Obs & Gynae Flashcards
1
Q
Why do contact tracing?
A
-Prevent re-infection of index case
-Identity and treat asymptomatic infected individuals
Public health measures
2
Q
What is the average age for menopause?
A
Average is 51- greater than or equal to 45 is considered normal range
3
Q
What is considered abnormal menopause?
A
Younger than 40 years premature ovarian insufficiency
4
Q
Why does HRT have progesterone as well as oestrogen?
A
Progesterone is needed to prevent over proliferation of the endometrium caused by oestrogen
5
Q
What’s the difference between gestational HTN and preeclampsia?
A
Gestational HTN = new HTN after 20 weeks of gestation >140/90 with little or no proteinuria.
Preeclampsia = new HTN as above but with high levels of proteinuria. There may be associated swelling of hands, feet and face.
6
Q
What’s the pathophysiology of preeclampsia?
A
- vasoconstriction leading to HTN
- platelet activation leading to intravascular coagulation
- endothelial dysfunction i.e. fluid shifting from vascular to interstitial compartments
- spiral arteries fail to be converted to vascular sinuses
- causes placental ischemia
7
Q
What are complications of pre-eclampsia?
A
Mum:
- CVA
- DIC
- Liver failure
- Renal failure
Bab:
- growth retardation
- early placental detachment
- death
8
Q
What is the metabolic state of pregnancy?
A
PO2 goes up
PCO2 goes down
Compensated metabolic alkalosis
9
Q
What is the DDx for acute pelvic pain?
A
Gynaecological -Endometriosis (ruptured endometrioma) -Ovarian Cyst (rupture) -Ovarian Torsion -Ectopic Pregnancy -PID -Malignancy Non-Gynaecological -UTI -Appendicitis
10
Q
Define Acute Pelvic Pain.
A
Acute lower abdomen or pelvic pain that may be constant or intermittent that lasts for less than 3 months
11
Q
Define Chronic pelvic pain.
A
Intermittent or constant pain felt with within the lower abdomen or pelvis that lasts for 6 months. It is not associated exclusively with menstruation, intercourse or pregnancy.
12
Q
What test would you do for acute pelvic pain?
A
- Urine - dipstick for signs of infection or kidney damage
- Pregnancy test - HcG if +ve but no sign of pregnancy in uterus
- Ultrasound
13
Q
What is the DDx for Chronic Pelvic Pain?
A
- Endometriosis
- adenomyosis
- PID
- STI
- Pregnancy
14
Q
What sign on bimanual examination suggests PID or ectopic pregnancy?
A
Cervical motion tenderness (cervical excitation) - Woman finds cervix being touched more painful than usual examinations.
15
Q
Define Normal labour.
A
Baby is born spontaneously in the vertex position between 37-42 weeks. Mother and baby are well.
-No medical intervention needed
16
Q
What are the 3 stages of labour?
A
1 - Dilation period - latent (up to 4cm) and active (up to 10cm)
2 - Engagement/Expulsion period from complete dilation to complete delivery - cardinal movements of the foetus
3 - After birth period
17
Q
Define Cervical Effacement.
A
Also known as cervical ripening - the cervix thins and moves up to become part of the uterine wall
18
Q
What happens during the latent phase of labour?
A
- irregular contractions
- mucoid plug is passed through the vagina
- cervix effaces
- can take 6 hours - 2-3 days.
19
Q
How does the second phase of labour differ for primiparous women and multiparous women?
A
- longer in primip women
- 45-120mins vs 15-45mins
20
Q
Why is delayed clamping of the umbilical cord recommended?
A
delay for 30 seconds helps to increase foetal haematocrit and decreased the need for transfusion.
21
Q
Define engagement.
A
When the largest part of the babies head has entered the pelvis.
22
Q
What is the process of movements does a foetus goes through when being birth?
A
- descent down to the ischial spines
- flexion head presses onto chest
- internal rotation - foetal shoulders rotate
23
Q
What happens during the 3rd stage of birth?
A
- delivery of placenta and membranes + controlling of bleeding
- routinely give syntometrine (oxytocin + ergometrine maleat) reduces third stage to <5 mins and reduces risk of post partum haemorrhage
24
Q
What’s the difference between chronic hypertension, gestational HTN and preeclampsia?
A
Chronic HTN - diagnosed pre pregnancy or before week 20
Gestational HTN - increased BP after week 20
Preeclampsia - increased BP after week 20 + proteinuria
25
What are some systemic features of preeclmapsia?
