FBC+WCC+CRP
Imaging: TV USS
Name some complications of PID
Chronic pelvic pain-tubal damage from inflammation
Infertility
Ectopic pregnancy
Fitz-High Curtis syndrome
What condition might Fitz Hugh Curtis syndrome be confused with?
Cholecystitis
Name some risk factors for developing renal stones
Obesity
Dehydration
Diet rich in oxalate foods like fruit, nuts, cocoa
Previous stones
Anatomical abnormalities
FHx
Name some differentials for urinary tract calculi
Pyelonephritis
Appendicits
Diverticulitis
Ovarian torsion
Ectopic pregnancy
AAA
What investigaitons might be done to diagnose renal stones?
Urinalysis
Uirne mc+s
Observations to check for sepsis
FBC, UE, calcium and uric acid
GS: non contrast helical CT KUB
What is a prolactinoma?
Benign tumour of the pituitary gland-secretes excessive prolactin
What does the aerola contain and how do they change during pregnancy?
Contain sebaceous glands
Enlarge during pregnancy and secrete an oily substance that acts as a protective lubricant
What are the 3 main parts that make up the anatomical structure of the breast
Mammary glands
Connective tissue stroma
Pectoral fascia
What are the groups of lymph nodes that receive lymph from breast tissues?
Axillary nodes(75%)
Parasternal nodes(20%)
Posterior intercostal nodes(5%)
What is a fibroadenoma?
Benign tumour consisting of a mixture of fibrous and epithelial tissue
Name some differentials for fibroadenomas
Breast cyst
Invasive breast cancer
Intraductal papilloma
Lipoma
What investigations might be done in a patient presenting with a likely fibroadenoma?
Triple assessment:Clinical exam
Imaging: US/Mammogram
Needle biopsy-fine needle aspiration/core biopsy
What is fibrocytic breast disease?
Benign condition->presence of fibrous tissue and cysts in the breast
Considered a variation of normal breast tissue
Name some differentials for fibrocystic breast disease
Breast cancer
Cysts
Fibroadenoma
Mastitis/abscess
What investigations might be used to diagnose fibrocystic breast disease
Clinical exam
Mammogram and US
Biopsy: exclude malignancy if suspicious findings
What genetic mutations are implicated in breast cancer?
BRCA1/2
Name some risk factors for developing breast cancer
High hormone exposure:
Endogenous oestrogen: early menarche, nulliparity, late menopause
Exogenous oestrogen and progestin:
COCP, HRT
Inherited gene mutations: BRCA1/2
Increasing age
F history/personal history of breast cancer
Alcohol/tobacco use
What are the subtypes of breast cancer?
Pre-invasive:
Ductal carcinoma in situ
Lobular carcinomaa in situ
Invasive:
Invasive ductal carcinoma
Invasive lobular carcinoma
Medullary carcinoma
Others:
Inflammatory
Mucinous
Tubular
HER2 positive breast cancer
Triple negative breast cancer
Name some differentials for breast cancer
Fibroadenoma
Cysts
Mastitis
Lipoma
Name 2 methods for staging breast cancer
TNM staging(tumour node metastasis)
Stage 1A/B/2A/B/ETC
What are some methods used to treat breast cancer?
Surgery
Radiotherapy
Hormone therapy
Biological therapy
Chemotherapy
What are some features that wwould favour a mastectomy instead of awide local excision?
Multifocal tumour rather than solitary lesion
Central tumour rather than peripheral
Large lesion in small breast rather than small lesion in large breast
DCIS
>4CM rather than<4cm
Name a biological therapy that might be used in breast cancer treatment and when it might be used?
Trastuzumab(Herceptin)-used in HER2 positive tumours
Can’t be used in patients with heart disorders
Name some examples of hormonal therapies that might be used in patients with breast cancer
Tamoxifen: pre/peri menopausal women
Anastrozole: aromatose inhibitors: post-menopausal women
Name some side effects of tamoxifen
Increased risk of endometrial cancer
VTE
Menopausal symptoms
Name some differentials for Paget’s disease of the nipple
Atopic dermatitis/contact dermatitis/psoriasis
Intraductal papilloma
Mastitis/abscess
What is cervical effecement?
Also called cervical ripening
Thinning of the cervix
Before: shaped like a bottleneck and up to 4cm
Through pregnancy: cervix tightly closed and protected by mucus plug
What are the 7 mechanisms of labour?
Descent
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of body
What happens during the ‘descent’ stage of labour?
Fetus descends into pelvis
What encourages the ‘descent’ stage of labour?
Increased abdominal muscle tone
Increased frequency and strength of contractions
What happens during the ‘flexion’ stage of labour?
Fetus descends through pelvis->uterine contractions exert pressure down fetal spine towards occiput forcing the occiput to come into contact with pelvic floor
Fetal neck flexes allowing the circumference of the head to reduce-easier to pass through pelvis
What happens during the internal rotation stage of labour?
With each contraction, fetal head is pushed onto pelvic floor, supporting a small degree of rotation
Regular contractions eventually lead to head completing 90 degree turn
What happens during the ‘extension’ phase of labour?
Fetal occiput slips beneath suprapubic arch allowing the head to extend-fetal head born and usually facing maternal back
What happens during the ‘restitution/external rotation’ stage of labour?
fetus naturally aligns head with shoulders
Visually head may be seen to externally rotate face to right or left
What is delayed cord clamping?
