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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

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2
Q

What is ‘Gravidity’?

A

The number of pregnancies a woman has had, to any stage.

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3
Q

What is ‘Parity’?

A

The number of offspring that a woman has delivered beyond week 28.

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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
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5
Q

What are the reasons for urinary frequency in pregnancy?

A
  • Enlarged uterus puts pressure on bladder

- Increased GFR

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6
Q

What are the reasons for constipation in pregnancy?

A
  • Decreased gastric motility

- Pressure on the GIT from a growing uterus

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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.

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8
Q

What changes in the legs might be seen in a pregnant woman?

A

Varicose veins

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9
Q

What changes in the skin might be seen in a pregnant woman?

A

Abdominal stretch marks - these may become highly pigmented.

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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,.
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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
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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.

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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)

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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.

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15
Q

Describe ‘Stage 3’ of ‘Normal’ Labour.

A

Delivery of the placenta.

This should take place within one hour of delivery.

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16
Q

What are the classifications of CTG traces?

A

Reassuring
Non-reassuring / Suspicious
Abnormal

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17
Q

What does a CTG show?

A

Fetal Heart Rate & Uterine Contractions

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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
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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
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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).
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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

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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.
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23
Q

What might cause ‘decreased’ variability?

A
  • Fetal sleeping
  • Fetal hypoxia & acidosis
  • Opiate use
  • Prematurity
  • Congenital heart issues (of the foetus).
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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.

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25
Q

Describe ‘decelerations’ with regards to a CTG.

A

Decelerations:

- a decrease of 15bpm or more from baseline FHR for 15 or more seconds.

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26
Q

What are the 3 classes of deceleration?

A

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.

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27
Q

What are the options for pain relief during labour?

A
  • Waterbirth
  • Nitrous Oxide (gas & air)
  • Narcotic injections (IM Pethidine)
  • Pudendal block
  • Epidural anaesthesia
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28
Q

Name 3 pregnancy hormones & their role during pregnancy

A

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.

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29
Q

What do we mean by ‘Maternal physiological adaptation to pregnancy’?

A

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.

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30
Q

Glucose is the principle fetal nutrient, but fetal gluconeogenic enzymes are inactivated. Why?
How does the foetus get glucose?

A

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.

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31
Q

Describe glucose / glycogen synthesis / control in i) Early pregnancy and ii) late pregnancy

A

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.

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32
Q

Describe the insulin response in i) Early pregnancy and ii) late pregnancy

A

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.

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33
Q

Give two possible explanations for Maternal Insulin Resistance seen in pregnancy.

A
  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.
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34
Q

Give two in utero complications of gestational diabetes for the foetus.

A
  1. Macrosomic infant - at risk of shoulder dystocia.

2. Glucose at high concentrations in teratogenic.

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35
Q

Describe the process of blastocyst implantation.

A
  • 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.
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36
Q

What complications might arise as a consequence of poor endovascular remodelling in utero?

A
  • Pre-eclampsia: extent and depth of spiral artery remodelling greatly decreased. Reduced fetal O2 / nutrient supply.
  • IUGR
  • Pre-term birth
  • Recurrent miscarriage
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37
Q

What are the 3 main types of incorrect placentation?

A

Morbidly adherent placenta:

  • Accreta: superficial myometrium
  • Increta: deeper myometrium
  • Percreta: into other abdominal organs
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38
Q

What separates the placenta from the myometrium (if placental location is ‘normal’)?

A

Decidua basalis.

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39
Q

The foetus is immunologically different to the mother. Why is it not rejected?

A
  • 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.
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40
Q

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?

A

Normal pregnancy:

  • Th2 bias observed
  • Immune response modified

Th2 bias not observed

  • exaggerated inflammatory response see
  • ? pre-eclampsia, recurrent miscarriage, IUGR
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41
Q

Which cells make antibodies?

A

B cells (plasma cells)

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42
Q

Which antibody is secreted in breast milk?

A

IgA

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43
Q

Which is the only immunoglobulin to cross the placenta?

A

IgG

This has a role in rhesus disease / haemolytic disease of the newborn

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44
Q

Explain the phenomenon of Rhesus disease.

A

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.
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45
Q

What can be done to minimise the risk of Rhesus disease?

A

Anti-D prophylaxis
> This destroys Anti Rh +ve IgG
> Fetal RBCs not attacked.

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46
Q

What are the 3 stages of parturition?

A
  1. Cervical dilatation (remodelling)
  2. Fetal expulsion (myometrial contraction)
  3. Placental delivery
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47
Q

Which electrolyte is elevated during myometrial contractility stage?

