Obs and gynae quesmed Flashcards
What is most sensitive test for pre-eclamsia?
-Urine protein:creatinine ratio (PCR)
-A PCR >30mg/mmol
When to repeat smear test if HPV + but no dyskaryosis?
12 months (if HPV still + then repeat at 24 months, if positive at 24 months colposcopy)
What are the two main associations of obstetric cholestasis?
-Fetal death
-Maternal haemorrhage
When should you plan to deliver baby in mother with obstetric cholestasis?
37-38 weeks
What is the action of clomifene and what re the side effects?
-Selective oestrogen receptor modulator
-Side effects include ovarian hyperstimulation syndrome
Post menopausal bleeding in women is what until proven otherwise?
Endometrial cancer
What are the most common causes of post menopausal bleeding?
-Atrophic vaginitis (inflammation and thinning)
-Endometrial atrophy
-Cervical/endometrial polyps
-Endomterial hypertrophy
What is the HRT of choice in a women with regular periods?
Monthly, cyclical HRT
What is the HRT of choice in a women with irregular periods?
3 monthly, cyclical HRT
What is the HRT of choice in post-menopausal women ?
Continuous combined HRT
What can VWD disease cause?
-Menorrhagia (heavy periods)
-Will have prolonged APTT
What is first line to induce labour?
Prostaglandin pessary
What does PCOS do to risk of endometrial and ovarian cancer?
Increases the risk by 2-3 times
What symptoms can risperidone cause?
-Reduced libido, galactorrhoae and amenorrhoea
What is the treatment for lichen sclerosus?
-Topical corticosteroids (potent steroids such as dermovate) to reduce inflammation and itching
-Avoid soaps
-Emollients to relieve dryness and soothe itching
Describe first degree perineal tear
Tear limited to the superficial perineal skin or vaginal mucosa only
-Heal quickly, no muscle involvement and heal quickly superficial
Describe second degree perineal tear
Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
Describe third degree perineal tear
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
Describe fourth degree perineal tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
What can cause an enlarged, irregular and firm non tender uterus?
Fibroids
When does uterus return to non-pregnant size?
4 week post party
When is the anomaly scan performed?
18-20 + 6 weeks
What can you give women prior to fibroid surgery to mange bleeding?
Goserelin
What is the triad of hyperemesis gravidarum?
weight loss, dehydration and electrolyte disturbance
A key finding is ketonuria
What age group do germ cell ovarian tumours normally affect?
younger women
What is the Kleihauer test used for?
Used to assess the number of foetal cells within the maternal circulation
If cervial ectropion that is bothersome?
Non-urgent colpscopy
Why is diabetes mellitus a risk factor for developing endometrial cancer?
There are several possible mechanisms linking diabetes and endometrial cancer, one of which is the proliferation of endometrial stromal cells in response to high insulin levels.
What are the infection routinely screened for in pregnancy?
-Syphilis
-Hep B
-HIV
-Rubella
What is choice of medication for GBS prophylaxis?
IV intrapartum benzylpenicillin
What is the cut off Hb for high dose folic acid?
110
What is a risk factor for hyperemesis gravidarum?
Trophoblastic disease due to raised beta-HCG
What is diagnostic of a miscarriage with crown-length rump >7mm?
A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity is diagnostic
What is Human chorionic gonadotropin (hCG)?
-A hormone first produced by the embryo and later by the placental trophoblast
-Main role is to stop degeneration of corpus luteum
-
Contraceptives - time until effective (if not first day period)?
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Treatment for vaginal vault prolapse?
Sacrocolpopexy - this suspends the vaginal apex to the sacral promontory. This support is usually afforded by the uterosacral ligaments.
What are the normal laboratory findings during pregnancy?
Reduced urea, reduced creatinine, increased urinary protein loss (look out for pre-eclampsia)
What is most common cause of postmenopausal bleeding?
vagianal atrophy
Methotrexate when conceiving?
6 months before stop in male and female
How long does urine pregnancy remain positive for following termination?
