Obs&Gynae Flashcards
Based on Dr Clarke
1
Q
What’s the best way to measure a baby’s gestational age Measuring what?
A
Doing an ultrasound at 12/40. Measuring CRL = Crown rump length
2
Q
Define Nulliparous, multiparous and primigravid
A
Primigravid first ever pregnancy G1P0 Nulliparous, no deliveries of babies >24/40 Multiparous, has had deliveries of a baby(ies) >24
3
Q
Whats parity and gravity?
A
Parity is the number of babies delivered older than 24/40 Gravity is how many times a woman has been pregnant
4
Q
What is Nagele’s rule?
A
LMP (First day) - 3 months +1 year +7 days
5
Q
When are screening tests offered?
A
Booking in 1st trimester: USS and hCG and PAPP-A @ 10-13 weeks and detection rate 85% (dec. to 80 after) Late bookers: Quadruple testing (14-20) -> AFP, hCG, Inhibin A, unconjugated oestriol
6
Q
Which disorders is AFP raised in?
A
Down’s, spina bifida, liver condition
7
Q
What happens when the down’s screen is positive?
A
Amniocentesis (15+w and lower risk)/chorionic villous sampling (11-14w) 1 in 9 have Down’s
8
Q
Risks of Breech presentation?
A
Cord prolapse, difficulty delivering head, fetal hypoxia , increased fetal morbidity and mortality
9
Q
Describe external cephalic version
A
Uterine relaxants given, Fetal HR monitored. 50% success rate. Emergency CS in 1:200 cases.
10
Q
CIs to external cephalic version
A
Previous CS, <37w gestation, Placenta praevia, Fetal/uterine abnormality, multiple pregmnancy
11
Q
Reasons for large foetus during dating scan?
A
Wrong dates, big baby (macrosomia), Poluhydramnios or both
12
Q
Detection of Polyhydramnios (PH)
A
Inc. symphysiofundal height, tense cystic uterus (fetal parts hard to feel), Amniotic fluid index, Pool depth >18 indicates PH
13
Q
Causes of PH
A
Idiopathic in 60%, Maternal (Diabetes, infection) in 20 and Fetal in 20% of cases
14
Q
Mechanisms of PH
A
Swallowing probs (upper GI atresia, anencephaly) Polyuria in maternal DM HF due to structural defect Anaemia/HF - Rh Immunisation, Parvovirus Twin twin transfusion syndrome (1 HF)
15
Q
Risks of PH
A
Placental abruption Pretty unusual lie Premature labour Prolapse of cord Postpartum haemorrhage Perinatal mortality
16
Q
Stages of labour
A
First - from onset of painful contractions to full dilatation Latent -> up to 4cm Active -> 4-10cm Takes 5-8hrs multi < primi Second - From full dilatation to delivery - up to 1hr in multi, 1-2 hrs in primi Third - from delivery of infant to delivery of placenta -up to 30 min
17
Q
Causes of failure to progress in 1st stage
A
Epidural, abnormal presentation, dehydration, stress, Primiparous
18
Q
7 stages of Mechanism of labour and delivery
A
Every - Engagement in transverse position Decent - Descent of head into pelvis Female - Flexion In - Internal rotation of head into pelvis England - Extension of head during delivery Rules - Restitution ie external rotation Lovingly - Lateral Flexion of head to deliver shoulders
19
Q
4Ps main indicators for induction
A
Post-dates (41-42 weeks) Pre-labour rupture of membranes (inc infection risk) PROM Pre-eclampsia Plus diabetes
20
Q
What is membrane sweeping
A
Finger passed between cervix and membrane, thought to invoke hormone regulation; may help avoid induction
21
Q
3 stages of induction
A
Stage 1: Ripening of cervix - using Prostin Pessaries - soften and shorten cervix and cause uterine tightening Stage 2: Amniotomy - artificial rupture of membranes with amnihook Stage 3: Intravenous oxytocin to generate uterine contractions (Syntocinon) - 3-4 strong contractions/10min
22
Q
How do you counteract Uterine Hyperstimulation
A
with Terbutaline - beta adrenergic receptor antag. which relaxes myometrial smooth muscle and opposes Oxytocin.
23
Q
Treatment for dysmenorrhea? and for heavy bleeds?
