Obs & Gynae 1 Flashcards
1
Q
Describe a ‘normal’ pregnancy. What are the parameters for 1st, 2nd and 3rd trimesters?
A
A normal pregnancy lasts for 40 weeks following LMP.
1st: LMP - 12 weeks gestation
2nd: 13 weeks - 27 weeks gestation
3rd: 28 weeks to partuition
2
Q
What is ‘Gravidity’?
A
The number of pregnancies a woman has had, to any stage.
3
Q
What is ‘Parity’?
A
The number of offspring that a woman has delivered beyond week 28.
4
Q
Describe the physiological changes during pregnancy.
A
- Blood volume increases: RBC, WBC & platelets increase; Albumin, Urea & Creatinine decrease
- Increased Cardiac Output
- Increased tidal volume
- Increased skin pigmentation
- Breast & nipple enlargement
- Increased GFR
- Water retention
- Increased temperature
- Decreased gut motility
5
Q
What are the reasons for urinary frequency in pregnancy?
A
- Enlarged uterus puts pressure on bladder
- Increased GFR
6
Q
What are the reasons for constipation in pregnancy?
A
- Decreased gastric motility
- Pressure on the GIT from a growing uterus
7
Q
Describe the changes in blood pressure seen with pregnancy.
A
- BP may fall during the 2nd trimester
- BP recovers to ‘normal’ levels by the 3rd trimester.
8
Q
What changes in the legs might be seen in a pregnant woman?
A
Varicose veins
9
Q
What changes in the skin might be seen in a pregnant woman?
A
Abdominal stretch marks - these may become highly pigmented.
10
Q
Give a definition of ‘normal labour’.
A
- Spontaneous in onset, with absence of risk-associated features throughout.
- The infant is born in the vertex position between 37 - 42 weeks gestation.
- After birth, the mother and baby are in good condition,.
11
Q
When might labour be considered to be ‘not normal’?
A
Labour is not normal if:
- Induced
- Forceps, Ventouse, or C-section is used
- Spinal, epidural or GA is required
- Episiotomy is required
12
Q
What are the stages of labour?
A
Stage 1: Lasts 8 - 24 hours
(includes Latent phase; then Established phase)
Stage 2:
(includes passive stage; then active stage)
Stage 3: Delivery of the placenta. Should take place within one hour of delivery.
13
Q
Describe ‘Stage 1’ of ‘Normal’ Labour
A
- Lasts 8 - 24 hours (usually quicker in multiparous women)
i) Latent phase - Irregular contractions
- Cervical thinning and effacing
- Show of mucoid plug
ii) Established phase
- Contractions become regular
- Cervix is dilated more than 4cm (and should continue to dilate at 0.5cm/hour)
14
Q
Describe ‘Stage 2’ of ‘Normal’ Labour.
A
i) Passive stage
Cervix is completely dilated (10cm) but the mother has no active desire to push.
ii) Active stage
- Baby’s head can be seen
- Expulsive contractions with maternal effort
The 2nd stage ends following delivery of the baby, which should be within 3 hours for primiparous women or 2 hours for multiparous women.
15
Q
Describe ‘Stage 3’ of ‘Normal’ Labour.
A
Delivery of the placenta.
This should take place within one hour of delivery.
16
Q
What are the classifications of CTG traces?
A
Reassuring
Non-reassuring / Suspicious
Abnormal
17
Q
What does a CTG show?
A
Fetal Heart Rate & Uterine Contractions
18
Q
What is the acronym for assessing a CTG?
A
Dr - Define risk C - Contractions Br - Baseline fetal Heart rate A - Accelerations Va - Variability D - Decelerations (always bad!!!!) O - Overall impression of the CTG
19
Q
What factors might contribute to how risky a pregnancy is?
A
- Maternal asthma
- Maternal gestational diabetes
- Maternal HTN
- Multiple gestation
- Previous Caesarian section
- Intra Uterine Growth Restriction (IUGR)
- Pre-eclampsia
- Smoking
- Drugs
20
Q
How are Uterine contractions assessed / reported?
A
- Shown on the bottom of the CTG trace
- 1 square represents one minute
- Contractions are often described by how many there are in a 10 minute period (eg. 2 in 10).
- Note how long each contraction lasts & how intense it is (guided by palpation of the uterus during contraction).
21
Q
What are the parameters for a baseline fetal heart rate on a CTG?
A
The baseline fetal HR is the average over the previous 10 minutes
Normal: 110 - 160
Non-reassuring: 100-109; 161-180
Abnormal: <100bpm or >180bpm
22
Q
Describe ‘variability’ with regards to a CTG.
A
- How variable the heart rate is from the highest FHR to the lowest in a 3 minute period.
23
Q
What might cause ‘decreased’ variability?
A
- Fetal sleeping
- Fetal hypoxia & acidosis
- Opiate use
- Prematurity
- Congenital heart issues (of the foetus).
24
Q
Describe an ‘acceleration’ with regards to a CTG.
A
Acceleration = an increase of 15bpm or more for 15 secs or more from baseline FHR.
The presence of accelerations is assuring, and these should occur alongside uterine contractions.
25
Describe 'decelerations' with regards to a CTG.
Decelerations:
| - a decrease of 15bpm or more from baseline FHR for 15 or more seconds.
26
What are the 3 classes of deceleration?
1) Early: usually normal.
Start with the uterine contraction & end after the uterine contraction
2) Variable: not necessarily related to uterine contractions & may not recover smoothly following the end of a contraction.
- often due to cord compression
3) Late: start at the peak of a contraction & recover at the end of the contraction.
- often due to insufficient blood supply to the uterus & placenta.
If a deceleration lasts for 2-3 minutes, it's classed as 'prolonged' and is non-reassuring.
If it lasts for longer than 3 minutes = BE WORRIED
- Indicates fetal blood sampling and may require emergency C section.
27
What are the options for pain relief during labour?
- Waterbirth
- Nitrous Oxide (gas & air)
- Narcotic injections (IM Pethidine)
- Pudendal block
- Epidural anaesthesia
28
Name 3 pregnancy hormones & their role during pregnancy
Progesterone: prepares the endometrium (vascularisation etc), stops contractions.
- increases maternal ventilation
- promotes glucose deposition in fat stores.
* inhibition of progesterone with Mifepristone will terminate pregnancy.
Oestrogen: E3 (Oestradiol) = main oestrogen in pregnancy. Derived from the ovary initially, then foetus -> it is a measure of fetal wellbeing.
- promotes changes in the cardiovascular system.
hCG: produced by the trophoblast, hCG prevents luteal regression. hCG prevents decline of corpus luteum, ensuring the corpus luteum synthesised progestins until the placenta forms.
29
What do we mean by 'Maternal physiological adaptation to pregnancy'?