4 weeks - if beyond this then indicates incomplete abortion or persistent trophoblasts
How does the COCP work?
-Inhibiting ovulation to reduce LH and FSH
-Also thought to alter the cervical mucus
What type of contraception isn entogestrel (implantable contraceptive)?
-Long acting reversible method of contraception
-Prevents ovulation
-Also prevent sperm implantation by altering cervical music and preventing implantation but thinning endometrium
How does the copper intrauterine device work?
Decreases sperm motility and survival
How does intrauterine system (levonorgestrel) work?
Prevents endometrial proliferation
Also thickens cervical mucus
How does Progestogen-only pill (excluding desogestrel) work?
Thicken cervical mucus
-this is the pill that you must take within 3 hour time frame
How does the desogestrel only pill work?
-Inhibits ovulation
-Thickens cervial mucus
-Take within 12 hours
How does Injectable contraceptive (medroxyprogesterone acetate) work?
-Inhibits ovulation
-Thickens cervical mucus
If 1st repeat smear at 12 months is hrHPV positive then when do you repeat the smear? (cytology normal cells)
repeat in 12 months
Why should COCP not be used in 1st 21 days?
Increased venous thromboebolsim risk
What are the classic symptoms of endometriosis?
pelvic pain, dysmenorrhoea, dyspareunia and subfertility
When should referral be made to maternal fetal medicine unit if no metal movements are felt?
24 weeks
How does acute fatty liver disease of pregnancy present?
jaundice, mild pyrexia, hepatitic LFTs, raised WBC, coagulopathy and steatosis on imaging
Why is it normal for ALP to be raised in pregnancy?
Due to placental ALP
Management of PPH in order
1.Bimanual uterine compression to manually stimulate contraction
2.Intravenous oxytocin and/or ergometrine
3.Intramuscular carboprost
4. Intramyometrial carboprost
5.Rectal misoprostol
6.Surgical intervention such as balloon tamponade
What is salpingectomy?
Removal of fallopian tube
What score can be used to assess severity of symptoms for vomiting?
-Pregnancy unique quantification of emesis (PUQE) score
When does patient have smear test ever 5 years instead of eery 3 years?
Once over 50
How should women be managed who are bleeding <6 weeks gestation? (with no pain or risk factor for ectopic pregnancy?)
-These women can be managed expectantly
-Return if bleeding continues or pain develops
-Advise to repeat urine pregnancy test after 7-10 days
-A negative pregnancy test means the pregnancy has miscarried
Progesterone only pill and antibiotics?
-No need for extra precautions
What antibiotics can affect the pill?
-Enzyme inducing antibiotics, such as rifampicin
What is gestational trophoblastic disease?
-Abnormal cells or tumours that start in the uterus from cells that would normally develop in the placenta
What is hyperemesis gravidarum?
The extreme form of vomiting and nausea
-occurs in 1% pregnancy and is thought to be associated with raised beta hCG levels
When is hyepermesis gravidarum most common?
-Between 8-12 weeks but may persist put to 20 weeks
What are the risk factor for hyperemesis gravidarum?
-Increased levels of beta hCG (multiple pregnancy and trophoblastic disease)
-Nulliparity
-Obesity
-Family or personal history of NVP
Relationship with smoking and hyperemesis?
-Associated with decreased incidence of hyperemesis
What is the NICE criteria for referral of nausea and committing in pregnancy?
- Continued nausea and dominating and unable to keep down liquids and oral antiemetics
- Continued nausea and committing with ketonuria and/or weight loss (greater 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected cormorbitiy e.g. unable to tolerate oral ABx for infection due to vomiting
When do NICE recommended to lower the threshold for admission to hospital?
If has co-existing condition (e.g. diabetes) that many be adversely affected by N and V
What is the triad of hyperemesis gravidarum?
-5% pre pregnancy weight loss
-Dehydration
-Electrolyte imbalance
What are the simple measures that can be taken for hyperemesis gravidarum?
-Rest and av oid triggers
-Bland, plain food
-Ginger
What are the first line medications for hypermedia gravidarum?