A

Calcium

  • leads to myocyte contraction
  • release is mediated by oxytocin: elevates Ca2+ & stimulates contraction by releasing intracellular stores.
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48
Q

What is the role of oxytocin in parturition?

A
  • 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.
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49
Q

What is the ‘Ferguson Reflex’?

A

Membrane sweep
- Cervical stimulation / myometrial stretch induces oxytocin secretion.
- Initiates a positive feedback mechanism (Ferguson Reflex)
> May stimulate uterine contractions.

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50
Q

What is Atosiban?

A
  • Antagonist of the oxytocin receptor

- Inhibits premature myometrial contractions

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51
Q

What does Carboprost do?

A

Induces contractions.

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52
Q

List some risk factors for Breast Cancer.

A
  • Age
  • FHx: Sporadic, Polygenic, Single gene
  • Duration of oestrogen exposure
  • Late first pregnancy
  • HRT
  • Obesity
  • Alcohol
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53
Q

List some clinical features of breast cancers.

A
  • Lump: irregular, hard, fixed
  • Metastatic disease: bone -> pathological fracture
  • Nipple discharge
  • Skin tethering
  • Indrawn nipple
  • peau d’orange: lymphatics blocked -> causes oedema
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54
Q

How is a diagnosis of breast cancer made?

A

Triple Assessment:
> Clinical score 1-5
> Imaging score (Mammogram) 1-5
> Biopsy score 1-5

Aim for concordance

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55
Q

What views of each breast should you request for mammography?

If the lump has a ‘fluffy edge’ on imaging, what does this indicate?

A

Craniocaudal (CC) & Mediolateral oblique (MLO) views of each breast.

‘Fluffy edge’ = ? malignant

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56
Q

If a woman has a breast implant, what would be the imaging mode of choice?

A

MRI.

MRI would also be used for high risk screening.

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57
Q

What are surgical options for ‘primary operable breast cancer’?

What considerations should you make when making a decision?

A
  • Breast conservation
  • Mastectomy.

Considerations:

  • multiple tumours
  • tumour size relative to breast
  • patient choice
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58
Q

When would surgery to the axilla be indicated?

A
  • for local control

- prognostic factors

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59
Q

What do we mean by tumour ‘grade’?

A

Histologically - what the tumour looks like.
Grade 1, 2 or 3.

NB: ‘Grade’ is NOT the same as ‘stage’.

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60
Q

What do we mean by tumour ‘stage’?

What model do we use to ‘stage’ tumours?

A

Stage = the anatomical extent of the disease.

TNM: Tumour, Nodes, Metastasis

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61
Q

Give some examples of chemotherapy regimes.

A

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

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62
Q

Chemotherapy is generally used for high risk disease. Give some risk factors for high risk disease.

A
  • Young age
  • ER -ve
  • Her2 +ve
  • High grade
  • Node positive
  • Ki67 positive
  • Tumour size
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63
Q

Give some therapeutic treatment options other than chemotherapy for breast cancer.

A
  • Endocrine therapy (if ER+ve disease)
  • Radiotherapy
  • Bisphosphonates (if post-menopausal with ER+ve disease)
  • HER2 (give Herceptin)
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64
Q

What is Tamoxifen used for?

A
  • If oestrogen receptor positive
  • inhibits oestrogen receptor on cancer cells.
  • An endocrine therapy.
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65
Q

What are Aromatase inhibitors used for?

A
  • If ER +ve
  • Post-menopausal women
  • Anti-oestrogen.
    Slightly better efficacy than Tamoxifen.
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66
Q

What are the implications of a Her-2 diagnosis?

A

Her-2 +ve = worst prognosis of any subtype
High metastatic risk, particularly to the brain.
Give chemo + Trastuzumab

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67
Q

When will radiotherapy be needed?

A
  • T3 + T4 cancers usually require post-operative chest wall radiotherapy
  • High grade plus nodal disease
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68
Q

List some problems associated with radiotherapy:

A
  • Skin viability risk
  • Wound healing
  • Loss of elasticity
  • Fat necrosis
  • Fibrosis
  • Implant extrusion
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69
Q

The 1st stage of labour involves uterine contraction, cervical effacement and dilatation. Which nerve roots are involved in pain transmission during this time?

A

T10 - L1: uterine sympathetic nerve via paracervical ganglia

S2 - S4: Pelvic Splanchnic Nerves

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70
Q

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?