Re-setting of 'normal' physiological values. All systems are affected:
endocrine, resp, CV, GI, renal, reproductive, immune system, metabolic etc.
Synchronisation between maternal / blastocyst tissues.
30
Glucose is the principle fetal nutrient, but fetal gluconeogenic enzymes are inactivated. Why?
How does the foetus get glucose?
Fetal gluconeogenic enzymes are inactivated due to a low arterial PO2.
Foetus gets glucose from the maternal circulation (via the placenta). Carrier system saturates at 20mmol/l.
Fetal glucose levels directly relate to mother's glucose levels.
31
Describe glucose / glycogen synthesis / control in i) Early pregnancy and ii) late pregnancy
i) Early pregnancy: Maternal glycogen synthesis (plasma glucose levels don't rise as high); fat deposition -> storing energy for the baby.
ii) Late pregnancy: Glucose levels peak at higher for longer -> ? glucose sparing for the foetus?
? Maternal insulin resistance.
32
Describe the insulin response in i) Early pregnancy and ii) late pregnancy
i) Early pregnancy: progressive rise in gestational insulin response.
ii) Late pregnancy: massive insulin response: body appears to be less sensitive to the insulin being produced.
? Maternal insulin resistance.
33
Give two possible explanations for Maternal Insulin Resistance seen in pregnancy.
1. Spares glucose for fetal use. hPL = a hormone which induces insulin resistance in the mother.
2. Elevated maternal insulin protects mother and antagonises fetal hPL.
? Maternal restriction of nutrient supply to foetus.
34
Give two in utero complications of gestational diabetes for the foetus.
1. Macrosomic infant - at risk of shoulder dystocia.
| 2. Glucose at high concentrations in teratogenic.
35
Describe the process of blastocyst implantation.
- Window of implantation (days 20 - 24 of cycle). Implantation will not happen if outside of this time frame.
- Human blastocyst undergoes interstitial implantation -> primary decidual reaction occurs (increased vascularity etc).
- Implantation: placenta forms (under hypoxic conditions). Floating villi & anchoring villi formed.
- Endovascular invasion: spiral artery remodelling.
36
What complications might arise as a consequence of poor endovascular remodelling in utero?
- Pre-eclampsia: extent and depth of spiral artery remodelling greatly decreased. Reduced fetal O2 / nutrient supply.
- IUGR
- Pre-term birth
- Recurrent miscarriage
37
What are the 3 main types of incorrect placentation?
Morbidly adherent placenta:
- Accreta: superficial myometrium
- Increta: deeper myometrium
- Percreta: into other abdominal organs
38
What separates the placenta from the myometrium (if placental location is 'normal')?
Decidua basalis.
39
The foetus is immunologically different to the mother. Why is it not rejected?
- Down regulation of immune system during pregnancy
- Fetus is immune-privileged: syncytiotrophoblast has not cell markers and is therefore unlikely to stimulate the maternal immune system.
- Upregulation of Th2 helper cells. Down regulation of Th1 (Th1 would reject foetus) -> results in a modified immune response.
40
In a non-pregnant woman, there is a balance between Th1:Th2, which brings about an appropriate immune response.
What happens to this balance during pregnancy?
What happens if this balance is not altered during pregnancy?
Normal pregnancy:
- Th2 bias observed
- Immune response modified
Th2 bias not observed
- exaggerated inflammatory response see
- ? pre-eclampsia, recurrent miscarriage, IUGR
41
Which cells make antibodies?
B cells (plasma cells)
42
Which antibody is secreted in breast milk?
IgA
43
Which is the only immunoglobulin to cross the placenta?
IgG
| This has a role in rhesus disease / haemolytic disease of the newborn
44
Explain the phenomenon of Rhesus disease.
Rh -ve mum (dd); Rh +ve dad (DD or Dd)
Rh +ve = dominant antigen
> 50 - 100% offspring affected
1st pregnancy:
- Fetal and maternal blood mix (during birth).
- Mum sensitised to fetal blood. Memory cell made.
Subsequent pregnancy:
- IgG made (can cross the placenta)
- leads to lysis of fetal RBCs
- causes fetal anaemia, death.
45
What can be done to minimise the risk of Rhesus disease?
Anti-D prophylaxis
> This destroys Anti Rh +ve IgG
> Fetal RBCs not attacked.
46
What are the 3 stages of parturition?
1. Cervical dilatation (remodelling)
2. Fetal expulsion (myometrial contraction)
3. Placental delivery
47
Which electrolyte is elevated during myometrial contractility stage?
Calcium
- leads to myocyte contraction
- release is mediated by oxytocin: elevates Ca2+ & stimulates contraction by releasing intracellular stores.
48
What is the role of oxytocin in parturition?
- Elevates Calcium: stimulates contraction by releasing intracellular stores.
- Increased no. of Oxytocin receptors seen at term on fundal myometrium.
- Clinically, oxytocin analogues (syntocinon) are used to induce labour.
49
What is the 'Ferguson Reflex'?
Membrane sweep
- Cervical stimulation / myometrial stretch induces oxytocin secretion.
- Initiates a positive feedback mechanism (Ferguson Reflex)
> May stimulate uterine contractions.
50
What is Atosiban?
- Antagonist of the oxytocin receptor
| - Inhibits premature myometrial contractions
51
What does Carboprost do?
Induces contractions.
52
List some risk factors for Breast Cancer.
- Age
- FHx: Sporadic, Polygenic, Single gene
- Duration of oestrogen exposure
- Late first pregnancy
- HRT
- Obesity
- Alcohol
53
List some clinical features of breast cancers.
- Lump: irregular, hard, fixed
- Metastatic disease: bone -> pathological fracture
- Nipple discharge
- Skin tethering
- Indrawn nipple
- peau d'orange: lymphatics blocked -> causes oedema
54
How is a diagnosis of breast cancer made?
Triple Assessment:
> Clinical score 1-5
> Imaging score (Mammogram) 1-5
> Biopsy score 1-5
Aim for concordance
55
What views of each breast should you request for mammography?
If the lump has a 'fluffy edge' on imaging, what does this indicate?
Craniocaudal (CC) & Mediolateral oblique (MLO) views of each breast.
'Fluffy edge' = ? malignant
56
If a woman has a breast implant, what would be the imaging mode of choice?
MRI.
| MRI would also be used for high risk screening.
57
What are surgical options for 'primary operable breast cancer'?
What considerations should you make when making a decision?
- Breast conservation
- Mastectomy.
Considerations:
- multiple tumours
- tumour size relative to breast
- patient choice
58
When would surgery to the axilla be indicated?
- for local control
| - prognostic factors
59
What do we mean by tumour 'grade'?
Histologically - what the tumour looks like.
Grade 1, 2 or 3.