-Antihistamine: oral cyclizine or premethazine
-Phenothiazines: oral prochlorperazine or chlorpromazine
-Combination drug doxylamine/pyridoxine: pyridoxine (vitamin B6) monotherapy is actually used commonly outside of the UK as a first-line treatment for NVP. However, pyridoxine monotherapy is specifically not recommended in the RCOG guidelines
What are second line medications for hyperemesisgravidarum?
-Oral ondansetron (discuss risk of cleft palate with woman)
-Oral metocloprmid for domperiodone - metoclopramide may cause extrapyramidal side effects so do not use more than 5 days
What is used to hydrate patients with hyperemesis gravidarum?
-Normal saline with added potassium
Aside from weight loss, electrolyte imbalance what are the other complications of hyperemesis gravidarum?
-AKI
-Wernicke’s encephalopathy
-Oesophagitis, Mallory-Weiss tear
-Venous thromboembolism
How does hyperemesis gravidarum impact the foetus ?
-Studies show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms
-Severe NVP resulting in multiple admissions and failure to ‘catch up’ may be linked to small increase in preterm birth and low birth weight
What are the types ovarian cysts?
-Can get simple and complex
-Physiological cysts
-Benign germ cell tumours
-Benign epithelial tumours
-Benign sex cord stromal tumours
What is a complex cyst?
Cysts containing a solid mass, or those which are multi-loculated - should be treated as malignant until proven otherwise.
What are the tests recommended for premenopausal women with a complex cyst?
Serum CA-125, αFP and βHCG
What are the two types of physiological (functional cysts)?
-Follicular cyst
-Corpus letup cyst
What is a follicular cyst?
-Commonest type of ovarian cyst
-Due to a non-rupture of the dominant follicle or failure of atresia in a non-domain follicle
-Commonly regress after several menstrual cycles
How does a corpus lute cyst occur?
-During menstrual cycle if pregnancy doesn’t occur the corpus lutes may fill with blood or fluid and form a corpus luteal cyst
-These are more likely to present with intraperitoneal bleeding than follicular cyst
Give an example of a benign germ cell tumour?
-Dermoid cyst also called mature cystic teratoma
What is a dermoid cyst?
-A cyst lined with epithelial tissue, may contain skin appendages, hair and teeth
What is the median age of diagnosis with a dermoid cyst?
-30 years old
-This sis the ,out common benign ovarian tumour in woman under age 30 yrs
What percent of dermoid cysts are bilateral?
10-20%
What is the presentation of dermoid cyst?
-Usually asymptomatic
-More likely than with other ovarian tumours
Where of benign epithelial tumours arise?
-Arise form the ovarian surface epithelium
What are two types of benign epithelial ovarian tumours ?
-Serous cystadenoma
-Mucinous cystadenoma
What is serous cystadenoma?
- Most common benign epithelial tumour - bears resemblance to most common type of ovarian cancer (serous carcinoma)
-It is bilateral in around 20%
What is a mucinous cystadenoma?
-Second most common benign epithelial tumour
-They are typically large and become massive
-If rupture may cause psuedomyxoma peritonei (which can be fatal)
What is adenomyosis?
-Presence of endometrial tissue within the myometrium
-More common in multiparous women towards end of reproductive years
What are the feature of adenomyosis?
-Dysmenorrhoae
-Menorrhagia
-Enlarged, boggy uterus
What are the investigation for suspected adenomyosis?
-NICE recommend transvaginal ultrasound as first line
-MRI is an alterative
How do GnRH agonist work?
Act on pituitary gland to suppress ovulation and production of ovarian hormones
What are prescribed along GnRH agonists?
-Combined hormonal contraception or combined HRT
Why should GnRH only be used for 6 months?
-Risk of osteoporosis
-If taken for long term need DEXA scans every 12-18 months
Give examples of GnRH agonists
Leuprolide, goserelin, triptorelin and histrelin
What is the management of adenomyosis?