A

S2 - S4: Pudendal nerve

L5 - S1

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71
Q

Give some examples of non-pharmacological therapies which may help to alleviate pain during labour

A 
> Trained support 
> Acupuncture
> Hypnotherapy
> Massage
> TENS 
> Hydrotherapy 
> Alternative therapy: homeopathy; aromatherapy
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72
Q

Give some examples of simple analgesics that women can self administer in the early stages of labour

A

> Paracetamol

> Codeine

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73
Q

Give 3 examples of opioids used in labour to alleviate pain.
How are they administered?

A

Morphine, Diamorphine, Pethidine.

Administered as a single shot (usually IM) or IV via a patient-controlled analgesic pump.

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74
Q

Give some properties of opioids.

A

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.

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75
Q

Why should you not give ibuprofen (or any other NSAID) during labour?

A

Baby’s Ductus Arteriosus may not shut if you’ve given mother ibuprofen / an NSAID).

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76
Q

Give 3 examples of PCA opioids.

A

Fentanyl: rapid onset of action
Alfentanil
Remifentanil

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77
Q

What is ‘Entonox’?

A

50% N2O; 50% O2

> Rapid onset of analgesia
minimal side effects

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78
Q

At what spinal level should you perform an epidural?

A

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.

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79
Q

Give 3 examples of ‘regional anaesthesia’ techniques.

A

> Epidural
Spinal
Combined spinal-epidural (CSE)

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80
Q

What i) local anaesthetic; ii) opioids would be used in a spinal? What kind of drugs are these?

A

i) Local anaesthetic: Bupivacaine

ii) Opioids:
Fentanyl
Diamorphine

These are examples of neuroaxial drugs.

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81
Q

What would a woman feel like after having a spinal?

A

Dense, heavy numbness.

Can’t feel contractions.

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82
Q

List some indications for an epidural.

A 
> Maternal request
> Cardiac / other medical disease 
> Augmented labour 
> Multiple births 
> Instrumental / operative delivery likely
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83
Q

Give 3 absolute contraindications to regional* anaesthetic techniques.

  • Regional anaesthetic techniques = Epidural, Spinal, CSE
A
  • Maternal refusal
  • Local infection
  • Allergy
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84
Q

Give 5 relative contraindications to regional* anaesthetic techniques.

  • Regional anaesthetic techniques = Epidural, Spinal, CSE
A
  • Coagulopathy
  • Systemic infection
  • Hypovolaemia
  • Abnormal anatomy
  • Fixed cardiac output
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85
Q

Give some examples of adverse effects of regional anaesthesia on the different organ systems.

A

CVS: Hypotension; Bradycardia if high block

Resp: blocked intercostal nerves, poor cough

Neuro: (rare!) related to haematoma or abscess

Drug related: allergy, anaphylaxis, neurotoxicity.

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86
Q

Describe the 4 types of ‘Epidural regimens’.

A

1) Traditional (intermittent bolus)
2) Continuous infusion
3) Continuous infusion + bolus
4) Combined spinal-epidural

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87
Q

Give some outcomes of labour following regional anaesthesia usage.

A
  • Superior analgesia
  • Maternal satisfaction better with low dose
  • May prolong labour
  • May increase instrumental delivery
  • Maternal pyrexia ?significance
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88
Q

What are the anaesthetic options for an operative delivery (i.e. C-section).

A
  1. General anaesthesia
  2. Regional anaesthesia
    - Epidural top up
    - Spinal
    - CSE
  • to a certain degree, this depends on urgency.
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89
Q

When would a general anaesthetic be considered for an operative delivery?

A
  • Imminent threat to mother and/or foetus
  • Contraindication to regional
  • Maternal preference
  • Failed regional technique
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90
Q

There may be increased risks with general anaesthesia for a C-section delivery. Give examples of these.

A
  • Increased risks associated with altered physiology
  • Aspiration
  • Failed intubation
  • Awareness
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91
Q

Give 4 advantages of regional anaesthesia.

A
  • Safer
  • Can see baby immediately
  • Partner present
  • Improved post-op analgesia
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92
Q

Give 4 disadvantages of regional anaesthesia

A
  • Hypotension
  • Headache
  • Discomfort associated with pressure sensations
  • Failure
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93
Q

What percentage of pregnancies end in miscarriage?

A

Approx 20%

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94
Q

What is a ‘threatened miscarriage’?

A

A pregnancy associated with vaginal bleeding + with or without abdominal pain. Closed cervix.

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95
Q

What is an ‘inevitable miscarriage’?

A

Bleeding + pain.

Open cervix.

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96
Q

What is a ‘complete miscarriage’?

A

Bleeding and pain cease. Closed cervix. Empty uterus.

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97
Q

What is an ‘incomplete miscarriage’?

A

Bleeding ± pain.

Possible open cervix.

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98
Q

What is a ‘missed miscarriage’ / early fetal demise?