NB: 'Grade' is NOT the same as 'stage'.
60
What do we mean by tumour 'stage'?
| What model do we use to 'stage' tumours?
Stage = the anatomical extent of the disease.
TNM: Tumour, Nodes, Metastasis
61
Give some examples of chemotherapy regimes.
FEC: Current standard
5FU, Epirubicin, Cyclophosphamide
FEC-T: used in HER2 +ve disease
As above, plus Texans
TC: Taxane plus cisplatin.
Used in triple negative disease
62
Chemotherapy is generally used for high risk disease. Give some risk factors for high risk disease.
- Young age
- ER -ve
- Her2 +ve
- High grade
- Node positive
- Ki67 positive
- Tumour size
63
Give some therapeutic treatment options other than chemotherapy for breast cancer.
- Endocrine therapy (if ER+ve disease)
- Radiotherapy
- Bisphosphonates (if post-menopausal with ER+ve disease)
- HER2 (give Herceptin)
64
What is Tamoxifen used for?
- If oestrogen receptor positive
- inhibits oestrogen receptor on cancer cells.
- An endocrine therapy.
65
What are Aromatase inhibitors used for?
- If ER +ve
- Post-menopausal women
- Anti-oestrogen.
Slightly better efficacy than Tamoxifen.
66
What are the implications of a Her-2 diagnosis?
Her-2 +ve = worst prognosis of any subtype
High metastatic risk, particularly to the brain.
Give chemo + Trastuzumab
67
When will radiotherapy be needed?
- T3 + T4 cancers usually require post-operative chest wall radiotherapy
- High grade plus nodal disease
68
List some problems associated with radiotherapy:
- Skin viability risk
- Wound healing
- Loss of elasticity
- Fat necrosis
- Fibrosis
- Implant extrusion
69
The 1st stage of labour involves uterine contraction, cervical effacement and dilatation. Which nerve roots are involved in pain transmission during this time?
T10 - L1: uterine sympathetic nerve via paracervical ganglia
S2 - S4: Pelvic Splanchnic Nerves
70
The 2nd stage of labour involves stretching of the vagina, perineum and extrauterine pelvic structures. Which nerve roots are involved in pain transmission during this time?
S2 - S4: Pudendal nerve
L5 - S1
71
Give some examples of non-pharmacological therapies which may help to alleviate pain during labour
```
> Trained support
> Acupuncture
> Hypnotherapy
> Massage
> TENS
> Hydrotherapy
> Alternative therapy: homeopathy; aromatherapy
```
72
Give some examples of simple analgesics that women can self administer in the early stages of labour
> Paracetamol
| > Codeine
73
Give 3 examples of opioids used in labour to alleviate pain.
How are they administered?
Morphine, Diamorphine, Pethidine.
| Administered as a single shot (usually IM) or IV via a patient-controlled analgesic pump.
74
Give some properties of opioids.
Opioids: Morphine, Diamorphine, Pethidine
> All cause sedation, respiratory depression, N&V, pruritus.
> Lipid soluble, therefore cross the placenta rapidly.
> Diamorphine rapidly eliminated by the placenta.
> Pethidine metabolites can cause seizures. Avoid in epileptics.
75
Why should you not give ibuprofen (or any other NSAID) during labour?
Baby's Ductus Arteriosus may not shut if you've given mother ibuprofen / an NSAID).
76
Give 3 examples of PCA opioids.
Fentanyl: rapid onset of action
Alfentanil
Remifentanil
77
What is 'Entonox'?
50% N2O; 50% O2
> Rapid onset of analgesia
> minimal side effects
78
At what spinal level should you perform an epidural?
L3/4, just outside of the dura
> This should avoid potential damage to the spinal cord.
> Ultrasound may be used to aid placement of epidurals.
79
Give 3 examples of 'regional anaesthesia' techniques.
> Epidural
> Spinal
> Combined spinal-epidural (CSE)
80
What i) local anaesthetic; ii) opioids would be used in a spinal? What kind of drugs are these?
i) Local anaesthetic: Bupivacaine
ii) Opioids:
Fentanyl
Diamorphine
These are examples of neuroaxial drugs.
81
What would a woman feel like after having a spinal?
Dense, heavy numbness.
| Can't feel contractions.
82
List some indications for an epidural.
```
> Maternal request
> Cardiac / other medical disease
> Augmented labour
> Multiple births
> Instrumental / operative delivery likely
```
83
Give 3 absolute contraindications to regional* anaesthetic techniques.
* Regional anaesthetic techniques = Epidural, Spinal, CSE
- Maternal refusal
- Local infection
- Allergy
84
Give 5 relative contraindications to regional* anaesthetic techniques.
* Regional anaesthetic techniques = Epidural, Spinal, CSE
- Coagulopathy
- Systemic infection
- Hypovolaemia
- Abnormal anatomy
- Fixed cardiac output
85
Give some examples of adverse effects of regional anaesthesia on the different organ systems.
CVS: Hypotension; Bradycardia if high block
Resp: blocked intercostal nerves, poor cough
Neuro: (rare!) related to haematoma or abscess
Drug related: allergy, anaphylaxis, neurotoxicity.
86
Describe the 4 types of 'Epidural regimens'.
1) Traditional (intermittent bolus)
2) Continuous infusion
3) Continuous infusion + bolus
4) Combined spinal-epidural
87
Give some outcomes of labour following regional anaesthesia usage.
- Superior analgesia
- Maternal satisfaction better with low dose
- May prolong labour
- May increase instrumental delivery
- Maternal pyrexia ?significance
88
What are the anaesthetic options for an operative delivery (i.e. C-section).
1. General anaesthesia
2. Regional anaesthesia
- Epidural top up
- Spinal
- CSE
* to a certain degree, this depends on urgency.
89
When would a general anaesthetic be considered for an operative delivery?
- Imminent threat to mother and/or foetus
- Contraindication to regional
- Maternal preference
- Failed regional technique
90
There may be increased risks with general anaesthesia for a C-section delivery. Give examples of these.
- Increased risks associated with altered physiology
- Aspiration
- Failed intubation
- Awareness
91
Give 4 advantages of regional anaesthesia.
- Safer
- Can see baby immediately
- Partner present
- Improved post-op analgesia
92
Give 4 disadvantages of regional anaesthesia
- Hypotension
- Headache
- Discomfort associated with pressure sensations
- Failure
93
What percentage of pregnancies end in miscarriage?
Approx 20%
94
What is a 'threatened miscarriage'?
A pregnancy associated with vaginal bleeding + with or without abdominal pain. Closed cervix.
95
What is an 'inevitable miscarriage'?
Bleeding + pain.
| Open cervix.
96
What is a 'complete miscarriage'?
Bleeding and pain cease. Closed cervix. Empty uterus.