A
Mefenamic Acid, transexamic acid
24
Q
Indicate the approximate time for the following Anomaly Scan Dating Scan Rhesus Immunisation Screening Oral Glucose tolerance test for @risk mom Onset of Gestational HTN Quadruple screening test for downs Combined screening test for Downs
A
Anomaly Scan - 20/40 Dating Scan - 11-13/40 Rhesus Immunisation - 28+34/40 Screening Oral Glucose tolerance test for @risk mom - 24-28/40 Onset of Gestational HTN - 24/40 Quadruple screening test for downs - 14-20/40 Combined screening test for Downs - 10-13/40
25
When is gestational diabetes most likely to start and what happens postpartum(PP)
2nd trimester (no micro/macrovasc comps) higher risk for more GD or DM2 in the future, though may revert to normal PP. Give lifestyle advice.
26
Name Diabetes Risks (SMASH)
Shoulder dystocia Macrosomia Amniotic fluid excess Stillbirth HTN and hypoglycaemia Miscarriage and cong. malformations (DM) Polyhydramnios
27
Effects of pregnancy in pre-existing diabetes
Inc insulin requirement Acc. of retinopathy Deteriorating renal function Maternal hypoglycemia early on
28
Management of preexisting diabetes
Refer to Diabetes clinic, pre-conception counseling, monitor vasc comps, early viability and detailed anomaly scan. Special growth scans.
29
Screening eligibility for Gest. Diabetes
Obesity Previous GD Previous large baby Fhx Previous unexplained stillbirth Polyhydramnios and large for dates
30
Shoulder dystocia maneuvers
McRoberts (flex and externally rotate hips, Suprapubic pressure, episiotomy
31
In pregnancy, what BP would cause you concern?
160/90
32
Main causes of HTN and what percentage of pregancies?
Pre-eclampsia, pre-existing, gestational 10%
33
Define Pre-eclampsia
HTN and proteinuria in 2nd trimester
34
Complications of pre-eclampsia?
still birth, premature delivery, fetal growth restriction Placental abruption, eclampsia, HELLP, DIC, Death
35
Explain pre-existing HTN
Uncommon; 1/3 may turn into pre-eclampsia. Dx before 20/40 or before conception. Careful monitoring required
36
Gestational HTN
\>20/40; BP\> or =140/90; usually resolves 2 weeks PP
37
Pre-eclampsia What is it, when, how does it progress?
Disease of placenta, onset after 20 w. Resolves after delivery. HTN +/\>140/90 first, then proteinuria \>300 and variable oedema (hands, face, ankles...)
38
Normal placentation
Early blastocyst attachment -\> trophoblast invades myometrium (lacunae) -\> chorionic villi surrounded by maternal blood -\> 2nd trophoblast invasian causes despiraling of maternal spiral arteries - high blood flow
39
Pre eclampsia Placentation
Failure of 2nd trophoblast invasion -\> no spiral artery remodeling - high R, low flow placenta -\> vasospasm and endothelial dysfunction
40
Risk Factors for pre-E
precious Pre-E - 5% recurrence 1st or twin pregn. Anti-PL syndrome Chronic HTN, renal dx Obesitym smoking Fhx
41
Treatment of pre-E and drugs used
treat BP \<160/90 (prevent stroke) until 6w PP Delivery of placenta is key Labetalol NOT IN asthma, small for dates Methyldopa NOT IN depression Nifedipine Caution in CV probs NOT ACE-i - cong malformations or DIURETICS - red. maternal plasma volume
42
4 RED FLAGS pre-e -Symptoms -Signs
- Headache - visual disturbance - epigastric or RUQ pain - SOB - periorbital oedema - hyperreflexia - clonus - fits
43
What are the "Pre-eclampsia bloods"?
FBC - dec platelets Low Hb - Hemolysis with HELLP U&E raised Urate raised AST raised
44
What is monitored in Pre-e?
Sx, BP, urine; fetus; umbilical artery flow, bloods
45
Emergency mx - Pre-e
ABC - oxygen, intubation Turn pt onto side Control fits with IV magnesium sulfate Control htn with IV labetalol/hydralazine
46
HELLP - what is it and what are the complications
Haemolysis, Elevated Liver enzymes, Low platelets. Microangiopathi hemolysis. Risks are DIC, renal failure, low platelets
47
Pre-e timing of delivery; what about steroids, CS?