Umbilical cord not immediately clamped and cut at point of birth but allowed >1 minute to transfuse blood to baby
Baby can receive up to 214g of blood
Name some benefits of delayed cord clamping
Allows baby time to transition to extra-uterine life
Increase in RBC, irone and stem cells
Reduced need for inotropic support
What are some benefits of an upright birth?
Increases diameter of pelvic inlet
Less risk of compressing mother’s aorta
Encourages stronger and longer contractions
Gravity
What are the advantages of using entotox as pain relief in labour?
Fast acting-20-30 seconds
Can be used alongside analgesia
Does not require further fetal monitoring
What is an epidural?
Mix of bupivacaine and fentanyl
Epidural catheter inserted by anaesthetist and drugs administered through pump
Name some pros and cons of using an epidural
Pros:
Total pain relief in 90% of cases
Effect will last until baby is born
Cons:
Reduced mobility
Cant take up to an hour to take effect
Will need urinary catheter
Can slow down labour if not already established
What is an operative vaginal delivery?
Use of an instrument to aid delivery of the fetus
What are the 2 main instruments used in operative deliveries?
Ventouse
Forceps
What are ventouse deliveries associated with?
Lower success rate
Less maternal perineal injuries
Less pain
More cephalhaematoma
More subdural haematoma
More fetal retinal haemorrhage
What are forceps and how are they used for delivery?
Double bladed instruments
Inserted into pelvis, applied round sides of fetal head with blades locked together
Gentle traction applied during uterine contractions
What are forceps associated with?
Higher rate of 3rd/4th degree tears
Less often used to rotate
Doesn’t require maternal effort
Name some indications for performing an assisted vaginal delivery
Maternal:
Maternal exhaustion
Maternal medical conditions that mean active pushing should be avoided(intracranial pathologies, severe heart disease/htn)
Fetal:
Suspected fetal compromise in 2nd stage of labour0
CTG monitoring/abnormal fetal blood sample
Cinical concerns like significant antepartum haemorrhage
Name some absolute contraindications to an instrumental delivery
Unengaged fetal headIncompletely dilated cervix
True cephalo pelvic disproportion
Breech and face presentation
Preterm gestation(<34 weeks)
What are the pre-requisites for intstrumental delivery?
Fully dilated
Ruptured membranes
Cephalic presentation
Defined fetal position
Fetal head at least at level of ischial spines and no more than 1/5 palpable per abdomen
Empty bladder
Adequate pain relief
Adequate maternal pelvis
Name some fetal complications from an instrumental deliver
Neonatal jaundice
Scalp lacerations
Cephalohaematoma
Subgaleal haematoma
Retinal heamorrhage
Skull fractures
Name some maternal complications of instrumental deliveries
Vaginal tears: 3rd/4th degree
VTE
Incontinence
PPH
Shoulder dystocia
Infection
What results of a quadruple test might indicate a higher risk of Down’s syndrome?
AFP: Low
hCG: high
Inhibin A: high
Unconjugated oestriol: low
What are the 2 types of invasive prenatal diagnostic testing?
Chorionic villus testing(CVS)
Amniocentesis
What is CVS?
US guided smapling of placental tissue by insterting a fine needle through abdomen and into uterus
Rules out mosaicism-if positive will need amniocentesis
What is amniocentesis?
US guided insertion of fine needle through abdomen into uterus to take a sample of amniotic fluid-contains baby’s cells so is a true reflection of baby’s DNA
Name some risks of invasive prenatal testing
Miscarriage
Infection
What does the anomaly scan screen for?
11 physical confitions
Some associated with Down’s-congenital heart disease, abdominal wall defects
Name some risk factors for mastitis
Poor breastfeeding technique
Nipple damage
Maternal stress
Previous hx of mastitis
Name some differentials for mastitis
Breast abscess
Breast cancer
Breast engorgement-> bilateral, associated with milk stasis and tense breasts
Name a complication of mastitis
Breast abscess
What is a breast abscess?
Accumulation of pus within an area of breast tissue, often a complication of infectious mastitis
What is bacterial vaginosis?
Bacterial imblaance of the vagina cuased by an overgrowth of anaerobic bacteria and loss of lactobacilli
What are the features of lactobacilli bacteria?
Rod-shaped
Produce hydrogen peroxide->keeps vaginal pH >4.5 which inhibits growth of other organisms
Name some risk factors for bacterial vagnosis
Sexual activity
Receptive oral sex
Presence of an STI
Smoking
Recent antibiotic use
Ethnicity(higher in black women)
Vaginal douching/use of scented soaps/vaginal deoderants
Name some differentials for bacterial vaginosis
Vulvovaginal candidiasis
Trichomonas vaginalis infection
Chlamydia/gonorrhoea
Atrophic vaginitis
What investigations are done to diagnose bacterial vaginosis?