-Symptomatic treatment (tranexamic acid to manage menorrhagia)
-GnRH agonists
-Uterine artery embolisation
-Hysterecotmy (considered definitive treatment)
what are then main key points of nexplanon?
-Highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
-Long-acting: lasts 3 years
-Doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
-Can be inserted immediately following a termination of pregnancy
What is the implantable contraception that is used?
-Nexplanon - releases progesterone hormone etonogestrel
-This prevents ovulation and thickens the cervical mucus
What is needed to nexplanon is not inserted on day 1 to 5 of woman’s menstrual cycle?
Additional contraceptive methods are needed for first 7 days
What are the adverse effects of implantable?
-Irregualr/heavy bleeding
-Progesteron effects which include nausea, breast pain and headache
What are contraindications for implantable?
-Ischaemic heart disease/stroke
-Unexplained vaginal bleeding
-Past breast cancer
-Severe liver cirrhosis, liver cancer
-Current great cancer - this is an absolute contraindication
When should magnesium sulphate infusion be stopped in women with eclampsia?
Continue for 24 hours after last seizure or delivry
Why is magnesium sulphate used in preeclampsia and eclampsia?
-Used in serve pre-eclampsia to prevent seizures
-Used in eclampsia to treat seizures
What are the guidelines for giving magnesium sulphate?
-Should be given once decision to deliver has been made
-In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by infusion 1g/hour
-Urine output/reflexes, RR and oxygen stats should be monitored during treatment
What is first line treatment for magnesium sulphate induced respiratory depression?
-Calcium gluconate
Why is fluid restriction important when using magnesium sulphate?
To avoid potentially serious consequences of fluid overload
What are the risk factors for gestational diabetes ?
-BMI >30
-Previous macrocosmic baby weighing 4.5 kg or above
-Previous gestational diabetes
-First degree relative with diabetes
-Family origin with high prevalence of diabetes
What is the test of choice for GD?
Oral glucose tolerance test
When should OGTT be performed in patient with previous gestational diabetes?
-As soon as possible after booking and at 24-28 weeks if the test is normal
What can be used as a alternative to oral glucose tolerance test?
-Self monitoring of blood glucose
When should women with risk factors be offered a OGTT?
24-28 weeks
What are the risk factors for urinary incontinence?
-Advancing age
-Previous child brith or pregnancy
-High BMI
-Hysterectomy
-Family hisotry
How can urinary incontinence be classified?
-Urge incontinence
-Stress incontinence
-Mixed incontinence
-Overflow incontinence
-Functional incontinence
What is urge incontinence?
-Overactive bladder
-Due to detrusor overactivity
-The urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
What is stress incontinence?
-Leaking small amounts when coughing or laughing
What is mixed incontinenece?
both urge and stress incontinence
What is overflow incontinence?
Due to bladder outlet obstruction e.g. due to prostate enlargement
What is fucntional incontinenece?
-Co-morbid physical conditions that impair the patients ability to get to bathroom in time
-Causes include dementia, sedating medication dn injury/illness resulting in decreased ambulation
What is the management If urge is predominant?
- Bladder retraining (gradually increase intervals between voiding, should last for minimum 6 weeks)
- Bladder stabilising drugs - antimuscarinics are first-line
- Mirabegron may be useful if there is concern about anticholinergic side effects in frail elderly patients
Give examples of antimuscarinics used in urge incontinence
-Oxybutynin (immediate release)
-Tolterodine (immediate release)
-Darifenacin (once daily preparation)
NOTE: oxybutynin should be avoided in frail older women
What is the management if stress incontinence is predominant?
- Pelvic floor muscle training
(Nice Recommend at least 8 contractions 3 times per day for a minimum of 3 months) - Surgical procedures e.g. retropubic mid-urethral rape procedures
- Duloxetine may be offered to women if they decline surgical procedures
How does duloxetine work?
-It is a combined noradrenaline and serotonin reuptake inhibitor
-It increases synaptic concentration of serotonin and NA within the pudenal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
How long is IUS effective for?