34+w if possible; use maternal steroids up to 34w. Delaying delivery by 24hrs to give steroids red. fetal mortality by 50% CS: high BP, renal/hep probs, fetal distress
48
Eclampsia: what is it and how do you manage it?
Tonic-clonic seizures - before during or after delivery. obstetric emergency; O2, Mg Sulfate, IV hydralazine/labetalol; monitor fluids.
49
What does dichorionic mean?
Two placentas
50
What are the complications of twin pregnancies
Prematurity IUGR TTS Emergency Cs HTN, anaemia, Polyhydramnios, acute fatty liver, placnta praevia Increased risk of abruption, Cord prolapse, Increased perinatal mortality
51
Define Zygosity, chorionicity and Amnion
Zygosity = egg # Chorionicity = placenta # Amnion = inner layer of fetal membranes
52
What about dizygous twins
Always dichorionic; no anastomoses; show thick dividing membranes and Lambda sign (triangle between sacs)
53
Monozygotic twins
dichorionic - approx 1 in 3 monochorionic/diamniotic (4-8d) - 70%; monoamniotic (8-13 days) - 30% and highest mortality Conjoined twins in case of 2 week-division Thin membrane and T sign!
54
Twin preg. antenatal care
early dx, frequent visits, high folic acid and iron, recognize and mx preterm labour. watch for HTN/pre-E
55
Explain the Twin-twin transfusion syndrome and side effects for both twins
In monochorionic twins which share intraplacental anastomoses (circulation) Umbilical artery of donor twin feeds the vein of the recipient Develops in 20% Varies in severity and may need lasering of vessels. Donor twin: Anaemic, growth restriction, Hypotension, Oligohydramnios Recipient twin: Polycythemic, Hypertensive, cardiac hyertrophy, Oedema, Polyhydramnios.
56
Definition of SGA (Small for gestational age)
A newborn with the birth weight \<10th percentile for gestational age. For fetus its the estimated weight.
57
Aetiology of SGA - types (SWAN)
Starved small (IUGR) - asymmetric (abdomen more) Wrong small - dating wrong Abnormal small - chomosomal, structural, infection, genetic Normal small - genetic, constitutional
58
Causes of IUGR
Multiple pregnancies, multiple fibroids, uterine anomaly, Maternal diabetes, Pre-E, Drugs and Alc, Placental dysfunction
59
Define IUGR
A fetus that has failed to achieve its genetic growth potential Perinatal mortality rate increased by up to 10 fold
60
Early complications vs later ones?
Early: Hypoglycemia, Plycythemia, NEC, Prematurity complications (neonatal death, RDS, intaventricular hemorrhage) Late - Cognitive delay, cerebral palsy - Chronic adult diseases ie metabolic syndromes
61
How do you identify high risk pregnancies for IUGR
(SWAN) SHIT Smoking HTN IUGR previously Twins USS Dating, Low threshold for growth scans. Risk reduction and optimise medical conditions, screen for pre-E, serial growth scans
62
Management of IUGR
Give steroids between 24-34 weeks to reduce risk of NEC, RDS, IVH. Induction or CS; deliver from 34/40 onwards.
63
What's the percentage of pre-term (PT) labour in the UK? What are its risks?
7-10% Cerebral palsy, most common risk factor is prematurity Mortality and morbidity inc the earlier delivered.
64
Risk factors causing PT labour
Multi-fetal pregnancy Previous hx or miscarriage More common after cervical surgery
65
Causes of PT labour
Stretch of myometrium and fetal membranes Weak cervix Ascending infection
66
Screening to prevent preterm labour
Cervical length measurement, for those with previous PT delivery or late misc.
67
Treatment to prevent PT labour and when its happened
Cervical stitch, Progesterone tx If viable, consider steroids, tocolysis and specialist care. Tocolysis only if membranes not ruptured.
68
PPROM what is it and what should we do?
Preterm Prelabour rupture of membranes. A clinical syndrome ass. with SROM but no contraction - only induce if \>34 w or infection apparent.
69
What does abruption mean? Percentage? Risk factors? Symptoms and signs?