Ansel criteria: 3/4 of:
pH>4.5grey/milky discharge
clue cells on wet mount(vaginal epithelial cells studded with gram variable coccobacilli)
KOH whiff test
Microscopy: high vaginal smear: clue cells, decreased lactobacilli and no pus cells
Name some complications for bacterial vaginosis
Pregnancy related-> premature birth, miscarriage, chorioamnionitis risks
Name some risk factors for vulvovaginal candidiasis
Pregnancy
Diabetes
Antibiotic use
Corticosteroid use/immunosuppression
Name some signs of vulvovaginal candidiasis
Erythema/swelling of vulva
Discharge
Satellite lesions-red, pustular lesions with superficial white/creamy pseudomembranous plaques
What is chlamydia?
STD caused by obligate intracellular bacteria chlamydia trachomatis
What are the different serotypes of chlamydia and what infections do they cause?
A-C: Ocular infection: chlamydial conjunctivitis
D-K: classical GU infection
L1-L3: Lymphogranuloma venereum(LGV), MSM, proctitis
What group of people is L1-L3 chalmydial infections found in most commonly?
MSM
Name some risk factors for chlamydia
<25yrs
Recent change in sexual partner/infected partner
Co-infection with other STIs
Non-barrier contraception
What does chlamydia in rpegnancy increase the risk of?
Low birth weight
Miscarriage
What contact tracing should be done in patient with chlamydia?
Men with urethral sx: all partners 4 weeks prior to sx onset
asx men and women: last 6 months r most recent partner
Name some complicatons of chlamydia
Reactive arthritis
Infertility
Epididymitis
PID
Endometritis
Increased incidence of ectopics
Perihepatitis
Name some risk facotrs for gonorrhoea
<25yrs
MSM
High density urban areas
Previous gonorrhoea infections
Multiple sexual partners
Name some complications of gonorrhoea
PID
Epididdymo-orchitis
prostatitis
Dissminated gonococcal infection
Name some complications of disseminated gonococcal infection
Septic arthriits: mc cause of septic arthritis in young people
Endocarditis
Perihepatitis
Fitz-Hugh-Curtis syndrome
What is gonorrhoea in pregnancy associated with?
Perinatal mortality
Spontaneous abortion
Premature labour
fetal membrane rupture
Vertical transmission->gonococcal conjunctivitis
What are gential herpes?
Infectious disease that causes painful sores/ulcers on the genitalsHSV1/2
What does HSV1 cause?
Oral/genital herpes-coldsores
What does HSV2 cause?
Anogenital herpes
Name some risk factors for developing gential herpes
Multiple sexual partners
Oral sex with partner with cold sores
What are genital warts?
Benign epithelial/mucosal outgrowths caused by HPV
Name some risk factors for developing genital warts
Early age at 1st sex
Multiple partners
Smoking
Immunosuppression
Diabetes-> persistence of warts
Name some differentials for genital warts
Molluscum contagiosum
Condyloma lata(secondary syphilis)
Genital herpes
Skin tags
What is a risk of gential warts in pregnancy?
Very low risk of transmission during birth-can cause respiraotry papillomatosis
What is HIV?
Single stranded RNA retrovirus that infects and replicates in CD4(T helper) cells
Name some risk factors for developing HIV
MSM
IVDU
High prevalence areas
Other STDs, breaks in skin
What are the different stages of HIV infection?
Seroconversion illness
Symptomatic HIV
AIDS defining illness
Name some AIDS defining illnesses/infections/malignancies
Pneumocystis jiroveci
Non-Hodgkin’s lymphoma
TB
What are NRTI’s?
nuceloside analogue reverse transcriptase inhibitors
E.g. zidovudine, abacavir etc
General SE: peripheral neuropathy
Is the cervical os open or closed in a threatened miscarriage?
Closed
What are the surgical options for miscarriage management?
<12 weeks: manual vacuum aspiration
>12 weeks: evacuation of retained products of conception(ERPC)
Name some causes of polyhydramnios
Idiopathic: 50-60% of cases
Excess production due to increased fetal urination:
Maternal diabetes mellitus
Fetal renal disorders
Fetal anaemia
Twin to twin transfusion syndrome
Insufficiency removal due to decreased fetal swallowing:
Oeosphageal/duodenal atresia
Diaphragmatic disorders
Anencephaly
Chromosomal disorders
What are some risks of amnioreduction in patients with polyhydramnios?
Infection
Placental abruption->sudden increase in intrauterine pressure
What are the risks of indomethacin for polyhydramnios?
Associated with premature closure of ductus arteriosus(<32 weeks only)
Name some complications of polyhydramnios
Higher incidence of preterm labour
Malpresentation-fetus has more space to move within uterus
Higher risk fo cord prolapse and postpartum haemorrhage
What is a prolonged pregnancy?
5-10% of pregnancies that persist after 42 weeks gestation
Name some risk factors for a prolonged pregnancy
Nulliparity
Maternal age &>40yrs
Previous prolonged pregnancy/fhx
High BMI
Name some symptoms patient with a prolonged pregnancy might experience
Static growth/macrosomia
Oligohydramnios
Decreased fetal movements
Presence of meconium
Dry/flaky skin with reduced vernix
What investigations might be done in a patient with a prolonged pregnancy?
Dating between 11+0 and 13+6 wk gestation during 1st triemster scan
US scanning to check growth and liquor volume-> poor prognostic value in determining placental function and predicting fetal distress
What are the 2 main types of placenta praevia?
Minor placenta praevia: placenta is low but not coverig cervical Major placenta praevia: placenta lies over internal cervical os
What are the risks associated with placenta praevia?