- headache
- vision disturbance
- RUQ pain - epigastric pain - hepatic ischaemia
- reduced urine output
- lower abdomen pain - placental abruption
- pitting oedema
- pulmonary oedema
- stroke
- eclampsia (essentially seizure)
- hyperreflexia
26
What are risk factors for preeclampsia?
- previous preeclampsia
- FHx
- Diabetes
- Primagravida
- Renal disease
- obesity
- connective tissue disease - RA/SLE
- already having HTN
27
What is the pathophysiology of endometriosis?
- condition where endometrial tissue grows outside of the uterus
- relapsing and remitting as tissue responds to changing levels of hormones during menstrual cycle (therefore Sx cyclical)
- Sampson's theory - retrograde menstruation carries sloughed off endometrial cells that stick to none uterine sites and grow and thicken in accordance to menstrual cycles
- endometrial patches are oestrogen dependent
28
What are the symptoms of Endometriosis?
1/3 asymptomatic
- chronic pelvic pain - worsens before meneses
- deep dyspareunia
- dysmenorrhea
- intermenstrual bleeding
- infertility
29
What sites can endometriosis implants be found?
- ovaries
- fallopian tubes
- cervix
- bladder
- less commonly - extra-pelvic organs (lungs or diaphragm)
30
How do you diagnose endometriosis?
- patient history
- physical examination - rectovaginal tenderness, adnexal masses
- TVUS - evidence of chocolate cysts
- confirmatory laparoscopy
31
How do you medically treat endometriosis?
first line - mild to moderate:
-NSAIDS + continuous hormone contraceptive
second line -severe:
-GnRH agonists - buserelin
32
How do you surgically treat endometriosis?
first line - laparoscopic excision and ablation of endometrial implants
second line - hysterectomy w/ or w/o bilateral salpingo-oophorectomy
33
Describe the pattern of pain seen in endometriosis?
- cyclical pelvic pain
- in a young woman
- low parity
- dyspareunia
- dysmenorrhea
34
How does endometriosis effect fertility?
- lowers fertility
- immune factors
- oocyte toxicity
- adhesions
- tubal dysfunction
- ovarian dysfunction
35
What are the main epidemiological differences between adenomyosis and endometriosis?
endo - young and nulliparous
| adeno - older and multiparous
36
Describe the pathophysiology of adenomyosis?
- endometrial tissue and stroma extend into the uterine myometrium
- causing diffusely enlarged and thickened myometrium
37
How does adenomyosis present?
- cyclical pain
- dysmenorrhea
- dyspareunia
38
How do you treat adenomyosis?
-hormonal suppression or removal
39
How may a fibroid present?
- asymptomatic
- heavy periods
- anaemia
- infertility
- miscarriage
40
How would you remove a fibroid whilst trying to preserve fertility?
myomectomy
41
If you suspect polyps, what must you also check for?
-histologically test for endometrial cancer because there's a close association
42
Define primary and secondary amenorrhoea.
primary - failure to start menstruating (Ix at 16 w/ secondary sex characteristics or 14 w/o)
secondary - menstrual bleeding stops for over 6 months NOT due to pregnancy
43
What are some causes of primary amenorrhoea?
w/o secondary sex characteristics:
- turner's syndrome
- congenital adrenal hyperplasia
WITH secondary sex characteristics:
-genitourinary malformation - imperforate hymen
44
What are some causes of secondary amenorrhoea?
- HPA dysfunction - stress, exercise, low weight
- hyperprolactinaemia - inhibits FSH & LH
- PCOS
- menopause
- uterine adhesions
- asherman's syndrome
45
What investigations would you do for someone presenting with amenorrhoea?
- beta HCG - rule out pregnancy
- serum free androgens - raised LH and progesterone suggests PCOS
- prolactin levels
- TFTs
46
Test results show low FSH and low LH in a woman presenting with amenorrhoea. What are you differentials?
- suggests dysfunction of the HPA axis
- stress, exercise, low weight
- hyperprolactinaemia
47
Test results show high FSH and high LH in a woman presenting with amenorrhoea. what are you differentials?
- suggests ovarian dysfunction
- PCOS
- menopause
48
What do irregular periods, being every 3-4 months, tend to indicate?
oligomenorrhoea - indicates anovulation
49
How do you treat PCOS?