97
What is an 'incomplete miscarriage'?
Bleeding ± pain.
| Possible open cervix.
98
What is a 'missed miscarriage' / early fetal demise?
± bleeding ± pain ± loss of pregnancy symptoms. Closed cervix.
99
What indicates a pregnancy of unknown location (PUL)?
± bleeding ± pain. closed cervix.
Positive pregnancy test. Empty uterus. No sign of extrauterine pregnancy.
Serial serum b-hCG assay (48hours apart) + initial serum progesterone to exclude ectopic pregnancy / failing Pregnancy of unknown location.
100
How is a 'delayed miscarriage' diagnosed?
Ultrasound scan:
- empty gestation sac OR
- fetal pole with no heart beat.
101
What are the 3 options for miscarriage management?
1. Expectant management
2. Medical management
- Mifepristone (anti-progesterone priming)
then;
- Misoprostol (prostaglandins analogue)
3. Surgical management
102
List some complications of surgical management of miscarriage (SMM).
- Infection
- Haemorrhage
- Uterine perforation
- Retained products of conception
- Intrauterine adhesions
- Cervical tears
103
Where is the commonest site for an ectopic pregnancy to occur?
Fallopian tube
104
When is an ectopic pregnancy considered?
Ectopic considered to be a possibility when an empty uterus is found on USS in a patient with a positive pregnancy test.
105
What factors make an ectopic pregnancy more likely?
- STIs eg. chlamydia
- Fertility treatment
- Anything that causes tube damage
106
When would medical treatment of an ectopic be appropriate? Which drug should be used?
- Methotrexate
- Patient needs to fulfil a number of criteria, including b-hCG level, and have satisfactory renal and liver function.
- Must also be willing to attend the hospital for regular monitoring, until the pregnancy has completely resolved.
107
What is another name for a 'Molar' pregnancy?
| How is a molar pregnancy characterised?
Hydatidiform mole:
| Characterised by the presence of large, fluid filled vesicles within the placenta.
108
What does a molar pregnancy look like on USS?
| Are the b-hCG levels high or low in a molar pregnancy?
USS: Snow storm
b-hCG = Very high in a molar pregnancy.
109
What is the initial treatment for a molar pregnancy?
Surgical.
b-hCG levels are monitored.
Chemo is offered if the levels fail to fall satisfactorily.
110
What clinical features indicate Hyperemesis Gravidarum?
- Excessive vomiting
- Dehydration
- Ketosis
In severe cases, weight loss can be a problem.
More common in women with high levels of b-hCG (eg. twin pregnancies).
111
What is the initial management of Hyperemesis Gravidarum?
- Rehydrate with IV fluids
- Vitamin supplements
- Nil by mouth until oral fluids can be tolerated.
- Anti-emetics
- Small, frequent meals are recommended once eating is recommenced.
112
What is the point of monitoring the fetal heart rate?
Identification of a baby at risk of dying in utero
113
What methods are used to measure the fetal heart rate in utero?
1) Intermittent auscultation
- Pinard stethoscope
- Hand held doppler
2) Continuous FHR monitoring
- CTG
- Fetal ECG ('scalp' ECG)
114
When & why might you use intermittent auscultation in labour?
- Used for low risk women
- Inexpensive & non-invasive
- Mother needs to be in a stable position to monitor FHR for 1 min.
- Quality of FHR can be affected by mother's heart sounds
115
When & why might you use CTG for continuous FHR monitoring?
- Antenatally & intrapartum for high risk women
- Records FHR & Uterine contractions
- Transducer is cumbersome; attachment belt is uncomfortable.
- Mum has got to be stable; mobility is restricted.
116
When & why might you use a Direct fetal ECG (scalp ECG)?
- Gold standard of FHR monitoring
- True beat-to-beat FHR is obtained.
BUT
- it's invasive
- monitoring is possible only in labour
- associated with scalp injury and perinatal infection.
117
Which pneumonic is used for CTG interpretation?
Dr C Bravado
Dr = Define risk
C = Contractions
Bra = Baseline Heart Rate
V = Variability
A = Accelerations (a rise in baseline HR by 10 - 15 bpm)
D = Decelerations (a fall in baseline HR by 10 - 15 bpm).
- Early: always bad (due to baby's head being compressed)
- Variable (non-reassuring): no apparent relationship to uterine contractions.
- Late: happens after the uterus relaxes. Very sinister. Mainly due to placental insufficiency. eg. pre-eclampsia.
O = Overall impression
118
What are the 3 descriptions given to CTGs following analysis using the pneumonic?
Reassuring (Normal)
Non-reassuring (Suspicious)
Pathological (Abnormal)
119
What are the normal FHR parameters?
110 - 160 bpm
120
What is meant by 'cellular senescence'?
"Growing old": normal cells limit the number of divisions by shortening of telomeres at the end of each chromosome.
Malignant cells lengthen telomeres.
121
What is 'apoptosis'?
'Normal' cell death
- Programmed cell death 'suicide pathway'
- maintains cell population
- prevents malignant transformation
122
Give 2 examples of tumour suppressor genes & describe their role in the cell cycle.
Tumour suppressor genes: p53 & Rb
In normal cells, these act as 'braking signals' during G1 of the cell cycle, to stop or slow the cycle before S phase.
If tumour suppressor genes are mutated, the normal 'brake' mechanism is disabled -> results in uncontrolled growth i.e. cancer.
123
What is an 'oncogene'?
Give 3 examples of oncogenes.
Oncogene: mutated genes whose presence can stimulate the development of cancer. -> stimulate excessive cell growth and division.
A single mutated oncogene is not usually enough to cause cancer, because it is counteracted by tumour suppressor genes (to an extent).
Examples: HER-2/neu, RAS, SRC
124
Describe the aetiology of endometrial cancer
- Obesity
- Diabetes
- Nulliparity
- Late menopause
- Ovarian tumours (granulosa)
- HRT
- Pelvic irradiation
- Tamoxifen
- PCOS
- HNPCC
125
What is the biggest risk factor for endometrial cancer?
unopposed oestrogen
126
What kind of bleeding is associated with endometrial cancer?
Post-menopausal bleeding
127
What investigations might you request if you suspected Endometrial cancer?
- History
- Examination
- Investigations:
> Transvaginal USS
> Endometrial biopsy
> Hysteroscopy
128
What staging system is used to stage endometrial cancer?
FIGO I / II / III / IV
129
What are the treatment options for endometrial cancer?
1. Surgery: hysterectomy ± pelvic lymph nodes
2. Radiotherapy (adjuvant_
3. Progesterone therapy
* endometrial cancer occurs due to unopposed oestrogen.
130
Describe the aetiology of cervical cancer.
- HPV = High risk!!!!