Defective attachment to uterine wall-> increased risk of haemorrhage
Bleeding can be spontaneous or from mild trauma
Placenta can be damaged as fetus moves into lower uterine segment
Name some risk factors for placenta praevia
High parity
Age >40yrsPrevious hx
Hx of endometritis
Curettage to endometrium post miscarriage
What investigations might be done for a patient with suspected placenta praevia?
TV USS; short distance between lower edge of placenta and internal os
Further USS at 37 weeks to reassess placental position
Kleihauer test if RH negative dose anti D for feto-maternal haemorrhage
<26 weeks: CTG to assess fetal wellbeing
What are the 2 kinds of placental abruption
Revealed: bleeding tracks down and drains through cervix->vaginal bleeding
Concealed: Bleeding stays in uterus and forms clot retroplacentally->not visible: can cause systemic shock
Name some risk factors for placental abruption
ABRUPTION
Abruption previously
B: BP-hypertension/pre-eclampsia
R: ruptured membranes
P-premature/prolonged uterine injury
Polyhydramnios
Twins/multiple gestation
Infection-chorioamnionitis
Older age: >35yrs
Narcotic use +smoking
Name some differentials for placental abruption
Placenta praevia
Vasa praevia
Marginal placental bleeed
Uterine rupture
Local genital causes
What investigations might be used in a patient with suspected placental abruption?
CTG
US-retroplacental haematoma-> poor negative predictive
value(shouldn’t be used to exclude abruption)
What are the different kinds of breech presentation?
Complete(flexed)-cross legged
Frank(extended): legs flexed at hip and extended at knees-mc
Footling: Atl least one leg extended at hip so foot is presenting part
Name some risk factors for breech presentation
Uterine:
Multiparity
Fibroids
Placenta praevia
Uterine malformations
Fetal:
Prematurity
Macrosomia
Polyhydramnios
Twins
Name some differentials for breech presentation
Oblique lie
Transverse lie
Unstable lie(position changes)
Name some complications of external cephalic version
Transient/persistent heart rate abnormalities
Placental abruption
Name some specific manouvers used during a vaginal breech birth
Flexing fetal knees
Lovsett’s manoeuver(rotate body and deliver shoulders)
Mauriceau-Smellie-Veit(MSV) manoeuver fails: forceps’hands off’: no tractions: fetal head would extend and get trapped
Name some complications of a breech presentation
Cord prolapse
Fetal head entrapment
Birth asphyxia->usually secondary from delay in delivery
Premature rupture of membranes
Intracranial haemorrhage->rapid head compression during delivery
Developmental dysplasia of the hip
What are the different kinds of fetal lies
Longitudinal
Transverse
Oblique
What are the different kinds of fetal presentation?
Cephalic-mc and safest
Shoulder
face
brow
breech
What are the different kinds of fetal position?
Occipito-anterior: mc and ideal
Occipito posterior
Occipito transverse
Name some risk factors for abnormal fetal lie/malpresentation/rotation
Prematurity
Multiple pregnancy
Fetal abnormalities
Placenta praevia
Primiparity
Uterine abnormalities(fibroids, partial septate uterus)
Name some contraindications for external cephalic version
Recent APH
Rutpured membranes
Uterine abnormaliites
Prior C section
Name some moderate risk factors for pre-eclampsia
Nulliparity
>40yrs
High BMI
Multiple pregnancy
Name some high risk factors for pre-eclampsia
Chronic hypertension
Previous eclampsia/pre-eclampsia
Diabetes
CKD
AI diseases: SLE, APS
Name some differentials for pre-eclampsia
Essential hypertension
Pregnancy induced hypertension
Eclampsia
What investigations might be done in a patient with suspected pre-eclampsia?
BP and proteinuria measurements
FBC: low Hb, low plateletsU&Es: high urea, high creatinine, low urine output
LFTs: high ALT, high AST
Name some maternal complications of pre-eclampsia
Eclampsia
Organ failure
DIC
HELLP syndrome
Name some fetal complications of pre-eclampsia
Intrauterine growth restriction
Pre-term delivery
Placental abruption
Neonatal hypoxia
What is eclampsia?
Occurence of one or more seizure in a pre-eclamptic women in the absence of another cause
What investigations might be done in a patient with eclampsia?
Exclude other reversible causes of seizure and assess for complications: blood glucose, neuro workup
Abdo USS->rule out placental abruption
Name some signs of magnesium sulfate toxicity
Hypo-reflexia
Respiratory distress
What are the risks of BP treatment for a patient with eclampsia
If drop in BP is too rapid->fetal HR abnormalities-> continuous CTG monitoring
Name some differentials for eclampsia
Hypoglycaemia
Stroke
Head trauma
Pre-existing epilepsy
Meningitis
Medication induced
Name some differentials for trichomoniasis
Bacterial vaginosis
Candidiasis
Gonorrhoea
Chlamydia
Name some complications in females of trichomoniasis
Perinatal complications
HIV transmission
PID
Bacterial vaginosis
Cervical cancer risk
Infertility
Name some complications in males of trichomoniasis
Prostatitis
HIV transmission
Prostate cancer risk
Infertility
What is chancroid?
STI of the genital skin
What causes chancroid?