Premature separation of placenta from uterus. 1%, Rx are smoking, previous hx, HTN, thrombophilia, cocaine, trauma. Sx: Dark red blood, Abdo pain, contractions (irritated) Shock, uterine tenderness, woody, uterus, fetal distress -\> death
70
What is the typical presentation of bleeding from a placenta praevia and what is it? Percentage at term Complications and Rx
Placenta implanted in the lower segment (minor vs major) Painless bright red vaginal bleeding. - Placental abruption usually dark red. Severe bleeds \> shocks. Fetus often unaffected. Major PPs delivered at 39 wks with CS, minor may do with vaginal. 0,5% at term, preterm is more common. Position of placenta assessed with USS may cx fetal malpositioning Rx previous Hx or surgery
71
What is a placenta accreta?
Placenta implants in previous CS scar. Past basalis layer into myometrium
72
Name the main causes of PP Haemorrhage
Tone - Atonic uterus (rub up contraction, syntometrine) Tissue - retained placenta Trauma - vaginal/cervical tear Thrombin - DIC...
73
Initial mx of lady with PPH
ABC - 2 large bore cannulas Bloods - FBC & Clotting Blood and Fluid replacement Initial Management of underlying cause
74
Presentation: 1.Painless vaginal bleed 2.Post coital bleed 3.Vaginal spotting, vulval irritation, discharge 4.Painful contractions, loss of blood stained mucus 5.Painless vaginal bleed - fetal death 6.Severe constant abdo pain, vaginal bleed
Path: 1.Placenta Previa 2.Cervical ectropion 3.STI 4."Show" 5.Vasa praevia 6. Placental abruption
75
Causes of antepartum haemorrhage (bleeding after 24/40)
Uterine - Pl. abruption or praevia, Vasa praevia, marginal blood Cervical - show - loss of mucus plug from cervix, cervical cnx, polyp or ectropion Vaginal - Trauma, infection
76
Vasa praevia - what is it
Placental vessels run over cervical os in the membranes (rare) Labour/ruptured membranes can cause catastrophic fetal exsanguination (fetal blood pumped into uterus) Dx with USS, often missed - elective CS (Haemorrhage indication for emergency CS) --\> poor progn for baby.
77
Rhesus neg women
give anti-D at 28&34 weeks to avoid Fetal hemolysis in Rh+ baby
78
Trichomonas Vaginalis - Sx, Tx, Incubation
Common STI Flagellated protezoon Incubation 103 wks Frothy green/grey discharge strawberry cervix Tx - METRONIDAZOLE
79
Differentials for vaginal discharge with fishy smell
Bacterial vaginosis Retained tampon trichomonas
80
PP Contraception what to avoid Explain Lactational amenorrhea method, effectiveness.. Long Acting Reversible Contraception
Contraception not required in FIRST 21 DAYS may be started if woman wishes earliest ovulation in non-breastfeeding woman is 28 days AVOID IUCD - inc isk of perforation, avoid COC in first 21 days bc of DVT risk, may inhibit lactation. Lactational amenorrhea method 98% effective \<6m fully breastfeeding. Protection reduced if dec. BF or period starts If not BF, can use COC from day 21 Long Acting Options Copper coil (Day 28, lasts 10 y) Mirena (Day 28, lasts 5 y) Progesteron implant (anytime) Injectable (anytime if not BF)
81
How may PCOS present clinically and on scans.
1) Subfertility/dysmenorrhoea 2) Clinical signs of hyperandrogenism (Acne, hirsutism, alopecia) USS - String of pearls appearance -- 10% have this appearance at any one time because of the pearls not being true cysts but multiple follicles. w
82
What are the tx options for PCOS?
Metformin for dec. insulin resistance COCP for dec. testosterone Clomifene for Ovulation induction
83
Other causes for 2ary amenorrhoea
PCOS, Pregnancy, Prolactinoma, Premature ovarian failure GnRH deficiency (stress, weight change, kallman's) Pituitary tumour or necrosis (sheehan's syndrome) Imperforate hymen, vaginal septum, cervical stenosis, absent uterus
84
What criteria are used for PCOS
Rotterdam criteria - SHOP; need 2/3 String of pearls Hyperandrogenism Oligomenorrhoea Prolactin normal (excl. prolactinoma)
85
Pgx of PCOS?