- Early age intercourse (<16 years)
- Multiple sexual partners
- STDs
- Cigarette smoking -> persistent HPV infection
- Previous CIN
- Multiparity
- OCP usage
- Other genital tract neoplasia
131
What is persistent HPV infection associated with?
- Increased risk of high grade Cervical Intraepithelial neoplasia
- Immunological competence
- HIV and renal transplant patients
132
Which is the most common cancer in UK women under 35yrs?
Cervical cancer
133
Describe the incidence of cervical cancer in the current population
Increasing in women aged 25 - 29 years.
134
What kind of bleeding is associated with cervical cancer?
Post-coital bleeding?
135
What are the treatment options for cervical cancer?
- Biopsy
- Hysterectomy
- Chemo / radiotherapy
136
Is vulval cancer common or uncommon?
Uncommon
| 1000 diagnoses of vulval cancer in the UK in 2011.
137
Describe the aetiology of vulval cancer
HPV / Lichen Sclerosis
138
What are the symptoms of vulval cancer?
- Vulval itching
- Vulval soreness
- Persistent lump
- Bleeding
- Pain on passing urine
- Past history of HPV or Lichen sclerosis
139
What are the treatment options for a woman with vulval cancer?
Surgery - conservative
Surgery - radical
Radiotherapy
140
How might a patient with Ovarian cancer present?
- Bloating / IBS-like symptoms
- Abdo pain / discomfort
- Change in bowel habit
- Urinary frequency
- Bowel obstruction
- Asymptomatic
141
Describe the aetiology of ovarian cancer.
- BrCa1/2, HNPCC gene mutation
| - Ovulation: menarche, menopause, parity, breastfeeding, OCP, hysterectomy, ovulation induction
142
What investigations should you request if you suspect ovarian cancer?
When should you make a referral?
- CA125
- Ultrasound (USS)
- Symptoms and age
Referral based on Risk of Malignancy Index (RMI) =
CA125 x USS score (1 or 3 [if abnormal USS]) x pre or post-menopausal (1 or 3)
A score of 250+ indicates referral to gynaecological oncologist.
143
What are the management options for ovarian cancer?
- Surgery
| - Chemotherapy
144
What is 'normal' labour?
- Spontaneous in onset
- Low risk
- Infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy.
- After birth, mother and infant are in good condition.
145
Describe the organisation of care during labour.
- Midwife = lead professional for low risk women
- Obstetricians = lead professional for women with complications
- All women = MDT care
146
What constitutes the 'latent phase' of labour?
- Irregular contractions
- "Show" - mucoid plug
- 6hrs -> 3 days long(!)
- Cervix is effacing and thinning
- Encouraged to stay at home ± paracetamol!!
147
Describe the process of cervical effacement.
- Starts in the funds
- Retraction / shortening of muscle fibres
- Build in amplitude as labour progresses.
Foetus forced down during labour -> puts pressure on the cervix.
148
What are the 5 modes of assessment of a woman in labour?
1. Presentation: the anatomical part of the foetus which presents itself first.
2. Lie: the relationship between the long axis of the foetus and the long axis of the uterus.
3. Attitude: presenting part flexed or deflexed
4. Engagement: widest part of the presenting part has passed through the brim of the pelvis
5. Station: relationship between the lowest point of the presenting part and the ischial spines.
149
Describe 'active labour'
- 4cm dilated
- Regular, frequent contractions
- Progressive
3Ps: Powers, Passage, Passenger
* Maternal position impacts on attitude & perceived control & pain perception.
150
Give 4 factors which affect a woman's satisfaction with pain during labour.
- Personal expectation
- The amount of support from caregivers
- The quality of the caregiver-patient relationship
- Maternal involvement in decision making
151
Give some methods which may help pain management during labour.
1. Psychological methods: relaxation, imagery, hypnosis
2. Sensory methods: position / posture; hydrotherapy
3. Birth environment: setting, environment
4. Complementary: massage, acupuncture, reflexology, aromatherapy
152
Give 2 examples of opiates.
| What are the i) fetal and ii) maternal side effects of opiate administration during labour?
Pethidine, Morphine
i) Fetal SE: respiratory depression; diminishes breast-seeking, breast-feeding behaviours
ii) Maternal SE:
euphoria & dysphoria; N&V; Longer 1st & 2nd stage labour.
153
An epidural is the most effective form of pain relief.
| List the side effects experienced by i) foetus and ii) mother of an epidural.
i) Fetal SE:
- Tachycardia due to maternal temp (give paracetamol -> not ibuprofen, as the ductus arteriosus may not shut!!!!!)
- Diminishes breast feeding behaviours
ii) Maternal SE:
- Longer 1st & 2nd stage labour
- Need for more oxytocin
- Loss of mobility
- Increased instrumental delivery rate
- Loss of mobility / loss of bladder control
- Hypotension, Pyrexia
154
Describe the 2nd stage of labour.
- Full dilatation
- External signs: head visible
- Spont bearing down
- Progress to descent
155
Describe the mechanism of labour
```
Descent
Flexion
Internal rotation
Crowning
Extension
Restitution
Internal restitution of shoulders
Lateral flexion
```
156
When should you suspect & diagnose delay in a i) Primigravid and ii) Multiparous woman?
i) Primigravid
Suspect: 1 hour into active phase
Diagnose: 2 hours into active phase
ii) Multiparous
Suspect: 30 mins
Diagnose: 1 hour
157
What time frame should the baby be born within if the woman is i) a primi; ii) a multip.
i) Primi: 3 hours of commencement of pushing.
| ii) Multip: 2 hours of commencement of pushing.
158
Describe the 3rd stage of labour.
1. Physiological management (increased blood loss)
2. Active management: oxytocic, cut and clamp cord
Nausea & vomiting
3. Check placenta and membranes are complete.
159
What are the risk factors for urinary incontinence?
- Increased age
- Increased parity
- Smoking
- Obesity
160
Pelvic floor disorders can't be considered in isolation. What other aspects of a patient's history should you ask about?
- Bowel history
- Lower urinary tract symptoms
- Vaginal Hx
- Sexual dysfunction
161
What is 'incontinence'?
- Involuntary leakage of urine
- Social or hygiene problem
- Objectively demonstrable
162
What are the two syndromes which constitute 'incontinence'?
- Overactive bladder
| - Stress urinary incontinence
163
What is the pathophysiology of an overactive bladder?
Involuntary bladder contractions:
- 'key in the door'
- hand washing, intercourse
- urgency incontinence, frequency, nocturne
164
Which incontinence type is associated with involuntary bladder contractions?
Overactive bladder
165
What is the pathophysiology of 'Stress urinary incontinence'?
Sphincter weakness:
- involuntary leakage
- cough, laugh, lifting, exercise
166
Give 4 simple assessments used to assess urinary incontinence.