Gram negative bacillus haemophilius ducreyi
Name some risk factors for chancroid
Tropical areas
Poor living conditions
Lack of public health infrastructure
Name some differentials for chancroid
HSV
Syphilis
Lymphogranuloma venereum
Name some risk factors for lymphogranuloma venereum
MSM
Tropics
Developed countries: concurrent HIV infection more common
Name some differentials for lymphogranuloma venereum?
Primary syphilis
HSV
Chancroid
What is balanitis?
Inflammation of the glans penis
Balanoposthitis: extends to underside of foreskin
Name some causes of balanitis
Candidiasis
Dermatits
Bacterial-mc Staph spp
Anaerobic
Lichen planus
Lichen sclerosus
What are the different stages of syphilis?
Primary
Secondary
Tertiary
Name some differentials for syphilis
Primary:
Herpes
Lymphgranuloma venereum
Malignancy
Secondary:
HIV
Mono
Malignancy
Tertiary:
Dementia
Psych conditions
Chronic granulomatous lesions
Name some causes of a false positive non-treponemal test for syphilis
Pregnancy
SLEAPSTB
Leprosy
Malaria
HIV
What conclusion could be drawn from a positive non-treponemal test and positive treponemal test for syphilis?
Consistent with active syphilis infection
What conclusion could be drawn from a positive non-treponemal test and negative treponemal test for syphilis?
False positive syphilis result
What conclusion could be drawn from a negative non-treponemal test and positive treponemal test for syphilis?
Successfully treated syphilis
What is a Jarisch-Herxheimer reaction?
May occur on treatment initiation for syphilis
Rash, fever, tachycardia after 1st dose NO wheeze/hypotension
Due to release of endotoxins following bacterial death
Tx: reassuring and antipyretics
Name some complications of syphilis
Neurosyphilis: general paresis, tabes dorsalis, meningitis, ocular/auditory abnormalities
CVR: aortic aneurysm, regurg, angina, heart failure
Gummatous syphilis: granulomatous lesions affecting skin and bone
HIV transmission facilitation
Name some complications of syphilis in pregnancy
Hydrops
Preterm labour
Low birth weight
Fetal loss
Congeital syphilis of the newborn
What is intraductal papilloma?
Benign tumour: local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant
What is a breast cyst?
Benign fluid-filled sacs inside the breast
What groups of people are more likely to get breast cysts?
Women before menopause: <50yrs
Post menopausal women on HRT
What is HELLP syndrome?
Complication of pregnancy characterised by hemolysis(H), elevated liver enzymes(EL) and low platelets(LP)
What can HELLP syndrome follow on from?
Severe pre-eclampsia: 10-20% of patients go on to get HELLP
Considered separate disorder
Name some differentials for HELLP syndrome
Acute fatty liver of pregnancy
ITP
TTP
Name somme investigations for HELLP syndrome
FBC: low platelets, hemolysis
LFTs: elevated liver enzymes
Coags: assess for DIC
US: liver abnormalities and placental abruption
Name some maternal complications of HELLP syndrome
Organ failure
Placental abruption
DIC
Name some fetal complications of HELLP syndrome
Intrauterine growth restriction
Preterm delivery
Neonatal hypoxia
What is cord prolapse?
Umbilical cord descends through the cervix into the vagina before the presenting part of the feotus
Name some risk factors associated with cord prolapse
Abnormal lie: breech, transverse
Multiple pregnancy
Polyhydramnios
High fetal head at delivery
Multiparity
Low birth weight
Prematurity
Premature rupture of membranes
Name some differentials for cord prolapse
Cord presentation
Funic presentation
Vaginal bleeding or unkown origin
Name some risk factors for vasa praevia
Multiparity
Previous C section
IVF
Velamentous cord insertion-BIG one
Name some differentials for vasa praevia
Placenta praevia-no change in fetal hr unless maternal haemorrhage
Placental abruption
Premature rupture of membranes
Name some complications of vasa praevia
Fetal exsanguination: rupture or unprotected vessels
Hypoxic ischaemic encephalopathy
Preterm labour
Intrauterine growth restriction-> compromised placental perfusion
Name some risk factors for peruperal psychosis
Hx of schizophrenia
Hx of bipolar affective disorder
FHx/hx of postpartum psychosis
Name a differential for peurperal psychosis
Postpartum depression
Baby blues
Name 2 antipsychotics that are safe for use in breastfeeding
olanzapine
quetiapine
Name some risk factors for postpartum depression
Low socioeconomic status
History of mental health disorders
Lack of social support
Name some differentials for postpartum depression
Baby blues
Postpartum psychosis
Adjustment disorders
GAD
Name some fetal complications of PPROM
Prematurity
Infection
Pulmonary hyoplasia
Name a maternal complication of PPROM
Chorioamnionitis
Name some risk factors for primary postpartum haemorrhage
Previous PPH
Prolonged labour
Pre-eclampsia
Increase maternal age
Polyhydramnios
Emergency C-section
Placenta praevia/accreta
BMI>35
Instrumental delivery and episiotomy
What investigations might be done in a patient with postpartum haemorrhage
Bloods for group/save and crossmatch
Consider FFP if clotting abnormalities
Secondary: US looking for retained products of conception
Endocervical/high vaginal swabs-infection
What health professionals are needed for a termination of pregnancy?