disease of the arcuate nucleus (hypoth.) Abnormal GnRH pulse generator (pulse every 60 instead of 90min) normally theres a cyclical switch but in PCOS it stays at 60min, meaning there is an increase in LH:FSH from 1:1 -\> 2:1 Inc. LH causes inc. androgens, but red. aromatase and oestrogen activity so not LH surge (anovulatory cycles)
86
Define 1ary and 2ary amenorrhoea
1ary - failure of menstruation by 16 years in presence of otherwise normal secondary sexual characteristics 2ary - absent periods for at least 6 months in a woman who had previously regular periods or 12 months in a woman who had irregular periods
87
Investigations for amenorrhoea
Pregnancy test, TFTs, LH/FSH, testosterone, USS
88
Whats the problem if LH/FSH raised? ....reduced? increased LH/FSH ratio?
raised: Ovarian failure reduced: hypothalamic failure ratio inc.: PCOS
89
Treatment of amenorrhoea?
Gonadotropin def.: COCP if no preg.; replacement for preg. Ovarian failure: Sx relief with COCP/HRT, use egg donation for preg.
90
whats the commonest std?
chlamydia- 5% of \<25y olds, national annual screening test until 25
91
Presentation of chlamydia? Treatment
Incubation 1-3 weeks; 50%men and 75% women are asymptomatic; other sx are dysuria and discharge. Intermenstrual/post-coital bleeding, Ascending ingection (acute salpingitis or PID) Implicated in about 75% of ectopics and 75% cases of tubal infertility Single dose azythromycin or doxycycline for 7 days Erythromycin in pregnancy
92
Life cycle of Chlamydia
Elementary bodies attach to sperm Enter columnar epithelium of enficervix reticulate bodies -\> inclusion body in cytoplasm (cloak around nucleus) Infectious EBs released with cell lysis (detect with PCR)
93
Subfertility - definition and 1ary vs 2ary
A failure to conceive after 12 months of regular unprotected sex (affects 10-15% of couples) 1ary - female partner has never conceived 2ary - the female partner has conceived previously
94
What is endometriosis? Is it common?
Ectopic tissue found outside uterus (most commonly pelvic peritoneum) - 1-2% of women
95
What percentage of uteruses are anteverted?
90%
96
Pathogenesis of endometriosis?
Theory of retrograde menstruation (flows to fallopian tube); Most women’s immune system clears endometrial cells, but in some, expression of endoth. GF stim. implantation, angiogenesis - lungs rectum possible
97
How does endometriosis cause pain?
Deposits thicken cyclically, so pain worsens before and at onset of period. Chronic inflammation —\> scarring and grey/white appearance. ‘Frozen’ Pelvis. Endometriotic chocolate cysts
98
Sx and Sx of endometriosis?
Lesions often asymptomatic - poor correlation between Sx and laparoscopic findings; Pain: dysmenorrhea, deep pareunia and chr. pelvic pain. Subfertility, rectal and bladder involvement, haemoptysis, umbilical bleed. Signs: Tenderness, mass, fixed pelvic organs, nosules.
99
Endometriosis - buzz word
The uterus is fixed in retroversion - fibrosis of uterosacral ligaments +shrinkage
100
Diagnosis of endometriosis
Laparoscopy, biopsy, CA-125 may be slightly raised
101
Endometriosis Mx?
Symptomatic relief, prevent hormonal stim. (COC, Progestogens, Mirena, GnRH analogues, oophorectomy), laser excision; surgery (only tx in case of subfertility)
102
Why wait 12 months? Subfertility
Chance of reproduction per cycle is approx 14% After 12m 84% of couples conceive, after 24m 92% of couples conceive
103
Three areas of causes for subfertility
Anovulation (30%), Tubal (20%), Male factor (25%) In 25% no cause is found. Couples may have more than one problem.
104
Causes of anovulation
Anywhere along HPO axis H- Stress, anorexia, weight loss P - Prolactinoma, necrosis O - PCOS, ovarian failure
105
Tubal disease causes and dx
PID (commonest - chlamydia) Endometriosis Surgical adhesions 1st line - histerosalpingogram (fill and spill) Gold standard: Lap and dye test
106
Causes of male factor subfertility
Azospermia, oligospermia, Teratozoospermia, asthenozoospermia Absent, few, excess abnormal, immotile Hypothalamic Testicular - orchitis, Klinefelters, orchidectomy, rtx, tumours
107
Investigation of subfertile couple
Female - tubal patency assessment (HSG, Lap and dye) Male semen analysis - count, motility, normal forms Assessment of axis - Prolactin, FSH/LH, Oestr., Test., D21
108
Treatment for subfertility
Lifestyle - wt loss, smoking cessation, red. caffeine and alcohol Intercourse 2-3x/wk Anovulation - stimulate using Clomifene, LH/FSH, GnRH, assisted reproduction Premature ovarian failure - egg donation and IVF Tubal damage - tubal surgery or IVF Male factor - assisted reproduction
109
What are assisted reproduction treatments licensed by the HFEA? Live birth rate?
