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Medicine > Obs & Gynae > Flashcards

Obs & Gynae Flashcards

1
Q

What is COCP

A

Combined oral contraceptive pill

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2
Q

How is anaemia in pregnancy defined?

A

1st Trimester: Hb <110g/L
2nd/3rd Trimester: Hb<105g/L
Post-partum: Hb <100g/L

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3
Q

What are footling presentations in pregnancy?

A

Footling presentations are a rarebit most risky form of breech.
One or both feet come 1st, with the bottom at higher position.
5-20% risk of cord prolapse, which can obstruct foetal blood flow.
It is an obstetric emergency.

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4
Q

What is a breech presentation in pregnancy?

A

Breech is when the caudal end of the foetus is lowest.

25% are breech at 28 wks, but only 3%are still breech at term.

A frank breech is most common, with hips flexed and knees fully extended.

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5
Q

What are the risk factors for breech Px?

A
  • Uterine malformations, fibroids
  • placenta praevia
  • polyhydramnios or oligohydramnios
  • Fetal abnormality (e.g. CNS malformation, chromosomal disorders)
  • Prematurity (due to increased incidence earlier in gestation)
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6
Q

What is the management of breech Px?

A
  • Many turn spontaneously
  • External cephalic version (ECV)
  • If still breech at delivery, then planned caesarean or vaginal delivery
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7
Q

What are the contraindications to External Cephalic Version (ECV)?

A
  • Planned c-section
  • Antepartum haemorrhage within last 7 days
  • Abnormal cardiotocography
  • Major uterine anomaly
  • Ruptured membranes
  • Multiple pregnancies
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8
Q

What is Oligohydramnios?

A

A low level of amniotic fluid during pregnancy.

Causes: Placental insufficiency, renal agenesis + viral infection.

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9
Q

What is Primary postpartum haemorrhage (PPH)?

A

PPH is the loss of at least 500ml of blood PV within 24hrs of delivery.

Risk factors: multiple pregnancies, placental problems, + instrumental delivery.

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10
Q

What are the features of Intrahepatic cholestasis of pregnancy (Obstetric cholestasis)?

A
  • Pruritis (intense + is worse on palms, soles and abdominal)
  • Jaundice
  • Raised bilirubin

Associated with premature birth and increases risk of stillbirth.

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11
Q

What is the management of Obstetric cholestasis?

A

Induction of labour at 37-38 wks
Ursodeoxycholic acid
Vit K supplements

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12
Q

What is endometriosis?

A

Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus.

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13
Q

What is an endometrioma?

A

A lump of endometrial tissue outside the uterus.

Endometriomas in the ovaries are often called “chocolate cysts”.

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14
Q

What is Adenomyosis?

A

Endometrial tissue within the myometrium (muscle layer) of the uterus.

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15
Q

What is retrograde menstruation?

A

When the endometrial lining flows back through the Fallopian tubes and out into the pelvis and peritoneum.

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16
Q

Endometriosis Px?

A
  • Asymptomatic
  • Cyclical abdo or pelvic pain
  • Deep dyspareunia
  • Dysmenorrhoea (painful periods)
  • Infertility
  • Cyclical bleeding from other sites, such as haematuria (due to the endometrial tissue outside the uterus responding to hormones in the same way that in the uterus does)
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17
Q

Endometriosis Examination Findings?

A
  • Endometrial tissue visible in the vagina on speculum, particularly in posterior fornix
  • A fixed cervix on bimanual
  • Tenderness of vagina, cervix and adnexa
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18
Q

What is the gold standard Ix for endometriosis?

A

Laparoscopy + biopsy of lesions.

Pelvic USS may also reveal endometriomas /chocolate cysts

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19
Q

How would you manage a patient with endometriosis?

A
  • Analgesia
  • Hormonal management –> COCP, POP, Depo-Provera, Nexplanon implant, Mirena coil (these stop ovulation and reduce endometrial thickening :. stopping cyclical pain)
  • GnRH agonists (induce menopause-like state)
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20
Q

What are fibroids?