NOT FOR FERTILITY Tx
- lifestyle advice - lose weight
- dianette - used for hirsutism + contraception
FERTILITY WANTED
-Clomiphene for ovulation induction
50
What's the difference between primary and secondary dysmenorrhoae?
primary = happens within 1-2 years of menarche, pain starts just before or within hours of onset of period, supra pubic cramps that may radiate
Secondary = develops many years after menarche and is the result of a different underlying pathology
51
What is the first & second line treatment for primary dysmenorrhoea?
first = mefenamic acid (NSAID)
Second = COCP if not already on LARC
52
What is the medical management of a uterine miscarriage?
Vaginal misoprostol (prostaglandin)
53
What initial assessment would you do on a pregnant woman who is bleeding?
- ABCD
- abdo exam (if painful and tender more likely abruption than praevia)
- TVUSS - diagnose praevia not abruption
- maternal bloods - FBC, clotting, cross match
- foetal heart rate with CTG
- maternal BP
54
What is the differential for a pregnant woman with antepartum haemorrhage?
- placental abruption
- placenta praevia
- vasa praevia
- low genital tracts causes (cervical polyps, vaginitis, vulval varioses)
55
How does one manage an antepartum haemorrhage? what counselling would you offer further for the birth/future pregnancies?
- offer corticosteroids (increased risk of prem bab)
- serial USS for foetal growth (increased risk of poor growth)
- C section - women with APH with associated maternal and/or foetal compromise should deliver immediately
- increased risk of post partum haemorrhage so forewarn and be prepared
56
What drug is given to shorten the length of the 3rd stage of pregnancy?
-IM syntocinon
57
How do you immediately manage a post partum haemorrhage?
- ABC
- bloods - FBC, crossmatch
- BP & HR
- bimanual compression of the uterus
- give oxytocin slowly
58
What are the 4 Ts that can cause post partum haemorrhage?
- Tone - uterine atony
- Tissue - retained placenta
- Tauma - lacerations//rupture
- Thrombin - coagulopathy
59
What are the increases risk of post partum haemorrhage?
- macrosomia
- placental abruption
- placenta previa
- multiple pregnancies
- gestation HTN
- prolonged labour
- infection
- obesity
- induced labour
- instrumental delivery
- GA
- coagulopathy
- use of oxytocin in 3rd stage
60
What surgical treatments are there for post partum haemorrhage?
- Rush balloon catheter
- artery ligation
- haemostatic brace suture
- hysterectomy
61
define ovulation.
Ovarian follicle (oocyte + surrounding tissue) matures and ovulation occurs. The eff is ejected into the fallopian tubes & the surrounding tissue becomes the corpus luteum and produces progesterone and oestrogen.
62
define fertilization.
Egg meets sperm and nuclei fuse forming a Zygote. Cells divide and form a blastocyst.
63
What happens to the blastocyst in a normal pregnancy?
Implants into the uterus (day 5). Corpus luteum makes progesterone > oestrogen (necessary for implantation). Trophoblasts (outer blastocyst cells) burrow into the endometrium to form placenta. trophoblasts produce HCG from day 8 - tells corpus luteum there's been successful implantation and needs to keep producing O&P.
64
when is and what happens during the first trimester?
- week 1 - 13.
- Hormones are produced by the corpus luteum.
- week 9 HCG peaks then falls - corpus luteum shrivels and placenta takes over.
65
What cells produce pregnancy hormones during the 2nd & 3rd trimesters?
- placental synctiotrophoblasts
| - produce progesterone & estriol (type of oestrogen)
66
What physiological changes happen during pregnancy?
CVS:
- blood volume increases
- plasma increases greater relative to haematocrit. (physiological anaemia of pregnancy)
- HR increases
- more blood through kidney = increase urinary frequency
- uterus presses on pelvic veins = ankle oedema.
Resp:
- Tidal volume increases (response to increase in progesterone loosening ligaments)
- uterus presses on diaphragm = SOB
Gastro:
- smooth muscle relaxation and decreased peristalsis = constipation and bloating
- relaxation of the LOS - GORD
skin:
-Increase in melanocyte stimulating hormone = linea nigra and darkening areola
O&P:
- breast development - increase blood flow = tingling, fullness and tenderness
- O stimulates prolactin that causes milk production
- O promotes blood clotting by increasing plasma fibrinogen and activity of coagulation factors - increased risk of VTE.
67
A woman who's 10 weeks pregnant presents to A&E with heavy vaginal bleeding. what are the potential DDx?
- threatened miscarriage
- missed/incomplete miscarriage
- ectopic pregnancy
68
What investigations would you perform for a suspected miscarriage?