Intrauterine insemination In vitro fertilisation Intracytoplasmic sperm injection 10% live per cycle IUI 25% per cycle for IVF/ICSI multiple pregnancy rates at 24% so only 2 embryos currently implanted per cycle
110
Causes of bleeding in early pregnancy
Normal Miscarriage Ectopic
111
Define ealy pregnancy loss
Loss within the first 12 weeks of pregnancy, increased morbidity (psych and physio) significant associated mortality
112
Define spontaneous miscarriage
Loss o intrauterine pregnancy before 24w. 80% in first 12 weeks 1 in 5 pregnancies \>24w --\> intrauterine death
113
Aetiology of miscarriage Causes and risk factors
Fetal chromosomal in 50%, unknown otherwise Risk factors: Maternal medical conditions (DM,SLE/APS) Environmental (inc mat. age, obesity, smoking, alc, cannabis) Anatomical - uterine anomalies Infection - Listeria, toxoplasmosis, varicella zoster, malaria
114
Main types of miscarriages
Threatened - Vaginal bleed+- pain; Os closed; viable pregnancy Inevitable - Bleeding usually heavier, pain - Os open, POC may be seen Incomplete - Ongoing pain and bleeding, Os open, POC may be seen - RPOC Complete - Bleeding and pain diminishing, Os closed, uterus small for dates, No RPOC Delayed/missed/silent: Brown loss, minimal pain, Os closed, empty sac: body's rejection of dead fetus delayed- often USS diagnosis at booking scan. Empty gestational sac or fetal pole with absent HR
115
How does USS scan help a miscarriage diagnosis
confirms location of pregnancy Demonstration of fetal HR is associate with successful pregnancy in 90% Visualise adnexa
116
Lab investigations for miscarriage
FBC, Blood Group, Rhesus, b-HCG
117
Management of miscarrriage
Conservative watch and wait Medical - antiprog. (mifepristone eases placenta from wall) followed by prostaglandin (misoprostol opens cervix) Surgical - ERPC (dilation and curettage/evacuation) Give anti-D if Rh-ve Info - Counseling - pregnancy loss/bereavement - Miscarriage association - advised to wait for one period before trying again when they are psychologically ready - emphasise probable success - Folic acid, healthy diet, smoking cessation
118
What's an ectopic pregnancy
Conceptus plant outside the uterus or in an abnormal position within the uterus (95% tubal) Incidence increasing in the UK in the last decade: 10 per thousand pregnancies Approx 10 women die every year (bleeding)
119
Risk factors for ectopic pregnancies
PIPPA Previous ectopic IUCD PID Pelvic/tubal surgery Assisted reproduction
120
Classic triad (not always present)
Pain and Bleeding after Amenorrhoea +ve pregnancy test
121
Why do you get shoulder pain with an ectopic? Examination - what signs to look for? What tests
The blood irritates the diaphragm Shock, pain, distended abdomen Fit young woman can lose up to 40% of their blood volume without sx; tachy -\> hypotension FBC, TVUS, blood group, b-hcg (suboptimal rise in b-hCG)
122
Diagnosis and management of ectopic pregnancies
\<25% of women come in with collapse and abdo pain Inc. number dxed with USS Discriminatory zone = level of b-hcg at which intrauterisne pregnancy should be seen on USS Conservative Medical: methotrexate Surgical: Laparotomy/ laparoscopy Salpingectomy vs -ostomy Removal (of ectopic or tube) Dont forget post-pregnancy loss counselling
123
What's the cause of pregnancy of an unknown location
early intrauterine pregnancy, failing inta/extrauterine pregnancy, ectopic.
124
Define dysfunctional uterine bleeding
Abnormal uterine bleeding in the absence of any organic disease
125
How does transexamic acid work?