1. Frequency volume chart (FVC)
2. Urinalysis (MSU)
3. Residual urine measurement (RU)
4. Questionnaire (ePAQ)
167
What should the 'functional bladder capacity' be in a normal individual?
400mls
168
What are the 2 treatment options for Stress Incontinence?
1. Conservative
| 2. Surgery eg. sling suspension.
169
Give examples for treatments which might be used in conservative management of stress incontinence.
- Reassurance & support
- Lifestyle adaptation
- Containment eg. intermittent self catheterisation, pads & pants, skin care, odour control
170
Describe the management for an overactive bladder.
- Bladder drill (training)
- Drugs eg. anticholinergics
- Botox
- Bypass (eg. catheters).
- Lifestyle adaptations
Also: reassurance, support etc.
171
Give some examples of lifestyle adaptations which may help to manage urinary incontinence.
- Weight loss
- Smoking cessation
- Reduced caffeine intake
- Avoidance of straining and constipation.
- Vaginal oestrogen (esp. for overactive bladder)
172
Describe the principles behind Urodynamics.
- Measure pressure in the bladder & bowel
- Increased bladder pressure -> detrusor contracts
OR intra-abdominal pressure increases (measured by pressure in the bowel).
173
Give an example of an anticholinergic used to treat bladder overactivity.
What are the side effects of this drug?
Oxybutinin
also: Tolterodine, Propiverine, Trospium, Solifenacin
Dry mouth
Blurred vision
Drowsiness
Constipation
174
What drug class is Mirabegron in?
What is its mode of action?
B-3 adrenergic receptor agonist
Relaxes smooth muscle detrusor.
Increases bladder capacity.
175
Urinary incontinence can be treated conservatively. List 4 examples of methods which might be used for this.
1. Pelvic floor exercises
2. Biofeedback
3. Electrical stimulation
4. Vaginal cones
176
When should one repair a utero-vaginal prolapse?
i) If patient is symptomatic: dyspareunia, discomfort, obstruction, bothersome
ii) If severe:
Outside vagina, ulcerated, failed conservative measures.
177
What is the mainstay of treatment for utero-vaginal prolapse?
- Reassurance & advice
- Treat pelvic floor symptoms
- Pessary
- Surgery
178
What are the 3 types of pessary available to treat utero-vaginal prolapse?
- Ring
- Shelf: in patients who've had a hysterectomy
- Gell horn
* clinical assessment is essential
179
What are the reasons for using contraception?
- Control level and timing of fertility
- increased births after 30years
- decrease in family size
- increase in rate of teenage pregnancy and second subsequrny unplanned pregnancies
- increased abortion rates
180
What factors should comprise your clinical assessment re: contraception.
- Age (OK up to 50yrs without risk factors)
- Menstrual history
- Previous contraception use
- Previous pregnancies
- Previous / current STI's
- Contraceptive need
- ? Medical problems
- FHx of heart disease, VTE, breast cancer
- ? Migraine with/without aura
- Breast feeding
- Smoking
- Drug history
- Herbal Medicines (eg. st John's Wort)
181
On clinical examination, what factors should you examine regarding contraception?
- BP > 140/159 systolic and/or >90/94 diastolic
- BMI >30
- Cervical smear if over 25 years
- STI screen
182
What is the Fraser Criteria / Gillick Competence?
Contraception can be prescribed to a girl under 16years if:
- The girl understands the dr's advice
- The dr has tried to persuade her to tell her parents or allow him to
- She will begin / continue to have intercourse without contraception
- Her physical or mental health is likely to suffer if she does not receive contraceptive advice
- Her best interests require the prescriber to give contraceptive advice ± treatment without parental consent.
183
What does the client need to know about methods of contraception
- Mode of action
- Efficacy / effectiveness
- Benefits / risks
- Side effects
- Drug interactions
- How to 'use' the method
- Procedure for initiation and removal / discontinuation
- When to seek help while using the method
- Advice on safer sex / STI prevention.
184
List the user-dependent contraceptives.
- COCP
- Contraceptive patches (Evra)
- POP
- Male condom
- Female condom
- Diaphragms / Caps
- Fertility awareness method
- Lactational Amenorrhoea Method
185
List the long acting reversible contraceptives.
- Injection (Depo-provera)
- Implants (eg. Nexplanon)
- Intrauterine contraceptive Devices (Copper coil)
- Intrauterine contraceptive system (Mirena)
186
List the permanent contraceptives.
- Female sterilisation
- Essure (hysteroscopic sterilisation)
- Vasectomy
187
List the options for emergency contraception
1. Hormonal: Levonelle (progesterone only) or ellaOne
| 2. Non-hormonal: IUD
188
How does the COCP work?
- Contains oestrogen and progesterone.
- Prevents ovulation
- Alters cervical mucus
- Thins the lining of the womb.
189
What are the advantages of using COCP as a method of contraception?
- Reversible, reliable
- Regular, predictable cycle
- Reduced menorrhagia, dysmenorrhoea
- decreased risk of PID (due to thickened cervical mucus)
- Protective against ovarian, endometrial & colorectal cancer.
190
What are the disadvantages of using COCP as a method of contraception?
- Possible drug interactions with anti-epileptics, antibiotics, herbals
- Doesn't protect against STIs
- Decreased efficacy if taken late or after D+V
- Possible small risk of breast cancer / cervical cancer
- Increased risk of thromboembolic disease
191
How should a patient use the contraceptive patch?
- Each patch worn for 7 days, for 3/52, followed by 1/52 patch free, during which a withdrawal bleed is likely to occur.
- Contains oestrogen and progesterone.
192
What are the advantages of using a contraceptive patch?
- More even delivery of hormones than pills
| - Good compliance in trials
193
What are the disadvantages of using a contraceptive patch?
- 20% experience skin irritation / reaction to the patches
- Possible drug interactions
- Doesn't protect against STIs
- Expensive
194
After an abortion or miscarriage, how should you advise a patient to use the contraceptive patch?
- After an abortion or miscarriage < 20/40, start patches immediately
- If <20/40, start on day 21 after abortion or 1st day of period + barrier methods for 1st 7 days.
195
Describe how the POP works as a method of contraception.
- Progesterone only
- Thickens cervical mucus
- Thins endometrium
- Decreases tubal motility
- Can stop ovulation
* precise daily compliance is required.
196
Give an example of the POP trade name.
Cerazette
| - A type of progesterone that stops ovulation (98-99% effective)
197
Give 4 advantages of using the POP as a method of contraception.
- Can be used to prevent oestrogenic side effects (breast tenderness, headache, nausea)
- Suitable for smokers > 35 years
- Can be used in grossly obese
- Used with medical problems (migraine, HTN)
198
List 5 disadvantages of using the POP as a method of contraception.