2 registered medical practitioners mmust sign legal document(only one needed in emergency)
Must be performed by a registered medical practitioner and done in an NHS hospital or licensed premise
What advice is there regarding anti D and termination of pregnancy?
Anti-D prophylaxis should be given to women who are rhesus D negative and having an abortion after 10 weeks gestation
Name some side effects/complications of medical termination of pregnancy
Severe nausea
Cramps
Diarrhoea
Vaginal bleeeding
Incomplete termination of pregnancy->must be maanaged surgically
Name some side effects/complications of surgical termination of pregnancy
Retained products of conception
Haemorrhage
Infection
Perforation
Name some risks of trichomoniasis vaginalis in pregnancy
Premature births
Low birth weight
Maternal postpartum sepsis
What is a uterine rupture?
Full-thickness disruption of the uterine muscle and overlying serosa
Can extend to affect bladder and broad ligament
What are the 2 main types of uterine rupture?
Incomplete: peritoneum overlying uterus is intact-uterine contents remain inside
Complete: peritoneum is torn and uterine contents can escape into peritoneal cavity
Name some risk factors for uterine rupture
Previous C-section(especially classical/vertical incision)
Previous uterine surgeryInduction(esp prostaglandins or augmentation of labour)
Obstruction of labour
Multiple pregnancy
Multiparity
Name some differentials for a uterine rupture
Placental abruption
Placenta praevia
Vasa praevia
What investigations might be done for a patient with a suspected uterine rupture
USS: abnormal fetal lie/presentation, haemoperitoneum and absent uterine wall
CTG ; changes in fetal heart rate pattern and prolonged fetal bradycardia: early indicators for uterine rupture
Name some causes of folic acid deficiency
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
Name some connsequences of folic acid deficiency
Macrocytic, megaloblastic anaemia
Neural tube defects
What advice should be given around pregnancy and folic acid?
All women should take 400mcg folic acid until 12th week of pregnancy
Women at higher risk of children with neural tube defects should take 5mg folic acid from before conception to 12th week
Name some risk factors for developing gestational diabetea
BMI>30kg/m2
Previous macrosomic baby weighing >4.5kg
Previous gestational diabetes
1st degree relatives with diabetes
Ethnic backgrounds with high prevalence of diabetes(middle easterm south asian, afro-caribbean)
Hx of stilllbirth/perinatal death
Name some fetal complications of gestational diabetes
Macrosomia(birthweight >4.5kg)->shoulder dystocia, birth injuries and C section
Sacral agenesis->Pre-term delivery and neonatal respiratory distress syndrome
Neonatal hypoglycaemia
Increased risk of T2DM later in life
Name some maternal complications of gestational diabetes
Increased risk of hypertension and pre-eclampsia
Increased risk of T2DM and gestational diabetes in subsequent pregnancies
What is hypertension defined as in pregnancy?
Systolic >140mmHg or diastolic <90mmHg OR
Increase above booking readings of >30 systolic or >15 diastolic
What are women with pregnancy induced hypertension more at risk of later in life?
Future pre-eclampsia
Future hypertension
Name some risk factors for Group B strep infection
Prematurity
Prolonged rupture of membranes
Previous sibling
GBS infection
Maternal pyrexia (e.g. secondary to chorioamnionitis)
Name some clinical features of Group B strep infection in the newborn
Sepsis
Pneumonia
Meningitis
Name some maternal risks of obesity in pregnancy
Miscarriage
VTE
Gestational diabetes
Pre-eclampsia
Postpartum haemorrhage
Wound infections
Higher C section rate
Name some fetal risks of maternal obesity in pregnancy
Congenital abnormality
Prematurity
Macrosomia
Stillbirth
Increased risk of developing obesity and metabolic disorders in childhood
Neonatal death
What is cephalopelvic disproportion?
Mismatch between size of fetal head and maternal pelvis causing difficulty in the safe passage of the fetus through the birth canal
Name some causes of absolute cephalopelvic disproportion
Maternal:
Contracted pelvis
Spondylolisthesis
Fetal:
Hydrocephalus
Macrosomia
Name some causative factors for prolonged labour
Cephalopelvic disproportion
Insufficient uterine contractions
Fetal malpresentation
Macrosomia
Anomalies in birth canal
Name some complications of prolonged labour
Maternal exhaustion
Post partum haemorrhage
Post partum infection
Fetal distress: hypoxia or acidosis
Name some differentials for obstetric cholestasis
Prurigo of pregnancy
Pruritus gravidarum
Other hepatobiliary dirsorders
What investigations might be done for obstetric cholestasis
LFT’s-. raissed bilirubin
Bile acid measurements
Fetal monitoring may be required- due to the risk of spontaneous intrauterine death
What is chorioamnionitis?
Bacterial infection that affects the amniotic sac and amniotic fluid within the uterus
Life threatening emergency to both mother and fetus
What is a major risk factor for chorioamnionitis?
Preterm premature rupture of membranes: expose normally sterile environment of uterus to pathogens
Name some signs and symptoms of chorioamnionitis
Fever
Abdo pain
Offensive vaginal discharge
Evidence of preterm rupture of membranes
Maternal and fetal tachycardia
Pyrexia
Uterine tenderness
Name some differentials for chorioamnionitis
UTIAppendicitis
Placental abruption
What is female genital multilation?