Anti-fibrinolytic, dec. blood loss by 50%
126
Main indications for using an IUD (3)? Esp. Mirena. Main contraceptive mechanisms of Mirena
1) Contraception 2) Primary menorrhagia 3) Endometrial protection during HRT - thickens cervical mucus, creates thin endometrium (unfavourable towards implantation), may inh. ovulation
127
Explain a molar pregnancy
Can be benign or malignant (choriocarcinoma, invasive mole); benign is divided up into complete - empty ovum with sperm penetrating, female Partial - 2x sperm, 1xegg, male Surgical removal, BHCG measuring - try again when at 0
128
What is menorrhagia, how common is it?
Commonest presentation at the gynae clinic; accounts for most hysterectomies Defined as \>80 mL blood loss per period/excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life
129
Causes of menorrhagia? Investigations
PERIODS PID Endometrial carcinoma Really bad hypothyroidism IUD Ovarian cancer Dysfunctional uterine bleeding Submucosal fibroids FBC ON ALL WOMEN WITH MENORRHAGIA - anaemia TFTs, vWF USS if suspicion
130
Who gets dysfunctional uterine bleeding, how is it diagnosed?
Commonly young teenagers and premenopausal women. typically irregular heavy bleeds. Dx of exclusion- normal Pelvic exam, no pregnancy or systemic disease Probs with luteal phase -\> anovulatory cycles
131
Fibroids - presentation, what are they
Commonly cx of menorrhagia; benign tumours of uterine smooth muscle. Protrude into uterine cavity inc. surface area from which one bleeds Can put pressure on surrounding organs. Malignant transformation rate \<1%
132
When is endometrial biopsy indicated?
Intermenstrual bleeding, \>45 yo, resistant to tx. to exclude endometrial cancer/hyperplasia
133
How is menorrhagia managed?
Depends on ass symptoms, desire for fertility, fitness for surgery... Medical - non-hormonal: Transexamic acid (2x500mg TDS), NSAIDs (metemamic acid) Hormonal: Mirena, COCP, progesterone only C., Progestogens Surgical: Fertility - myomectomy, uterine artery embolisation Non-fertility - endometrial ablation, hysterectomy
134
What would a history of prolapse sound like
Sensation of fullness, chafing, something coming down. Sexual dysfunction, GU (ass. stress incontinence) and GI symptoms Caused by Chronic raised pressure, COPD, constipation Ask about bowel symptoms, rectocoele may cause defaecation probs- Digitate to defaecate
135
Types of prolapse?
Urethrocele (urethra&bladder neck prolapse) Cystocoele Utero-vaginal prolapse - pelvic organ/middle compartment prolapse - Grade 1-3 (halfway down, as far as and beyond introitus) - POP-Q Rectocoele
136
Treatment of prolapse?
conservative - wt loss, pessary surgical - repair (ie anterior) or total vaginal hysterectomy with vault suspension
137
Type of incontinence - ever since I've had my babies its been getting worse, I can't run for the bus as I leak
Stress
138
Define stress, urge and mechanical incontinence
Stress - involuntary leakage on effort, exertion, sneezing.. Mx with pelvic floor exercises Urge- involuntary leakage accompanied by urgency Mx with antimuscarinics Mechanical - can't get to toilet fast enough ie cause bedbound...
139
Stress incontinence, what are buzz words and mx
- funnelling of bladder neck, urethral hypermobility Start tx at first appointment - PFME for 6m (Duloxetine helps muscle strength), then maybe surgery -\> retropubic mid-urethral tape; colposuspension
140
Buzz words for urge incontinence
Urge incontinence is suggestive of detrusor overactivity -\> clinical syndrome is "Overactive bladder syndrome" Detrusor overactivity is the urodynamic finding
141
Investigations for urge incontinence, management
Bladder diary for a minimum of 3 days covering work and leisure - times of micturition and volumes voided, pad usage and incontinence, fluid input Lose wt, avoid caffeine and alcohol Bladder training - use diary, then increase time between voiding, high motivation needed Antimuscarinics (oxybutinin) comb. with bladder training Side effects - dry mouth, blurred vision, diarrhoea, constipation... Occasionally can cause overflow incontinence; 30% discontinue it within 3m Botox, sacral nerve stimulataion
142
Urodynamics explained
not recommended for conservative thx but before surg. only if suspicion of detrusor overactivity, previous surgery for stress incontinence, or incomplete bladder emptying suspected Probes in bladder and rectum Voiding in front of investigators(cystometry) Instilling bladder with normal saline Pt tells investigators about urge, also coughs etc. Substraction cystometry
143
Red Flags for carcinomas
Intermenstrual bleeding - \<45 -\> chlamydia but \>45 - need to exclude endometrial carcinoma post-coital or postmenopausal bleeding
144
What's an ectropion?