A

Fibroids are benign tumours of the smooth muscle of the uterus.
AKA Uterine Leiomyomas.
They are oestrogen-sensitive, so grow in response to oestrogen.

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21
Q

What are the types of fibroids?

A
  • Intramural (within myometrium. Distort uterus as they grow)
  • Subserosal (just below outer layer of uterus, so grow out into the abdominal cavity. can grow v.big)
  • Submucosal (just below the endometrium)
  • Pedunculated (on the stalk)
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22
Q

What is the presentation of a pt with fibroids?

A
  • Often asymptomatic
  • Heavy menstrual bleeding (menorrhagia) is most frequent PC
  • Prolonged menstruation (>7 days)
  • Abdo pain (worse during menses)
  • Bloating
  • Urinary or bowel symptoms due to pelvic pressure
  • Deep dyspareunia
  • Low fertility
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23
Q

Fibroid Ix?

A
  • Bimanual exam (palpable mass)
  • Hysteroscopy is initial Ix for submucosal fibroids presenting with menorrhagia
  • Pelvic USS for large fibroids
  • MRI for surgery
24
Q

What is the medical management of fibroids?

A
  • Mirena coil (1st line) - fibroids must be less than 3cm w/ no distention of the uterus
  • Symptom Rx with NSAIDS and tranexamic acid
  • COCP
  • Cyclical oral progestogens
25
Q

What is the surgical management of fibroids?

A

Smaller fibroids with heavy menstrual periods:

  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy

For larger fibroids:

  • Uterine artery embolism
  • Myomectomy (only treatment to improve fertility)
  • Hysterectomy

*NB: GnRH agonists may be used to reduce the size of fibroids before surgery

26
Q

What are the potential complications of fibroids?

A
  • Heavy menstrual bleeding + Iron deficiency anaemia
  • Reduced fertility
  • Miscarriages, preterm labour and obstructive delivery
  • Constipation
  • UTIs and urinary obstruction
  • Red degeneration of fibroids
  • Torsion of fibroids (usually pedunculated fibroids)
  • Malignant change to leiomyosarcoma (rare)
27
Q

What is red degeneration of fibroids?

A

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

More likely in fibroids >5cm and during the 2nd or 3rd trimester of pregnancy.

28
Q

Why is red degeneration of fibroids more likely in pregnancy?

A

The fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic.

Also, Bfs may be kink as the uterus changes shaped expands.

29
Q

How does the red degeneration of fibroids present?

A
  • Severe abdo pain
  • Low-grade fever
  • Tachycardia
  • Vomiting

*NB: look out for the pregnant woman with Hx of fibroids presenting w/ severe abdominal pain and low-grade fever in exams.

30
Q

What is the Rx of red degeneration of fibroids?

A

Supportive - rest, fluids and analgesia

31
Q

What are the characteristic features of Polycystic Ovarian Syndrome?

A
  1. Multiple ovarian cysts
  2. Infertility
  3. Oligomenorrhea
  4. Hyperandrogenism
  5. Insulin resistance
32
Q

What is the Rotterdam criteria used to diagnose?

A

Polycystic Ovarian Syndrome.

Need 2/3 of:

  • Irregular or absent periods
  • Hyperandrogenism
  • Polycystic ovaries on USS
33
Q

PCOS Px?

A
  • Infertility
  • Oligomenorrhoea or amenorrhoea
  • Obesity (70% of PCOS pts)
  • Hirsuitism
  • Acne
  • Hair loss in a male pattern
34
Q

What are the DDs of hirsutism?

A
  • PCOS
  • Medications Eg phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
  • Ovarian and adrenal tumours that secrete androgens
  • Cushings syndrome
  • Congenital adrenal hyperplasia
35
Q

What will blood tests show if a patient has PCOS?

A
  • raised LH
  • Raised LH:FSH ratio (high LH compared to FSH)
  • high testosterone
  • high insulin
  • normal or raised oestrogen
36
Q

What is the gold standard investigation for PCOS?