5 years
What is the investigation of choice for patients with suspected deep vein thrombosis in pregnancy?
-Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
What is the procedure in a women with confirmed DVT on duplex doppler and symptoms of PE?
Initiate treatment dose of low molecular weight heparin
What are the investigations in women with a suspected PE?
-ECG and chest X-ray in all patients
-If DVT is confirmed no further investigation is necessary and treatment for VTE can continue
-Decision to perform V/Q or CTPA should be taken at a local level discussions with patient and radiologist
Why does D-dimer have limited use?
Often already raised in pregnancy
What is a contraindication for epidural anaesthesia during labour?
Coagulopathy
When to commence insulin?
Fasting glucose > 7 mol
What is vasa praaevia?
-A complication in which fatal blood vessels cross or run near the orifice of the uterus
-The vessels can be easily compromised when supporting membranes rupture leading to bleeding
What is the classic triad of symptoms in vasa praaevia?
-Rupture membranes
-Painless vaginal bleeding
-Fetal bradycardia
What is the risk of vasa praaevia?
-Unlike placenta preavia vasa preavia carries no major maternal risk but fetal mortality rates are high
How can you differentiate between placenta praaevia and vasa praveia?
-Difficult to distinguish in acute clinical situations but in examination purposes a preceding rupture of membranes will usually be emphasised
-Ulrasound scans can detect vasa preavia, ,many cases are undetectable antenatally
What are the risk factors of ovarian cancer?
-Family history: mutation of BRCA1 or BRCA2 gene
-Many ovulations: early menarche, late menopause, multiparty (these increase number of ovulations)
What blood pressure reading would make you admit the patient?
> 160/110 mmHg
What are the risk factors for endometrial cancer?
-Excess oestrogen (nulliparity late menopause, early menarche, unopposed oestrogen)
-Metabolic syndrome (obesity, DM, PCOS)
-Tamoxifen
-Hereditary non-polyposis colorectal carcinoma
What are protective factors against endometrial cancer?
-Multiparty
-COCP
-Smoking
What is the classic symptom of endometrial cancer?
-Post menopausal bleeding
-This is normal slight and intermittent initially before becoming heavier
NOTE: pain is not common and signifies extensive disease
What do women who are premenopausal present with in endometrial cancer?
-Menorrhagia or intermenstrual bleeding
What are the investigation in women with suspected cancer?
-1st line is trans-vaginal ultrasound - a normal endometrial thickness (<4mm) has a high negative predictive value
-Hysteroscopy with endometrial biopsy
What is a galactocele?
-Occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct
-A build up of milk creates a cystic lesion in the breast
How can you differentiate an abscess from galactocele ?
-Usually painless, with no local or systemic signs of infection
When do you give iron supplementation in pregnancy?
Cut off
1st trimester - 110g/L
2nd/3rd trimester - 105g/L
Postpartum <100g/L
What is the treatment given for oral iron therapy?
oral ferrous sulfate or ferrous fumarate
What is the medical management for abortion?
-Mifepristone (anti-progesterone) followed by misoprostol (prostaglandin)
How is the medication for abortion taken?
-Mifepristone followed by misoprotol 48 hours later
-Misoprostol stimulates uterine contractions
-Pregnancy test in 2 weeks to confirm the pregnancy has ended
-This should be a multi-level pregnancy test that detects the level of hCG
Wheelchair users and COCP?
Risk increase risk VTE
What are red flags to consider am urgent psychiatric evolution in puerperal psychosis ?
-Poor interaction with baby
-Talking in incoherent fashion about the future
-Stating baby has been bought into “very bad world” is odd and worrying
Why is dextrose not given in patients with hyperemesis gravidarum?
Thiamine deficiency is common in patient with hyperemesis gravidarum and dextrose increases body need for thiamine
Medical protocol for PPH?
-IV injection syntocinon 5 units followed by syntocinon infusion
What is the most common type of ovarian pathology associated with Meigs’ syndrome?
Fibroma
What is the most common benign ovarian tumour in women under 25 years?