A

± bleeding ± pain ± loss of pregnancy symptoms. Closed cervix.

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99
Q

What indicates a pregnancy of unknown location (PUL)?

A

± 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.

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100
Q

How is a ‘delayed miscarriage’ diagnosed?

A

Ultrasound scan:

  • empty gestation sac OR
  • fetal pole with no heart beat.
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101
Q

What are the 3 options for miscarriage management?

A
  1. Expectant management
  2. Medical management
    - Mifepristone (anti-progesterone priming)
    then;
    - Misoprostol (prostaglandins analogue)
  3. Surgical management
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102
Q

List some complications of surgical management of miscarriage (SMM).

A
  • Infection
  • Haemorrhage
  • Uterine perforation
  • Retained products of conception
  • Intrauterine adhesions
  • Cervical tears
103
Q

Where is the commonest site for an ectopic pregnancy to occur?

A

Fallopian tube

104
Q

When is an ectopic pregnancy considered?

A

Ectopic considered to be a possibility when an empty uterus is found on USS in a patient with a positive pregnancy test.

105
Q

What factors make an ectopic pregnancy more likely?

A
  • STIs eg. chlamydia
  • Fertility treatment
  • Anything that causes tube damage
106
Q

When would medical treatment of an ectopic be appropriate? Which drug should be used?

A
  • 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
Q

What is another name for a ‘Molar’ pregnancy?

How is a molar pregnancy characterised?

A

Hydatidiform mole:

Characterised by the presence of large, fluid filled vesicles within the placenta.

108
Q

What does a molar pregnancy look like on USS?

Are the b-hCG levels high or low in a molar pregnancy?

A

USS: Snow storm

b-hCG = Very high in a molar pregnancy.

109
Q

What is the initial treatment for a molar pregnancy?

A

Surgical.
b-hCG levels are monitored.
Chemo is offered if the levels fail to fall satisfactorily.

110
Q

What clinical features indicate Hyperemesis Gravidarum?

A
  • 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
Q

What is the initial management of Hyperemesis Gravidarum?

A
  • 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
Q

What is the point of monitoring the fetal heart rate?

A

Identification of a baby at risk of dying in utero

113
Q

What methods are used to measure the fetal heart rate in utero?

A

1) Intermittent auscultation
- Pinard stethoscope
- Hand held doppler

2) Continuous FHR monitoring
- CTG
- Fetal ECG (‘scalp’ ECG)

114
Q

When & why might you use intermittent auscultation in labour?

A
  • 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
Q

When & why might you use CTG for continuous FHR monitoring?

A
  • 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
Q

When & why might you use a Direct fetal ECG (scalp ECG)?

A
  • 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
Q

Which pneumonic is used for CTG interpretation?

A

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
Q

What are the 3 descriptions given to CTGs following analysis using the pneumonic?

A

Reassuring (Normal)

Non-reassuring (Suspicious)

Pathological (Abnormal)

119
Q

What are the normal FHR parameters?

A

110 - 160 bpm

120
Q

What is meant by ‘cellular senescence’?

A

“Growing old”: normal cells limit the number of divisions by shortening of telomeres at the end of each chromosome.
Malignant cells lengthen telomeres.

121
Q

What is ‘apoptosis’?

A

‘Normal’ cell death

  • Programmed cell death ‘suicide pathway’
  • maintains cell population
  • prevents malignant transformation
122
Q

Give 2 examples of tumour suppressor genes & describe their role in the cell cycle.

A

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
Q

What is an ‘oncogene’?

Give 3 examples of oncogenes.

A

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
Q

Describe the aetiology of endometrial cancer

A
  • Obesity
  • Diabetes
  • Nulliparity
  • Late menopause
  • Ovarian tumours (granulosa)
  • HRT
  • Pelvic irradiation
  • Tamoxifen
  • PCOS
  • HNPCC
125
Q

What is the biggest risk factor for endometrial cancer?

A

unopposed oestrogen

126
Q

What kind of bleeding is associated with endometrial cancer?

A

Post-menopausal bleeding

127
Q

What investigations might you request if you suspected Endometrial cancer?

A
  • History
  • Examination
  • Investigations:
    > Transvaginal USS
    > Endometrial biopsy
    > Hysteroscopy
128
Q

What staging system is used to stage endometrial cancer?

A

FIGO I / II / III / IV

129
Q

What are the treatment options for endometrial cancer?

A
  1. Surgery: hysterectomy ± pelvic lymph nodes
  2. Radiotherapy (adjuvant_
  3. Progesterone therapy
    * endometrial cancer occurs due to unopposed oestrogen.
130
Q

Describe the aetiology of cervical cancer.