Harful practice of injuring or cutting the female genitalia for non-medical reasons
Name some risk factors for shoulder dystocia
Maternal gestational diabetes
Macrosomia
Birthweight >4kg
Advanced maternal age
Maternal short stature/small pelvis
Maternal obesity
Post-dates pregnancy/prolonged labour
Name some internal rotational manoeuvres used in shoulder dystocia management
Woods’ screw: anterior shoulder pushed towards fetal chest and posterior shoulder pushed towards fetal back
Rubin 2: rotate anerior shoulder towards fetal chest
What is celidotomy?
Division of fetal clavicle
Name some maternal complications of shoulder dystocia
PPH
Perineal tears
Genital tract trauma
Name some fetal complications of shoulder dystocia
brachial plexus injury
Neonatal death
Hypoxic brain damage
Humeral/clavicle fractures
Name some risk factors for anaemia in pregnancy
Haemoglopinathies: thalassaemia/sickle cell disease
Increasing maternal age
Low socioeconomic staus
Poor diet
Anaemia during previous pregnancy
Name some differentials for congenital rubella syndrome
Toxoplasmosis
CMV
HSV
Syphillis
VZV
Name some risk factors for perineal tears
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
What is an amniotic fluid embolism?
Life threatening condition that occurs when amniotic fluid or other debris enters the maternal circulation
Name some differentials for an amniotic fluid embolism
Septic shock
Anaphylactic shock
PE
Hypovolaemic shock
What is hyperemesis gravidarum?
Severe nausea and vomiting commencing before the 20th week gestation
Different to ‘morning sickness’ -more severe
What is hyperemesis gravidarum thought to be related to?
Raised B hCG levels
Name some risk factors for hyperemesis gravidarum
Increased levels of B-hCG-multiple pregnancies, trophoblastic disease
Nulliparity
Obesity
Personal/family hx of hyperemesis gravidarum
Name a protective factor for hyperemesis gravidarum
Smoking
What criteria should be met for a diagnosis of hyperemesis gravidarum?
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
Name some differentials for hyperemesis gravidarum
Infections: gastroenteritis, UTI, hepatitis, meningitis
GI: appendicitis, cholecystitis, bowel obstruction
Metabolic: DKA, thyrotoxicosis
Drug toxicity
Molar pregnancy
What is a risk of odansetron use in pregnancy?
In first trimester: increased risk of cleft lip/palate
Name some complications of hyperemesis gravidarum
AKI
Wernicke’s encephalopathy
Oesophagitis
Mallory-Weiss tear
VTE
What is acute fatty liver of pregnancy?
Severe, rare, liver disease related to pregnancy which can result in hepatic failure and results in immediate medical and obstetric intervention
Name some risk factors for acute fatty liver of pregnancy
Fetal homozygous mutation for long chain 3 hydroxyl CoA dehydrogenase
Multiple pregnancies
Male fetuses
Name some signs and symptoms of acute fatty liver of pregnancy
N+V
Headache
Anorexia
Abdo pain
Can rapidly progress to liver failure:
HE, jaundice, hypoglycaemia and coagulopathy
What criteria can be used to diagnose acute fatty liver of pregnancy
Swansea criteria
What are the best predictors for the need for liver transplantation or risk of maternal death in acute fatty liver of pregnancy
Elevated lactate levels+hepatic encephalopathy
What are the 3 stages of postpartum thyroiditis?
Thyrotoxicosis
Hypothyroidism
Normal thryoid function(high recurrence rate in future pregnancies)
What antibodies are found in postpartum thyroidits?
Thyroid peroxidase antibodies in 90%
Name some risk factors for VTE that might suggest the need for postnatal thromboprophylaxis
Previous VTET
hrombophilia
Medical comorbidities(cancer, heart failure, systemic inflammatory conditions)
Age >35yrs
Parity >3
BMI>30
Smoking
Multiple pregnancy
Pre-eclampsia
C-section
Prolonged labour
Obstructed delivery
Preterm birth
Stillbirth
Postpartum haemorrhage >1000mL
Other surgical procedures carried out
Immobility
Systemic infection
Name some causes of obstructed labour
Head: large fetal head/cephalopelvic disproportion, hydrocephalus
Presentation: brow, face, shoulder, persistent malposition
Twin pregnancy: locked/conjoined twins
Bony pelvis: contracted(malposition), deformed(trauma, polio)
Soft tissue: tumour in pelvis, viral infection from uterus/abdomen, scars(FGM)
Name some complications from an obstructed labour
Fistula-mc
PPH
Sepsis
Paralytic ileusnoenatal sepsis
Asphyxia of the baby
Facila injury of the baby
What is intrauterine growth restriction?
Fetus is unable to reach its genetically determined potential size
Name some maternal causes of intrauterine growth restriction
Maternal BMI and nutritional status
Co-morbidities: diabetes, anaemia, htn, infection, sickle cell, CVR/renal disease, coeliac
Cigarette smoking, alchol and substance abuse
Structural uterine malformations
Name dome fetal causes of intrauterine growth restriction
Chromosomal defects
Multiple pregnancy
Vertically transmitted infection(CMV, rubella, toxoplasmosis)
Name some placental causes of intrauterine growth restriction
Utero-placental insufficiency
Pre-eclampsia
Name some differentials for intrauterine growth restriction
Normal physiological variation
Constitutional smallness-> small for gestational age but healthy
Chromosomal abnormalities
What investigations might be done for intrauterine growth restriction?
