Obs+Gynae Conditions Flashcards
1
Q
Causes of antepartum haemorrhage
A
Placenta praevia (placenta covering the cervix)
Placental abruption (placenta separating from the uterus)
Vasa Praevia (Foetal blood vessels exposed)
Preeclampsia (high blood pressure during pregnancy)
2
Q
Antepartum haemorrhage definiton
A
Genital track bleeding post 24 weeks
3
Q
What is placenta praevia
A
Placenta lies in the lower uterine segment causing poor attachment. if severe may lie over cervical OS
4
Q
Placenta praevia risk factors
A
previous C-section
previous termination
multiparity
maternal smoking
advanced maternal age
5
Q
Placenta praevia history
A
painless vaginal bleeding
maybe contractions
6
Q
Placenta praevia findings on examination
A
vaginal bleeding
non-tender uterus
abnormal lie/presentation
low lying placenta
7
Q
Placenta Praevia Investigations
A
Ultrasound - low lying placenta
FBC, U+E, LFT - rule out preeclampsia
8
Q
Placenta Praevia management
A
when detected, rescan
if present at 36 weeks c-section
9
Q
What is Placenta accreta
A
Placenta grows too deeply into uterine wall, cannot detach and causes blood loss
10
Q
Placenta accreta symptoms
A
sometimes vaginal bleeding in 3rd trimester
symptomless
11
Q
placenta accreta complications
A
severe vaginal bleeding
early labour onset
12
Q
placenta accreta management
A
C-section and hystorectoms if severe
if mild, normal vaginal delivery + blood transfustion
13
Q
Placenta accreta investigation
A
MRI/Ultrasound - inspect growth of placenta
14
Q
Placenta accreta risk factors
A
Placenta praevia
previous c-section
multiparity
age 35+
15
Q
what is placenta increta
A
placenta has grown into muscle wall of uterus
16
Q
what is placental abruption
A
complete or partial detachment of placenta prior to delivery
17
Q
Placental abruption risk factors
A
previous abruption
trauma
pre-eclampsia
maternal age 35+
smoking
18
Q
placental abruption investigations
A
ultrasound - identify bleed
FBC U+R LFT - rule out pre-eclampia
crossmatch - haemorrhage expected
19
Q
placental abruption symptoms
A
abdominal pain
vaginal bleeding
uterine contractions
dizzyness/loss of consciousness
20
Q
placental abruption examination findings
A
woody tense uterus
foetal heart rate distress/absent
21
Q
placental abruption managment
A
no foetal distress
under 36 - monitor
over 36 - induction+vaginal birth
foetal distress
c-section
foetal death
induction and vaginal delivery unless mother is haemodynamically compromised then C-section
22
Q
what is vasa praevia
A
foetal blood vessels are in foetal membrane instead of umbilical cord
may run across internal cervical OS
23
Q
types of vasa praevia
A
multi lobed placenta - blood vessels attach to different lobe than umbilical chord
velamentous umbilical cord insertion - the foetal vessels insert into the membranes and travel round to the placenta, rather than inserting directly into the placenta.
24
Q
vasa praevia risk factors
A
IVF
Placenta praevia
multiple pregnancy (twins)
25
vasa praevia symptoms
painless vaginal bleeding
membrane rupture
foetal bradycardia
26
vasa praevia management
c-section at 34-36 weeks
corticosteriods from 32 weeks
27
what are the foetal blood vessels
the two umbilical arteries and single umbilical vein
28
Post partum haemorrhage definition and categorisation
blood loss of 500ml + following childbirth
primary - within 24 hours
secondary - 24hr to 12 weeks
minor 500-1000ml no shock
major 1000+ or 500-1000 with shock
29
difference between major and minor PPH
minor 500-1000ml no shock
major 1000+ or 500-1000 with shock
30
Difference between primary and secondary PPH
primary - within 24 hours
secondary - 24hr to 12 weeks
31
Causes of primary PPH (4 T's)
Tone: an atonic (not well contracted) uterus (most common)
Trauma: injury, most commonly perineal tears or lacerations
Tissue: retained products of conception (e.g. retained placenta).