A
  • 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
Q

What is persistent HPV infection associated with?

A
  • Increased risk of high grade Cervical Intraepithelial neoplasia
  • Immunological competence
  • HIV and renal transplant patients
132
Q

Which is the most common cancer in UK women under 35yrs?

A

Cervical cancer

133
Q

Describe the incidence of cervical cancer in the current population

A

Increasing in women aged 25 - 29 years.

134
Q

What kind of bleeding is associated with cervical cancer?

A

Post-coital bleeding?

135
Q

What are the treatment options for cervical cancer?

A
  • Biopsy
  • Hysterectomy
  • Chemo / radiotherapy
136
Q

Is vulval cancer common or uncommon?

A

Uncommon

1000 diagnoses of vulval cancer in the UK in 2011.

137
Q

Describe the aetiology of vulval cancer

A

HPV / Lichen Sclerosis

138
Q

What are the symptoms of vulval cancer?

A
  • Vulval itching
  • Vulval soreness
  • Persistent lump
  • Bleeding
  • Pain on passing urine
  • Past history of HPV or Lichen sclerosis
139
Q

What are the treatment options for a woman with vulval cancer?

A

Surgery - conservative
Surgery - radical
Radiotherapy

140
Q

How might a patient with Ovarian cancer present?

A
  • Bloating / IBS-like symptoms
  • Abdo pain / discomfort
  • Change in bowel habit
  • Urinary frequency
  • Bowel obstruction
  • Asymptomatic
141
Q

Describe the aetiology of ovarian cancer.

A
  • BrCa1/2, HNPCC gene mutation

- Ovulation: menarche, menopause, parity, breastfeeding, OCP, hysterectomy, ovulation induction

142
Q

What investigations should you request if you suspect ovarian cancer?

When should you make a referral?

A
  • 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
Q

What are the management options for ovarian cancer?

A
  • Surgery

- Chemotherapy

144
Q

What is ‘normal’ labour?

A
  • 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
Q

Describe the organisation of care during labour.

A
  • Midwife = lead professional for low risk women
  • Obstetricians = lead professional for women with complications
  • All women = MDT care
146
Q

What constitutes the ‘latent phase’ of labour?

A
  • Irregular contractions
  • “Show” - mucoid plug
  • 6hrs -> 3 days long(!)
  • Cervix is effacing and thinning
  • Encouraged to stay at home ± paracetamol!!
147
Q

Describe the process of cervical effacement.

A
  • 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
Q

What are the 5 modes of assessment of a woman in labour?

A
  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
Q

Describe ‘active labour’

A
  • 4cm dilated
  • Regular, frequent contractions
  • Progressive

3Ps: Powers, Passage, Passenger

  • Maternal position impacts on attitude & perceived control & pain perception.
150
Q

Give 4 factors which affect a woman’s satisfaction with pain during labour.

A
  • Personal expectation
  • The amount of support from caregivers
  • The quality of the caregiver-patient relationship
  • Maternal involvement in decision making
151
Q

Give some methods which may help pain management during labour.

A
  1. Psychological methods: relaxation, imagery, hypnosis
  2. Sensory methods: position / posture; hydrotherapy
  3. Birth environment: setting, environment
  4. Complementary: massage, acupuncture, reflexology, aromatherapy
152
Q

Give 2 examples of opiates.

What are the i) fetal and ii) maternal side effects of opiate administration during labour?

A

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
Q

An epidural is the most effective form of pain relief.

List the side effects experienced by i) foetus and ii) mother of an epidural.

A

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
Q

Describe the 2nd stage of labour.

A
  • Full dilatation
  • External signs: head visible
  • Spont bearing down
  • Progress to descent
155
Q

Describe the mechanism of labour

A 
Descent
Flexion
Internal rotation
Crowning
Extension
Restitution 
Internal restitution of shoulders
Lateral flexion
156
Q

When should you suspect & diagnose delay in a i) Primigravid and ii) Multiparous woman?

A

i) Primigravid
Suspect: 1 hour into active phase
Diagnose: 2 hours into active phase

ii) Multiparous
Suspect: 30 mins
Diagnose: 1 hour

157
Q

What time frame should the baby be born within if the woman is i) a primi; ii) a multip.

A

i) Primi: 3 hours of commencement of pushing.

ii) Multip: 2 hours of commencement of pushing.

158
Q

Describe the 3rd stage of labour.

A
  1. Physiological management (increased blood loss)
  2. Active management: oxytocic, cut and clamp cord
    Nausea & vomiting
  3. Check placenta and membranes are complete.
159
Q

What are the risk factors for urinary incontinence?