USS: fetal biometry, amniotic fluid volume, placental appearance
Doppler studies: blood flow in umbilical artery, middle cerebral and ductus venosus
Biophysical profile to assess fetal wellbeing
What are the risks to the baby if exposed to VZV in pregnancy?
Fetal varicella syndrome
Shingles in infancy
evere neonatal varicella
Name some risk factors for placental insufficiency
Maternal hypertensive disorders
Smoking, alcohol consumption and drug use
Primiparity
Advanced maternal age
Use of antiepileptics/antineoplastics
What factor would make a pregnant woman immediately high risk for VTE?
Prevous VTE history
What are monozygotic twins?
Identical-fertilisation of one egg and one sperm
What are dizygotic twins? Describe the features
Non-identical
Fertilisation of 2 different eggs with 2 different sperms
All will be dichorionic and diamnotic(2 outer separate sacs and inner sacs) and separate placentas
Name some complications associated with monoamniotic monozygotic twins
Increased spontaenous miscarriage
Increased malformations, IUGR, prematurity
Twin to twin transfusion syndrome
Name some predisposing factors for dizygotic twins
Previous twins
Fhx
Increasing maternal age
Multigravida
Induced ovulation and IVF
Race(Afro-Caribbean)
Name some antenatal complications of monozygotic twins
Polyhydramnnios
Pregnancy induced hypertension
Anaemia
Antepartum haemorrhage
Name some fetal omplications of monozygotic twins
Perinatal mortality (twins x5, triplets x 10)
Prematurity
Light for date babies
Malformation(x3)
Name some labour complications of monozygotic twins
Increased PPH risk(x2)
MalpresentationCord prolapse, entanglement
Name some differentials for twin-to-twin transfusion syndrome
Anaemia
Cardiac failure
Hydrops fetalis
What is asymptomatic bacteriuria
Positive urine culture without UTI sx
What is a puerperal infection?
Occurs when bacteria infect the uterus and surrounding areas after birth
What are the types of puerperal infections?
Endometritis-uterine lining
Myometritis: uterine muscle
Parametritis(aka pelvic cellulitis): supportive tissue around uterus
Name some complications of puerperal infection
Sepsis-> organ failure and shock
Increased risk of infertility/ectopic pregnancy
What is constitutional delay?
Delay in puberty and growth with no medical cause-do reach normal height
Check fhx for delay in puberty
Name some causes of primary amenorrhoea
Primary hypergonadotropism: Turners
Primary hypogonadotropism: Kallmann’s
Androgen insensitivity syndrome
Imperforated hymen
What investigations might be done to investigate primary amenorrrhoea
Urine BHcg
HbA1c
Blood hormones: oestrogen, progesterone, testosterone, FSH ad LH
Prolactin, thyroid function, IGF1, estradiol
Name some causes of secondary amenorrhoea
Sheehan’s
Asherman’s
Breastfeeding
Contraceptives
Stress/exercise induced
PCOS
Ovarian failure
What is Ashermann’s syndrome?
Intrauterine adhesions formed typically as a result of surgery/infeciton and trauma to uterus
What investigations might be done for secondary amenorrhoea?
Pregnancy test
Bloods including hormones
USS/MRI
Endometrial biospy
Name some causes of menorrhagia
Idiopathic
Fibroids
Adenomyosis
Polyps
Endometriosis
IUD contraception
Bleeding disorders
What is infertility?
Diminished ability of a couple to conceive a child
Can be from a definable cause: ovulatory, tubal or sperm problems or
Unexplained failure to conceive over a two year period despite regular (3-4 times/week) unprotected sexual intercourse
Name some factors affecting natural fertility
Increasing age
Obesity
Smoking
Tight fitting underwear
Excessive alchohol consumption
Anabolic steroid use
Illicit drug use
Name some genetic causes of infertility
Turner’s(XO)
Kleinfelter’s(XXY)
Name some cervical abnormalities that can cause infertility
Cervical damage after biopsy/LLETZ procedure
Name some testicular disorders that can result in infertility
Cryptochordism
Varcicele
Testicular cancer
Congenital testicular defects
Name some ejaculatory disorders that can cause infertility
Obstruction of ejaculatory system
Retrograde ejaculation
What does anti-mullerian hormone show?
Measure of ovarian reserve
In what condition might you find a ‘woody’ uterus?
Placental abruption
Describe the symptoms of a fibroadenoma
Highly mobile encapsulated breast mass
Describe the symptoms of mastitis?
Breast rednesss
Mastalgia
Malaise
Fever
How is mastitis treated?
Keep breastfeeding
Flucloxacillin
Describe the symptoms of an intraductal papilloma
Bloody discharge from nipple
No mass
Describe the symptoms of a radial scar?
mammogram-stellite pattern-central scanning and glandular tissue
Describe the symptoms of fat necrosis
painless breast mass, skin thickening
Describe the symptoms of fibrocystic breast disease
breast lumps, pain, tenderness
Describe the symptoms of mammary duct ectasia
palpable peri-areolar breast mass, nipple discharge
What is most likely in a women a few weeks post breastfeeding with a breast lump?
Galactocele