-B HCG
-TVUSS:
~Os open?
~uterus size?
-Hx - have products of conception been seen?
69
What are the features and management of a threatened miscarriage?
- mild bleeding +/- pain
- cervix closed
- TVUSS - viable pregnancy
-management:
~if heavy bleeding admit/observe
~if not reassure and back to GP/midwife
~if greater than 12 weeks & rhesus -ve: give Anti-D
70
What are the features & management of an inevitable miscarriage?
- heavy bleeding
- clots
- pain
- Cervix open
- TVUSS - internal Os open
-management:
~if heavy bleeding admit + observe
~offer conservative/medical/surgical management
~if greater than 12 weeks & rhesus -ve: give Anti-D
71
What are the features and management of a missed miscarriage?
- asymptomatic or Hx of threatened miscarriage
- on-going discharge
- small dates for uterus
- TVUSS - not foetal heart pulsation where crown is >7mm
-management:
~may want to rescan and second person confirmation
~manage conservatively/medically/surgically
~if greater than 12 weeks & rhesus -ve: give Anti-D
72
What are the features and management of an incomplete miscarriage?
- Products of conception partially expelled
- Sx of missed miscarriage
- may be so bleeding/clots
- TVUSS - retained POC, proof that there was a previously an intrauterine pregnancy present.
-management:
~expectant, medical or surgical management
~if greater than 12 weeks & rhesus -ve: give Anti-D
73
What are the features and management of an ectopic pregnancy?
- acute onset iliac fossa or pelvic pain
- amenorrhoea/missed period
- vaginal bleeding
- TVUSS - uterine pregnancy not visualised and have signs of ectopic (donut sign) on USS.
Management:
~medical or surgical management
74
Define medical management of a miscarriage.
- single dose of methotrexate given
- prevents the proliferation of cytotrophoblasts and B-HVG secretion thus no progesterone support for pregnancy
-OR give vaginal misoprostol with pretreament of mifepristone 24hrs before hand
OR just vaginal misoprostol
OR oral misoprostol
GIVEN WHEN:
- haemodynamically stable
- no rupture
- minimal abdo pain
- no foetal heart
- no presence of contraindicating disease i.e. renal, liver or active peptic ulcers.
75
Define surgical management of a miscarriage.
- laproscopic salpingectomy for ectopic
- manual vacuum aspiration if <12 weeks
- evacuation of retained products of conception under GA if >12 weeks.
76
What are the risk factors for having an ectopic pregnancy?
- previous ectopics
- fallopian tube damage (previous surgery)
- infertility - IVF, endometriosis, tubal disease
- contraceptive failure - IUD, POP
- Smoking
- Age >35
- STI - chlamydia
- PID
- submucosal fibroids
77
Define small for dates.
- A foetus who is small than the usual amount for the number of weeks gestation.
- usually have birth weight <10th centile
78
Define Large for Dates.
- indication of high prenatal growth rate.
| - usually have birth weights >90th percentile.
79
Define a low birth weight.
<2500g
80
Define foetal growth restriction.
- pathological restriction of the genetic growth potential.
| - babies may manifest evidence of foetal compromise - abnormal dopplers or reduced liquor volume
81
Define foetal macrosomia.
Birth weight >4000g.
82
What are the 3 main reasons for a Small for Dates foetus?
- Normal - may happen because mother is small
- non-placental mediated growth restriction
- placental mediated growth restriction
83
What are some causes of non-placental mediated growth restriction?
- structural or chromosomal abnormalities of the foetus
- inborn errors of metabolism
- foetal infection
84
What are some causes of placental mediated growth restriction?
- placental abnormality - baby doesn't get enough O2 and nutrients
- decreased placental blood flow - HTN, DM, smoking, drug use)
- placental abruption
- placental praevia
- maternal infection
85
Define placental praevia.
placenta attaches fully or partially over the internal cervical os.
86
What are some maternal risk factors for foetal growth restriction??
-low pre-pregnancy weight
-under nutrition during pregnancy
-substance misuse
-severe anaemia
-Chronic disease - HTN, CKD, DM, anti-phospholipid
-Smoking
-Age >40
-daily vigorous exercise
-Maternal SGA (small for gestational age)
-previous still birth
-TORCH infection:
~TOxoplasmosis
~Rubella
~Cmv
~Herpes
87
What are some foetal risk factors for foetal growth restriction?