A
  • Increased age
  • Increased parity
  • Smoking
  • Obesity
160
Q

Pelvic floor disorders can’t be considered in isolation. What other aspects of a patient’s history should you ask about?

A
  • Bowel history
  • Lower urinary tract symptoms
  • Vaginal Hx
  • Sexual dysfunction
161
Q

What is ‘incontinence’?

A
  • Involuntary leakage of urine
  • Social or hygiene problem
  • Objectively demonstrable
162
Q

What are the two syndromes which constitute ‘incontinence’?

A
  • Overactive bladder

- Stress urinary incontinence

163
Q

What is the pathophysiology of an overactive bladder?

A

Involuntary bladder contractions:

  • ‘key in the door’
  • hand washing, intercourse
  • urgency incontinence, frequency, nocturne
164
Q

Which incontinence type is associated with involuntary bladder contractions?

A

Overactive bladder

165
Q

What is the pathophysiology of ‘Stress urinary incontinence’?

A

Sphincter weakness:

  • involuntary leakage
  • cough, laugh, lifting, exercise
166
Q

Give 4 simple assessments used to assess urinary incontinence.

A
  1. Frequency volume chart (FVC)
  2. Urinalysis (MSU)
  3. Residual urine measurement (RU)
  4. Questionnaire (ePAQ)
167
Q

What should the ‘functional bladder capacity’ be in a normal individual?

168
Q

What are the 2 treatment options for Stress Incontinence?

A
  1. Conservative

2. Surgery eg. sling suspension.

169
Q

Give examples for treatments which might be used in conservative management of stress incontinence.

A
  • Reassurance & support
  • Lifestyle adaptation
  • Containment eg. intermittent self catheterisation, pads & pants, skin care, odour control
170
Q

Describe the management for an overactive bladder.

A
  • Bladder drill (training)
  • Drugs eg. anticholinergics
  • Botox
  • Bypass (eg. catheters).
  • Lifestyle adaptations

Also: reassurance, support etc.

171
Q

Give some examples of lifestyle adaptations which may help to manage urinary incontinence.

A
  • Weight loss
  • Smoking cessation
  • Reduced caffeine intake
  • Avoidance of straining and constipation.
  • Vaginal oestrogen (esp. for overactive bladder)
172
Q

Describe the principles behind Urodynamics.

A
  • Measure pressure in the bladder & bowel
  • Increased bladder pressure -> detrusor contracts
    OR intra-abdominal pressure increases (measured by pressure in the bowel).
173
Q

Give an example of an anticholinergic used to treat bladder overactivity.

What are the side effects of this drug?

A

Oxybutinin
also: Tolterodine, Propiverine, Trospium, Solifenacin

Dry mouth
Blurred vision
Drowsiness
Constipation

174
Q

What drug class is Mirabegron in?

What is its mode of action?

A

B-3 adrenergic receptor agonist

Relaxes smooth muscle detrusor.
Increases bladder capacity.

175
Q

Urinary incontinence can be treated conservatively. List 4 examples of methods which might be used for this.

A
  1. Pelvic floor exercises
  2. Biofeedback
  3. Electrical stimulation
  4. Vaginal cones
176
Q

When should one repair a utero-vaginal prolapse?

A

i) If patient is symptomatic: dyspareunia, discomfort, obstruction, bothersome

ii) If severe:
Outside vagina, ulcerated, failed conservative measures.

177
Q

What is the mainstay of treatment for utero-vaginal prolapse?

A
  • Reassurance & advice
  • Treat pelvic floor symptoms
  • Pessary
  • Surgery
178
Q

What are the 3 types of pessary available to treat utero-vaginal prolapse?

A
  • Ring
  • Shelf: in patients who’ve had a hysterectomy
  • Gell horn
  • clinical assessment is essential
179
Q

What are the reasons for using contraception?

A
  • 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
Q

What factors should comprise your clinical assessment re: contraception.

A
  • 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
Q

On clinical examination, what factors should you examine regarding contraception?

A
  • BP > 140/159 systolic and/or >90/94 diastolic
  • BMI >30
  • Cervical smear if over 25 years
  • STI screen
182
Q

What is the Fraser Criteria / Gillick Competence?

A

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
Q

What does the client need to know about methods of contraception

A
  • 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
Q

List the user-dependent contraceptives.

A
  • COCP
  • Contraceptive patches (Evra)
  • POP
  • Male condom
  • Female condom
  • Diaphragms / Caps
  • Fertility awareness method
  • Lactational Amenorrhoea Method
185
Q

List the long acting reversible contraceptives.