- Less effective than COCP (except Cerazette)
- 3 hour window (Cerazette = 12 hours)
- Increased risk of ectopic (due to slow ovum transport)
- Disrupts menstrual pattern
- Functional ovarian cysts may develop.
199
The male condom prevents pregnancy and protects against STIs. True or False?
True - male condom is effective if used correctly.
| * Ensure awareness of how to use: do NOT assume prior use / knowledge
200
List reasons for condom failure.
- Condom put on after genital contact
- Condom not completely unrolled onto penis.
- Condom slipped off when withdrawing the penis or during sexual intercourse
- Leakage of sperm when penis withdrawn
- Condom rupture
- Mechanical damage (e.g.. fingernails, sex toys)
201
List the advantages of a female condom.
- Protects against STIs
- Inserted any time before intercourse
- Not affected by oils, no restriction of choice of lubricant
- Non-latex
202
List some disadvantages of the female condom.
- Failure rate higher than male condoms
- Needs careful insertion
- Easy for penis to miss it!!!
- Can noisy and intrusive
- Do not use with male condom as they can stick together(!)
203
Describe the use & effectiveness of the diaphragm / cap as a method of contraception.
- Failure rate 2-5% dependent on user
- If weight changes by >3kg, different size required
- Requires good pelvic muscle tone
- Fitted in advance of sexual intercourse to allow spontaneity.
204
Give some advantages of diaphragms / caps as a method of contraception.
- Woman in control
- Inserted any time before intercourse
- Can offer protection against some STI's (not HIV!)
205
Give some disadvantages of diaphragms / caps as a method of contraception.
- Requires correct initial fitting by trained staff
- requires spermicide which can be "messy"
- may become dislodged
- must remain in position for 6hrs after intercourse.
206
Explain the Fertility Awareness method (FAM) of contraception.
- Used to plan or prevent pregnancy
- Need 3-12 months of cycles to predict fertile time
- Commitment from both partners
- Supervision from FAM teacher
- Requires daily charting of temperature and vaginal secretions to predict onset and end of fertile time
- Periods of abstinence / barrier methods
- Predictor kits (eg. Persona)
207
Describe the Lactational Amenorrhoea Method of contraception.
- Based on postpartum infertility when woman amenorrhoeic if fully breast feeding, on demand, day and night.
- At <6 months post part = 98-99% effective
- If hand / pump expressing breast milk, failure rate increased to 5-6%.
- Once menses return (2 sequential days of bleeding / spotting), then no longer amenorrhoic & LAM becomes less effective.
- Should always have back up contraceptive plan.
208
How does injectable contraception work?
| Give an example & describe how it's used.
- Depo-Provera
- IM injection of progesterone
- 12 week interval
- Inhibits ovulation by suppressing LH and FSH
209
If a woman is diabetic, what should you advise if they are using injectable contraception?
- Insulin requirement alter on initiation of depo-provera
| - Advise close monitoring of blood sugar
210
List some advantages of injectable contraception (depo-provera).
- Effective & reversible with little user dependence
- May help PMS symptoms, ovulation pain and painful, heavy periods
- 55% women are amenorrhoeic after 1 year.
211
List some disadvantages of injectable contraception (depo-provera).
- Irregular, prolonged bleeding
- Amenorrhoea
- Increased appetite / weight gain
- May be a delay in return to fertility
- Linked to reduced bone mineral density, especially if aged under 19years.
212
Describe the principles behind the contraceptive implant.
- Single rod (Nexplanon)
- Contains progesterone (slow release)
- Easy insertion & removal
- Fitting following abortion or miscarriage (within 5 days)
- Contains barium sulphate (can be located by x-ray, USS, MRI)
213
List the advantages of using the contraceptive implant.
- Low dose, long acting (3 years), reversible
- No oestrogenic side effects
- Minimal medical intervention (insertion and removal)
- Decreased dysmenorrhoea & menstrual blood loss
214
List the disadvantages of using the contraceptive implant.
- Irregular bleeding
- Requires minor op for insertion and removal
- Occasional discomfort
- Rarely: infection at site
215
Explain the principles behind the Copper Coil (IUD) for use as a contraceptive device
- Copper contained within a plastic frame
- Causes a foreign body reaction within the uterus -> toxic to sperm & egg -> significantly reduces the chance of fertilisation
- Prevents implantation
- Fitted immediately following abortion or miscarriage, or 6 weeks following delivery (requires swabs prior to fitting).
216
List the advantages of an IUD (Copper coil) for use as contraception.
- Long term (5-10 years)
- Reliable, reversible
- Effective immediately
- Effective as emergency contraception
217
List the disadvantages of an IUD (Copper coil) for use as contraception.
- Menstrual irregularities, spotting and inter menstrual bleeding
- Menorrhagia / dysmenorrhoea
- Increased risk of PID first 20 days of insertion (screen for STDs)
- Risk of ectopic pregnancy
- Perforation at insertion
- Risk of expulsion
218
Explain the principles behind the Intrauterine contraceptive system (IUS) (Mirena).
- Contains progesterone
- Also used for menorrhagia & progesterone HRT
- Causes endometrial atrophy & may suppress ovulation
- Can be fitted immediately post abortion or miscarriage & 6 weeks following delivery.
219
List the advantages of the Mirena coil.
- Very effective
- Decreased menstrual blood loss
- Decreased dysmenorrhoea
- Decreased risk of ectopic
- Lowest hormone level of all methods -> lower risk of side effects / weight gain
- Lasts 5 years
220
List the disadvantages of the Mirena coil (IUS).
- Can cause irregular bleeding, esp in the first 3 months.
- Fitting may be painful
- Increased risk of PID after fitting
- Should not be used for emergency contraception.
221
Female sterilisation is a permanent method of contraception. List the advantages of this.
- Highly effective
- Immediately effective
- Permanent
- No hormonal effects.
222
Female sterilisation is a permanent method of contraception. List the disadvantages of this.
- Surgical procedure
- General anaesthetic
- Not easily reversible (not reversible on the NHS).
- Associated complications
223
Give 2 short term and 3 long term complications of female sterilisation.
Short term complications:
1. Anaesthesia
2. Surgical complications
Long term complications:
1. Failure 1:2000 (increased risk of ectopic pregnancy)
2. No effect on menstruation
3. Regret
224
Explain the principles behind Essure (hysteroscopic sterilisation) as a method of permanent contraception.
- Outpatient procedure (takes 30 mins)
- Totally irreversible
- Not immediately effective
- Pelvic X-ray required 3/12 following procedure to check tubes are fully blocked. May take longer in some women.
225
Give 4 advantages of a vasectomy as a method of contraception.