A

Pelvic USS and transvaginal USS.
The follicles may be arranged around the periphery of the ovary in a “string of pearls” appearance.

Need either 12+ follicles developing on one ovary or an ovarian volume of >10cm.

37
Q

What is the management of PCOS?

A
  • Assess and manage any associated features or complications
  • Weight loss is v.important –> may restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism etc.

Orlistat can be used to help weight loss in women with a BMI over 30

38
Q

How does PCOS increase the risk of endometrial cancer?

A

Women with PCOS do not ovulate frequently, so do not produce enough progesterone.

They do, however, continue to produce oestrogen, now unopposed by progesterone, allowing the endometrial lining to proliferate without the regular shedding of menstruation.

This results in endometrial hyperplasia and an increased risk of endometrial ca.

*NB: this is the same as giving unopposed oestrogen in HRT.

39
Q

How do we investigate women with extended gaps between periods (>3 months)?

A

Pelvic USS to assess endometrial thickness.
Cyclical progestogens should be used to induce a period prior to USS.

If the endometrial thickness is >10cm, they are referred for a biopsy to exclude endometrial hyperplasia and ca.

40
Q

How to we reduce the risk of endometrial cancer in women with PCOS?

A
  • Mirena coil for continuous endometrial protection
  • Inducing a withdrawal bleed evert 3-4 months using either cyclical progestogens (e.g. medroxyprogsterone acetate) or the COCP
41
Q

How do we improve fertility?

A
  • Weight loss
  • Clomifene
  • Laparoscopic ovarian drilling
  • IVF

Metformin and letrozole are also said to help.

42
Q

How do we manage hirsutism?

A
  • Topical eflornithine for facial hirsutism. Takes 6-8 weeks to see improvement.
  • Laser hair removal
  • Spironolactone
  • Finasteride
  • Flutamide
43
Q

What are the only 2 drugs that do NOT cross the placenta?

A

Heparin and Insulin

44
Q

What 3 types of drugs are absolutely contraindicated in pregnancy?

A

Alcohol
Acne drugs (Vit A)
Androgens

NB: Anti-metabolites Eg Chemo and Anti-psychotics and contraindicated also, but not absolutely

45
Q

What is the pre-cancerous stage of endometrial cancer?

A

Atypical hyperplasia

46
Q

What is the cut-off endometrial thickness for suspecting endometrial cancer?

A

4mm

If >4mm, suspect ca

47
Q

What is the gold standard Ix for diagnosing endometrial cancer?

A

Hysteroscopy to diagnose

MRI to stage

48
Q

What other cancer in endometrial cancer associated with?

A

Ovarian (30% of endometrial is assoc. w/ it)

49
Q

Which gynae cancer is most likely to have an asymptomatic Px?

50
Q

What are the tumour markers for Ovarian Ca?

A

Ca 125

AFP, HCG, Inhibin B

51
Q

What age group are Germ cell ovarian tumours most common in?

A

Adolescents and young women

52
Q

Why can Sex cord/stroma ovarian tumours cause PV bleeding?

A

They produce oestrogen or androgens

53
Q

What part of the cervix do cervical cancers develop?

A

The transformation zone

54
Q

Where do women go if they have an abnormal smear?

A

Colposcopy clinic

55
Q

What are the 3 stages of CIN (Cervical Intra-epithelial Neoplasia)?

A

CIN 1: in 1/3 of cervix depth
CIN 2: in 2/3 of cervix depth
CIN 3: Carcinoma in-situ

56
Q

What are the potential causes of vulval cancer?

A 
HPV (50%)
Lichen Sclerosis (basically exema of the vulva - 5% of women w/ lichen sclerosis get vulval cancer)
Advanced age (over 75)
57
Q

What is the Px of vulval cancer?

A

White, itchy patches on vulva.
Ulceration or bleeding can occur
most commonly on labia majora

Medicine (16 decks)

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