A
  • Injection (Depo-provera)
  • Implants (eg. Nexplanon)
  • Intrauterine contraceptive Devices (Copper coil)
  • Intrauterine contraceptive system (Mirena)
186
Q

List the permanent contraceptives.

A
  • Female sterilisation
  • Essure (hysteroscopic sterilisation)
  • Vasectomy
187
Q

List the options for emergency contraception

A
  1. Hormonal: Levonelle (progesterone only) or ellaOne

2. Non-hormonal: IUD

188
Q

How does the COCP work?

A
  • Contains oestrogen and progesterone.
  • Prevents ovulation
  • Alters cervical mucus
  • Thins the lining of the womb.
189
Q

What are the advantages of using COCP as a method of contraception?

A
  • Reversible, reliable
  • Regular, predictable cycle
  • Reduced menorrhagia, dysmenorrhoea
  • decreased risk of PID (due to thickened cervical mucus)
  • Protective against ovarian, endometrial & colorectal cancer.
190
Q

What are the disadvantages of using COCP as a method of contraception?

A
  • 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
Q

How should a patient use the contraceptive patch?

A
  • 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
Q

What are the advantages of using a contraceptive patch?

A
  • More even delivery of hormones than pills

- Good compliance in trials

193
Q

What are the disadvantages of using a contraceptive patch?

A
  • 20% experience skin irritation / reaction to the patches
  • Possible drug interactions
  • Doesn’t protect against STIs
  • Expensive
194
Q

After an abortion or miscarriage, how should you advise a patient to use the contraceptive patch?

A
  • 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
Q

Describe how the POP works as a method of contraception.

A
  • Progesterone only
  • Thickens cervical mucus
  • Thins endometrium
  • Decreases tubal motility
  • Can stop ovulation
  • precise daily compliance is required.
196
Q

Give an example of the POP trade name.

A

Cerazette

- A type of progesterone that stops ovulation (98-99% effective)

197
Q

Give 4 advantages of using the POP as a method of contraception.

A
  • 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
Q

List 5 disadvantages of using the POP as a method of contraception.

A
  • 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
Q

The male condom prevents pregnancy and protects against STIs. True or False?

A

True - male condom is effective if used correctly.

* Ensure awareness of how to use: do NOT assume prior use / knowledge

200
Q

List reasons for condom failure.

A
  • 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
Q

List the advantages of a female condom.

A
  • Protects against STIs
  • Inserted any time before intercourse
  • Not affected by oils, no restriction of choice of lubricant
  • Non-latex
202
Q

List some disadvantages of the female condom.

A
  • 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
Q

Describe the use & effectiveness of the diaphragm / cap as a method of contraception.

A
  • 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
Q

Give some advantages of diaphragms / caps as a method of contraception.

A
  • Woman in control
  • Inserted any time before intercourse
  • Can offer protection against some STI’s (not HIV!)
205
Q

Give some disadvantages of diaphragms / caps as a method of contraception.

A
  • 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
Q

Explain the Fertility Awareness method (FAM) of contraception.

A
  • 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
Q

Describe the Lactational Amenorrhoea Method of contraception.

A
  • 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
Q

How does injectable contraception work?

Give an example & describe how it’s used.

A
  • Depo-Provera
  • IM injection of progesterone
  • 12 week interval
  • Inhibits ovulation by suppressing LH and FSH
209
Q

If a woman is diabetic, what should you advise if they are using injectable contraception?

A
  • Insulin requirement alter on initiation of depo-provera

- Advise close monitoring of blood sugar

210
Q

List some advantages of injectable contraception (depo-provera).

A
  • Effective & reversible with little user dependence
  • May help PMS symptoms, ovulation pain and painful, heavy periods
  • 55% women are amenorrhoeic after 1 year.
211
Q

List some disadvantages of injectable contraception (depo-provera).

A
  • 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
Q

Describe the principles behind the contraceptive implant.

A
  • 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
Q

List the advantages of using the contraceptive implant.

A
  • Low dose, long acting (3 years), reversible
  • No oestrogenic side effects
  • Minimal medical intervention (insertion and removal)
  • Decreased dysmenorrhoea & menstrual blood loss
214
Q

List the disadvantages of using the contraceptive implant.

A
  • Irregular bleeding
  • Requires minor op for insertion and removal
  • Occasional discomfort
  • Rarely: infection at site
215
Q

Explain the principles behind the Copper Coil (IUD) for use as a contraceptive device

A
  • 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
Q

List the advantages of an IUD (Copper coil) for use as contraception.

A
  • Long term (5-10 years)
  • Reliable, reversible
  • Effective immediately
  • Effective as emergency contraception
217
Q

List the disadvantages of an IUD (Copper coil) for use as contraception.