Everted columnar Endocervix (due to hormonal stimulation)
145
What are triple swabs?
2x endocervical for chlamydia and gonorrhoea 1x high vaginal
146
Endometrial carcinoma, symptoms, prognosis
Presents early with abnormal bleeding - ie postmenopausal - otherwise also intermenstrual bleeding, postcoital bleeding, pelvic mass Presents early in 80% of women - good prognosis (75% 5y survival
147
Explain the unopposed oestrogen hypothesis and RFs
Unopposed oest. leads to endom. hyperplasia -\> malignant transformation - the more oestr in life the worse the risk (Nulliparity and obesity) RFs: Age, nulliparity, early menarche, late menopause, obesity, HRT, tamoxifen, COC protects Chronic anovulation - never shed endometrium, hyperandrogenism
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Endom. cx Associated with?
NOT BRCA genes Ass with breast cancer as shared risk factors
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Endom cnx investigations, staging and tx.
USS endometrial pipelle, hysteroscopy and enfometrial biopsy, MRI S1- uterus S2 - cervix S3 - adnexa, vagina, nodes S4 - distant mets Total abdo hysterectomy and bilat. salpingo-oophrectomy +/- radiothx
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How does carcinoma of the ovary present?
Non-specific bloating, ascites causing swelling) abdom pain late with adv. disease - poor prognosis (25% 5y survival) consider uss for any woman over 40; if identified early, surv. rate is 90% very occasionally bleeding if tumour secretes hormones
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Risk factors for ovarian cancer?
anything increasing ovulatory cycles as well as BRCA genes (1\>2)
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What's the most common type of ovarian tumour?
Epithelial; 90% others are Germ Cell tumours (pre-menopausal, dysgerminoma, immature teratoma), and Sex cord tumours (stroma of ovary, secrete oestr., postmen. women, granulosa cell tumours)
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Which lymph nodes drain the ovary
Para-aortic nodes - involvment implies stage 3. bc no other ducts before thoracic, quick metastasis ad stage 4 progression.
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Treatment and prognosis of ovarian cancer
Surgery - debulking for advanced disease, pelvic clearance for early disease. neoadjuvant chemotherapy with taxane and cysplatin Stage I - 90% 5ys Stage IV - 5% 5ys 60% present with adv. disease
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What are the risk factors of cervical cancer?
Early sexual activity, multiple partners, immunocompromised -- Infection with HPV (95%) --
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What is the most common histiological type of cervical cancer?
Squamous cell carcinoma (90%)
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How does cervical cancer spread?
local - parametrium+ upper vaginal -\> walls of pelvis -\> distant spread - rectum, liver, bladder
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Whats the epidemiology of cervical cancer?
Worldwide 2nd most common female malignancy after breast cnx. In the UK its the third most common gynaecological malignancy behind ovarian and endometrial most commin between 45 and 55
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Warts and types of HPV Verrucas Warts Plane warts Genital warts
often asymptomatic, targets deep basal layer 1&2 2&7 3&10 6&11 MAINLY
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HPV Facts
45% of vaginal swabsat 20-24 have evidence of hpv but 90% clear it within 18 months 16 and 18 MOST LIKELY to progress to CIN Cervical screening bc dysplastic change is predictive of progression to CIN Vaccines Cervarix, Gardasil
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Treatment of CIN Followup
Excision/ destruction at colposcopu Large loop excision of transformation zone/LLETZ Cold coagulation/cryotherapu/laser vaporisation Core biopsy Repeat smears at 6 and 12m, then 4, then 3 years
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Treatment of cervical cancer
Combo of surgery, chemo and radio Radical hysterectomy Trachelectomy 5ys overall 50% with stage I being 80% and stage IV 7%
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Five year survivals for ovary cervix and endometrial cancer
ovary 25% cervix 50% endometrium 75%
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