- Safe & effective
- Permanent
- Minor operation under local anaesthesia
- Can be done by GP or a clinic
226
Give 3 disadvantages of a vasectomy as a method of contraception.
- Not easily reversible (not reversible on the NHS).
- Not immediately effective (2 negative semen analyses required).
- Associated complications
227
List 3 short term complications arising from a vasectomy
- Local anaesthetic reaction
- Wound infection
- Failure to achieve azoospermia
228
List 5 long term complications arising from a vasectomy.
- Sperm granulomas
- Chronic scrotal pain
- Sperm antibodies
- Late recanaliation
- Regret
229
Explain how emergency contraception works.
- Progesterone only (Levonelle, EllaOne)
- Decreases viability of ova, decreases sperm numbers, and may prevent implantation
- Does not dislodge an implanted embryo
230
What advice should you give someone who's just used emergency contraception?
- Advise pregnancy test if expected period is more than 7 days late.
- Resume 'regular' contraception within 12hrs + barrier method for 7 days with oestrogen containing contraception / 2 days for progesterone.
231
List the advantages of hormonal emergency contraception.
- Effective; low failure rate
- Easily available
- Levonelle: taken up to 72 hours after SI (50% efficacy up to 120hrs)
- ellaOne: same efficacy up to 120hrs
- Can be repeated in same cycle if necessary.
232
List disadvantages of hormonal emergency contraception.
- Associated N&V
- Can disrupt menstruation, causing inter menstrual bleeding
- Does not protect against STIs.
233
Explain the use of IUD in emergency contraception.
- Non-hormonal Emergency contraception
- Prevents implantation
- Can be fitted up to 5 days after the calculated earliest day of ovulation OR for a single episode of unprotected sexual intercourse in the cycle
- Needs professional fitting
234
List the advantages of non-hormonal emergency contraception.
- Can be used if multiple episodes of SI if within 5 days of ovulation
- Can be used if vomits hormonal method
- Ideal if IUD is the choice of long term contraception
- Most effective method, especially after 72 hours.
235
List the disadvantages of non-hormonal emergency contraception.
- Can be painful to insert, especially if a primi.
| - Increased risk of PID.
236
Explain the principle of 'confidentiality', as applied to sexual health.
Patients can be assured that information on STI testing, diagnosis and treatment will be not included in their shared patient records without their consent.
237
What questions should you consider asking in a sexual health history?
- Hx of presenting complaint
- Past GU Hx
- Past medical / surgical Hx
- Drugs (any antibiotics in the last month)
- Sexual Hx:
> Last sexual intercourse
> Regular / casual partner
> Male / female
> Condom use
> Type of Sexual intercourse
238
When taking a sexual Hx, what focussed questions should you ask i) females and ii) males?
i) Female:
- Menstrual Hx
- Pregnancy Hx
- Contraception
- Cervical cytology Hx
ii) Male:
- When last voided urine
239
If you are carrying out a genital examination of a woman, which areas should you look at?
- Vulva
- Perineum
- Vagina
- Cervix
- Bimanual pelvic examination
- Possibly: anus & oropharynx
240
If you are carrying out a genital examination on a male, which areas should you look at?
- Penis
- Scrotum
- Urethral meatus
- Anus & oropharynx in MSMs.
241
What investigations should be conducted for i) female and ii) male screening for asymptomatic STIs?
i) Female:
- Self-taken vulvo-vaginal swab (for Gonorrhoea/Chlamydia NAAT)
- Bloods for STS + HIV
ii) Male:
- First void urine for Chlamydia / Gonorrhoea NAAT
- Blood test for STS + HIV
242
What investigations should be conducted for asymptomatic STI screening of Men who have sex with Men (MSM)?
- First void urine for Chlamydia / Gonorrhoea NAAT
- Pharyngeal swab for Chlamydia / Gonorrhoea (may be self taken)
- Bloods for STS, HIV, Hep B (& Hep C, if indicated)
243
Give examples of STI presentations in females
- Vaginal discharge
- Vulval discomfort / soreness, itching or pain
- Superficial dyspareunia
- Pelvic pain / deep dyspareunia
- Vulval lumps
- Vulval ulcers
- Inter-menstrual bleeding
- Post-coital bleeding
244
Give examples of STI presentations in males.
- Pain / burning during micturition
- Pain / discomfort in the urethra
- Urethral discharge
- Genital ulcers, sores or blisters
- Genital lumps
- Rash on penis or genital area
- Testicular pain / swelling
245
What investigations should be conducted in a symptomatic (of an STI) female?
- Vulvo-vaginal swab for Gonorrhoea + Chlamydia NAAT
- High vaginal swab (wet + dry slides) for: bacterial vaginosis; trichomonas vaginalis, candida
- Cervical swab for slide + Gonorrhoea
- Dipstick urinalysis (if has dysuria)
- Blood STS + HIV
246
What investigations should you conduct in a symptomatic (of STI) heterosexual male?
- Urethral swab for slide + Gonorrhoea culture
- First void urine for Gonorrhoea + Chlamydia NAAT
- Dipstick urinalysis (if has dysuria)
- Blood for STS + HIV
247
What investigations should you conduct in a symptomatic MSM (male who has sex with men)?
- Test as for asymptomatic MSM
- + urethral and rectal slides
- + urethral, rectal and pharyngeal culture plates.
248
Who should you consider for Hepatitis B screening?
- Men who have sex with Men (MSM)
- Commercial sex workers (CSW) and their sexual partners
- IVDUs (current or past), and their sexual partners
- People from high risk areas and their sexual partners (eg. Africa, Asia, Eastern Europe)
* Aim to vaccinate them if non-immune.
249
Why should we treat partners of people diagnosed with STIs?
- Necessary to prevent re-infection of index patient
- To identify and treat asymptomatic individuals as a public health measure
* Remember the importance of confidentiality in maintaining a patient's trust.
250
Give a definition of 'screening'.
The process of identifying apparently health individuals who may be at an increased risk of a disease or condition.
They can then be offered information, further tests and appropriate treatment to reduce their risk, and / or any complications from the disease or condition.
251
List the key steps of the screening pathway for screening to be effective.
- Identify individuals eligible for screening
- invite eligible individuals for screening
- give information (re: screening) and facilitate uptake
- Undertake the screening test to ensure it's accurate
- Act on the screening results: referral, diagnosis, intervention and treatment
- providing support and follow up
- optimising health outcomes
252
Explain what screening can and cannot do.
Can:
- Save lives; improve QoL
- Reduce risk of developing a serious condition
- Produce false positive or false negative results
Cannot:
- Guarantee protection
- Prevent the person from developing the condition at a later date, even if a low risk result is received.
253
What pre-test information should be given to women?
- The condition that is being screened for
- When and how the test will be carried out
- How reliable the test is
- Different possible results and their meanings
- Options if the test is positive