Dermoid cyst (teratoma)
What is the most common cause of ovarian enlargement in women of reproductive age?
Follicular cyst
How is PCOS diagnosis according to Rotterdam cirteria?
-2 out of 3 must be present
1. Infrequent or no ovulation (usually manifested as infrequent or no menstruation)
- Clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total free testosterone)
- Polycystic ovaries on ultrasound (presence of >12 follicles in one or both ovaries)
What investigation should you perform if suspect PCOS?
-Pelvic ultrasound
-NICE recommend - FSH, LH, prolactin, SHBG, testosterone
-Check for impaired glucose levels
What should you be aware of when testing LH:FSH ratio in PCOS?
Raised ratio was a classic feature but is no longer considered useful
What should the results of prolactin, testosterone and SHBG in women with PCOS?
-Prolcatin may be normal or mildly elevated
-Testosterone normal or mildly elevated - if markedly raised consider other causes
-SHGB is normal to low in women with PCOS
If the results of FSH, LH , prolactin, TSH, testosterone and SHBG are often normal in PCOS then why are they useful?
Can be used to exclude other causes
When should surgical management ectopic occur?
All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically
Cocaine abuse?
Hypereflexia and dilated pupils
What is the mode of action of levonorgestrel?
-Not fully understood - acts to stop ovulation and inhibit implantation
When should levonorgestrel be taken?
-As soon as possible the efficacy decreases with time
-Must be taken within 72 hours of UPSI
What is the dose of levonorgestrel (progesterone) given?
-Single dose 1.5mg
-Dose doubled for those with BMI>26 or weight over 70kg
How effective is levonorgestrel?
-84% if used within 72 hours
When can hormonal contraception be started after using levonorgestrel?
Started immediately
What is the mode of action of Ellaone (Ulipristal)?
Inhibition of ovulation
What is the dose of Ella one (Ulipristal) and when should you take it?
-30mg oral dose ASAP
-No more than 12hours after intercourse
What contraception to women on sequential HRT?
All progesterone only methods of contraception are safe to use as contraception alongside HRT
When shouldnt progesterone injectable be used?
over the age of 50
Trans male contraception?
-Avoid COC
-Copper IUD
-POP/Implant/Injection
Trans female contracpetion?
-Advise use of condoms
-Hormonal treatments
What is metoclopramide use associated with?
Extrapyramidal effects - shoudld not use more than 5 days
How long does it take for POP to become effective?
48 hours
UKMEC 3?
-More than 35 AND smoking >15 cigs daily
-FHx of thromboembolicm in 1st degree relative<45
-BMI>35
-Controlled hypertension
-Immobility e.g. wheelchair
-BRAC gene
-Gallbladder disease
Ovarain cyst in early pregnancy?
These are usually physiological known as the corpus luteum
Dribbling incontinence after prolonged labour?
Vesicovaginal fistulae
What is a vesicovagibal fistula?
An abnormal opening between bladder an dvagina resulting in continuous and unremitting urinary incontinence
Investigation for vesicovagianbl fistula?
urinary dye studies can identify the presence of a fistula
How is vesicovaginal fistula treated?
-Catheter
-Surgery
What is vulval intraepithelial neoplasia?
VIN is a pre cancerous skin lesion of vulva, if left untreated may result in squamous skin cancer
What is the age range for women being affected by VIN?
50 years
What are the risk factors for vulvar intraepithelial neiplasia?
-HPV 16 and 18
-Smoking
-Herpes simplex virus 2
-Lichen planus
What are the features of vulval intraepithelial neoplasia?
-Itching and burning
-Rasiedm well defined skin lesions
2 week wait referral - persistent vulval skin lesions?
An unexplained vaginal lump, ulceration or bleeding prompt a 2 week wait referral to investigate possible cancer
RF for ectopic?
-Damage to tubes
-Previous ectopic
-Endometrioses
-IUCD
-Progesterone only pillm
-IVF
If secondary sexual characteristics but no period?