- chromosomal abnormalities
- congenital defects and dysmorphic syndromes
- infection
88
What are some placental risk factors for foetal growth restriction?
- uterine fibroids
- site of implantation - praevia or necreta
- Antepartum haemorrhage
89
How does the foetus adapt to reduction in placental perfusion and function?
- movements become less as tries to conserve energy
| - increased EPO to increase bloods capacity to carry oxygen - makes blood more viscous
90
How is a diagnosis of foetal growth restriction made?
-foetal abdominal circumference or estimated foetal weight using USS
91
Once foetal growth restriction is confirmed what further investigations would you perform?
- ask about movements
- urinanalysis
- USS
- uterine + umbilical artery doppler to assess blood flow
- Karyotyping in sever cases
- serological screening for TORCH infection
- Surveillance of foetus using umbilical artery doppler
- CTG
92
How would you manage an SGA foetus?
prevention:
- antiplatelet therapy with low dose aspirin in women high risk of preeclampsia
- antenatal corticosteroids 25-36 weeks where delivery is being considered
Delivery:
- C section if abnormal doppler
- if normal, can be induced
- closely monitor - foetus cannot handle periods of hypoxia
Post Partum:
- Early feeding
- keep baby warm
- high risk of neonatal jaundice
93
What does a low amniotic fluid index (AFI) suggest?
fluid volume = foetal urine output = kidney perfusion = placental function I.e. how much blood is getting to the foetus
94
What is the difference between symmetrical and asymmetrical intrauterine growth restriction?
- Symmetrical implies the body and head are in proportion so has been developing slowly from an early stages. More likely to be a central problem with the foetus and more likely to have neurological conditions when born.
- Asymmetrical weight is restricted but head size is normal (spared). Foetus is undernourished and directs nutrients to the head. More likely to be a problem with the placenta.
95
What are some risk factors for Macrosomia?
- Maternal DM
- maternal obesity
- maternal excessive weight gain during pregnancy
- previous macrosomia in other pregnancies
- overdue pregnancy
96
Describe the foetal response to maternal DM.
- foetus stores extra glucose as fat.
- foetal hyperinsulinaemia in response to high circulating blood glucose.
- once baby is born is at a higher risk of hypoglycaemia
- infant more likely to develop DM as a child
97
What are the risk factors for breast cancer?
- HRT
- Post menopausal obesity
- OCP
- alcohol intake
- multiple late pregnancy
98
What are the potent breast cancer causing genes?
- BRCA1
- BRAC2
- HER1
99
What are the symptomatic features of breast cancer?
- nipple inversion
- orange peel skin
- nipple discharge
- pathological fracture
100
How do you diagnose breast cancer?
Triple assessment
- examination
- imaging
- histology
101
Describe a breast cancer lump.
- Hard
- Irregular
- fixed
102
When would you use an MRI scan for breast screening?
- high risk BRCA patient
- younger women
- women with implants
103
What indications are there for mastectomy?
- BRCA carriers
- multiple tumours
- personal choice
- large tumours
104
What is the most important prognostic factor for breast cancer?
-lymph node disease
105
How do you identify lymph nodes affected by cancer?
Sentinel node lymph biopsy
Inject radioisotope into tumour and indentify node with gieger counter in surgery and take a couple for histological evaluation
106
How are breast cancers graded?
1-3
1 good 3 bad
Varying levels of mitotic division on histo
107
How do you decide which intermediate cancers are worse than others? And who to treat?
- oncotype DX
| - tests 21 different genes and allows for prognostication
108
What adjunct therapies for breast cancer have caused an increase in survival rates?
- endocrine tx - tamoxifen for oestrogen receptor sensitive cancers
- radiotherapy
- chemotherapy
- trastuzumab - all her-2 positive disease
- bisphosphonates - for post menopausal women and ER +ve women - reduces risk of bone Mets
109
How does tamoxifen work?
Inhibits oestrogen receptors on breast cancer cells increases survival by 15-25%
110
Why are herceptin breast cancers worse than none herceptin?
50% metastasize to the brain
111
When do you give an aromatase inhibitor? How does it work?
- post menopausal women with ER +ve cancer
| - inhibits production of oestrogen
112
How do you treat preeclampsia?
- oral labetalol aiming for a BP less than 160/110.
- nifedipine or hydralazine may be used
- delivery is the most definitive Tx but depends on the clinical picture
113
What's the treatment for PID?
IM ceftriaxone + PO doxycycline + PO metronidazole