A
  • 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
Q

Explain the principles behind the Intrauterine contraceptive system (IUS) (Mirena).

A
  • 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
Q

List the advantages of the Mirena coil.

A
  • 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
Q

List the disadvantages of the Mirena coil (IUS).

A
  • 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
Q

Female sterilisation is a permanent method of contraception. List the advantages of this.

A
  • Highly effective
  • Immediately effective
  • Permanent
  • No hormonal effects.
222
Q

Female sterilisation is a permanent method of contraception. List the disadvantages of this.

A
  • Surgical procedure
  • General anaesthetic
  • Not easily reversible (not reversible on the NHS).
  • Associated complications
223
Q

Give 2 short term and 3 long term complications of female sterilisation.

A

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
Q

Explain the principles behind Essure (hysteroscopic sterilisation) as a method of permanent contraception.

A
  • 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
Q

Give 4 advantages of a vasectomy as a method of contraception.

A
  • Safe & effective
  • Permanent
  • Minor operation under local anaesthesia
  • Can be done by GP or a clinic
226
Q

Give 3 disadvantages of a vasectomy as a method of contraception.

A
  • Not easily reversible (not reversible on the NHS).
  • Not immediately effective (2 negative semen analyses required).
  • Associated complications
227
Q

List 3 short term complications arising from a vasectomy

A
  • Local anaesthetic reaction
  • Wound infection
  • Failure to achieve azoospermia
228
Q

List 5 long term complications arising from a vasectomy.

A
  • Sperm granulomas
  • Chronic scrotal pain
  • Sperm antibodies
  • Late recanaliation
  • Regret
229
Q

Explain how emergency contraception works.

A
  • Progesterone only (Levonelle, EllaOne)
  • Decreases viability of ova, decreases sperm numbers, and may prevent implantation
  • Does not dislodge an implanted embryo
230
Q

What advice should you give someone who’s just used emergency contraception?

A
  • 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
Q

List the advantages of hormonal emergency contraception.

A
  • 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
Q

List disadvantages of hormonal emergency contraception.

A
  • Associated N&V
  • Can disrupt menstruation, causing inter menstrual bleeding
  • Does not protect against STIs.
233
Q

Explain the use of IUD in emergency contraception.

A
  • 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
Q

List the advantages of non-hormonal emergency contraception.

A
  • 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
Q

List the disadvantages of non-hormonal emergency contraception.

A
  • Can be painful to insert, especially if a primi.

- Increased risk of PID.

236
Q

Explain the principle of ‘confidentiality’, as applied to sexual health.

A

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
Q

What questions should you consider asking in a sexual health history?

A
  • 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
Q

When taking a sexual Hx, what focussed questions should you ask i) females and ii) males?

A

i) Female:
- Menstrual Hx
- Pregnancy Hx
- Contraception
- Cervical cytology Hx

ii) Male:
- When last voided urine

239
Q

If you are carrying out a genital examination of a woman, which areas should you look at?

A
  • Vulva
  • Perineum
  • Vagina
  • Cervix
  • Bimanual pelvic examination
  • Possibly: anus & oropharynx
240
Q

If you are carrying out a genital examination on a male, which areas should you look at?

A
  • Penis
  • Scrotum
  • Urethral meatus
  • Anus & oropharynx in MSMs.
241
Q

What investigations should be conducted for i) female and ii) male screening for asymptomatic STIs?

A

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
Q

What investigations should be conducted for asymptomatic STI screening of Men who have sex with Men (MSM)?

A
  • 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
Q

Give examples of STI presentations in females

A
  • 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
Q

Give examples of STI presentations in males.

A
  • 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
Q

What investigations should be conducted in a symptomatic (of an STI) female?

A
  • 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
Q

What investigations should you conduct in a symptomatic (of STI) heterosexual male?

A
  • Urethral swab for slide + Gonorrhoea culture
  • First void urine for Gonorrhoea + Chlamydia NAAT
  • Dipstick urinalysis (if has dysuria)
  • Blood for STS + HIV
247
Q

What investigations should you conduct in a symptomatic MSM (male who has sex with men)?

A
  • Test as for asymptomatic MSM
    • urethral and rectal slides
    • urethral, rectal and pharyngeal culture plates.
248
Q

Who should you consider for Hepatitis B screening?

A
  • 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
Q

Why should we treat partners of people diagnosed with STIs?

A
  • 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
Q

Give a definition of ‘screening’.

A

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
Q

List the key steps of the screening pathway for screening to be effective.

A
  • 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
Q

Explain what screening can and cannot do.

A

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
Q

What pre-test information should be given to women?

A
  • 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

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