More likely to be an obstructive cause of amenorrhoea rather than endocrine
What is atrophic vaginitis?
-Occurs in post-menopausal women
-Presents with vaginal dryness, dyspareunia and occaisional spotting
What will you find on examination in a patient with atrophic vaginitis?
Vagina appears pale and dry
What is the management for atrophic vaginitis?
Vaginal lubricants and moisturisers, if these do not help then topical oestrogen cream can be used
Hyperemesis gravidarum - ketonuria/weight loss despite antiemtics
Admission to hospital - this is due to risk to mother
First investigation in post menopausal bleeding?
TVUS - this is because it gives the clearest image of endometrial thickness which is a key factor in establishing whether bleed could be caused by endometrial cancer
What is Asherman’s syndrome?
-Occurs when there is scar tissue in the uterus (intrauterine adhesions)
-This can cause the endometrium to stop responding to oestrogen as it normally would
-It can occur following dilation and curettage
What condition is a strong risk factor for for endometrial cancer?
-HNPCC/lynch syndrome
-HNPCC - herediatry non-polyposuis colorectal carcinoma
What is a cervical ectropian?
- On the ectrocervic there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium on the cervical canal
-When oestrogen levels are elevated it results in larger area of columnar epithelium being present on ectocervix
What can cause an increase in oestrogen levels and therefore cause a cervical ectropion?
-Ovulatory phase, pregnancy, COCP
What are the features of cervical ectropion?
-Vaginal discharge
-Post-coital bleeding
What is management of cervical ectropion?
Albative treatment - only used for troublesome symptoms
Secondary dysmenorrhoea?
Refer to gynae
What is the diagnostic triad for hyperemesis gravidarum?
-5% pre-pregnancy weight loss
-Dehydration
-Electrolyte imbalance
What is the first line treatment for primary dysmenorrhoea?
Mefenamic acid (NSAID)
Ataxia and diplopia in patient with hyperemesis gravidarum?
Wernicke’s encephalopathy -supplement with thiamine (vit B1) and vit B and C complex (parbrinex)
What can be used to assess ovarian cysts that are incidentally found on ultrasound?
IOTA criteria - help classify cysts as benign “b rules” or malignant “M rules”
What does IOTA stand for?
International ovarian tumour analysis
What are M rules?
-Irregular solid tumour
-Ascites
-4 papillary structures
-Irrregualr multlocular solid tumour with largesrt diameter >100mm
-Very strong blood flow
How does Trichomonas vaginalius present?
-Offensive, yellow/green, frothy discharge
Vulvovaginitis
-Strawberry cervix
What is strawberry cervix?
-Sign of trichomoniasis
-Erythematous cervix with pinpoint areas of exudation
What is the management for bacterial vaginosis ?
oral metronidazole
What is the management for trichomonas vaginalis?
Oral metrondiazole
What is the Amsel criteria for bacterial vaginosis?
3 of 4 points should be present:
-Thin, white homogenous discharge
-Clue cells on microscopy: stippled vaginal epithelial cells
-Vaginal pH > 4.5
-Positive whiff test (addition of potassium hydroxide results in fishy odour)
What would swab show in gonorrhoea?
-Gram negative doplococcus
What is management for gonorrhoea?
IM ceftriaxone
What is the risk of using ondansetron in pregnancy?
-Smll risk of celft lip/palate - advised to discuss this with pregnant women
When is ondansetron used in pregnancy?
used in hyperemesis gravidarum
What is a side effect of GnRH agonists ?
Loss of mineral bone density
Why are GnRH agonists useful?
Shrink size of fibroid
What is a smear testing for?
High risk HPV (types 16 and 18 cause 4 out of 5 )
What do you give for incomoplete miscarriage?
single does of misoprostol (usually vaginal)
How are NSAID effective for dysmenorrheoa?
Ibhibit prostglandin synthesis which is a main cuase of dysmenorrheoea
Satge IA cervical cancer and maintain feritlty ?
cone biposy
Bladder palpable after urination ?
Urinary overflow incontinence