Thrombin: underlying disorders of clotting
32
causes of secondary PPH
retained products of conception
endometritis - infection
33
Risk factors of Post partum haemorrhage
Previous PPH
antepartum haemorrhage
Grand multiparity
multiple pregnancy (twins)
prolonged labour
induced labour
34
signs of haemodynamic instability
tachycardia, hypotension, prolonged capillary refill time or cool peripheries.
35
Primary PPH presentation
Haemodynamic instability
atony - enlarged soft boggy uterus
retained products - placement and membranes incomplete
injury - visible tears
36
endometritis presentation
vaginal bleeding
haemodynamic instability
Endometritis - sepsis - fever, hypotension, tachycardia
Also tender bulky uterus and foul discharge
37
Post partum haemorrhage investigations
(Blood tests)
FBC - anaemia
Coagulation screen - clotting disorder
Groups and save/crossmatch - allow transfusion
If secondary do sepsis screen - Blood cultures and CRP
38
How to reduce risk of post partum haemorrhage
anaemia testing (FBC)
Active third stage management
-uteronic drugs - oxytocin/synometrine
- deferred clamping and cord cutting
- controlled cord traction to deliver placenta
39
Emergency management of Post partum haemorrhage
Airway - anaesthesia support if required
Breathing - oxygen if required
Circulation - check for haemodynamic instability, estimate blood loss, establish IV access, administer warm crystalloid solution/blood products
Urinary catheter in case of surgery
40
Management of Primary Post partum haemorrhage (Atony)
Atony
Mechanical - rub uterine fundus to stimulate contractions
pharmacological - uterotonic drugs eg. oxytosin, syntometrine
Surgical - balloon tamponade/haemostatic sutures. rarely hysterectomy if severe
41
Management of primary post partum haemorrhage (excluding Atony)
trauma - repair surgically
tissue - theatre for placenta removal
thrombin - consider tranexamic acid or vitamin K before - blood products on standby
42
How is the 3rd stage of labour actively managed
-uteronic drugs - oxytocin/synometrine
- deferred clamping and cord cutting
- controlled cord traction to deliver placenta
43
Secondary post partum haemorrhage management
Ultrasound to check for retained products - removal in theatre
blood transfusion if anaemic
44
Ectopic pregnancy definition
Egg implants outside of the uterus, eg in the fallopian tube, ovary or abdomen
45
Risk factors for ectopic pregnancy
Previous ectopic
tubal damage
infertility/IVF
Smoking
age 35+
46
Symptoms of ectopic pregnancy
Vaginal bleeding
one sided pain - iliac fossa - ?appendicitis
shoulder pain if bleeding/peritoneal irritation
47
Ectopic pregnancy investigations plus findings
Serum beta hCG
Ultrasound - adnexal mass moving separately to ovary
48
Ectopic pregnancy management
conservative - only if clinically stable and pain free - monitor HCG (must be decreasing)
medical - methotrexate - prevents cell division - teratogenic so no conception for 3 months
Surgical - if significant pain, mass over 35mm or live ectopic - salpingectomy to remove fallopian tube
49
Miscarriage time categorisation
early - before 13 weeks
late - 13-24 weeks
50
Complete Miscarriage definition
the products of conception have passed, the cervical os is closed and ultrasound shows an empty uterine cavity
51
Incomplete Miscarriage definition
vaginal bleeding, an open cervical os and products of conception are seen on examination.
52
Miscarriage symptoms
Vaginal bleeding
Cramping abdominal pain
Passage of any foetal tissue or clots
53
Complete miscarriage diagnostic investigation
Beta hCG - decrease of 50% in 48 hours
54
Miscarriage management
expectant - waiting for spontaneous passage of the products of conception - only if incomplete miscarriage/delayed under 35mm
medical - prostaglandin agent (misoprostol) to induce uterine contractions
surgical removal of products of conception
55
delayed miscarriage investigation and diagnosis criteria
Transvaginal ultrasound
Required
gestation sac
yolk sac
foetal pole
no heart beat
over 7mm
If less than 7mm scan 1 week later
56
Cause of miscarriage in first trimester
chromosome abnormality
57
cause of miscarriage in second trimester
cervical incompetence
58
Ovarian torsion definition
Ovary twists and blocks blood supply
59
Causes/risk factors of ovarian torsion
cyst or ovarian mass
PCOS
endometriosis
60
Ovarian torsion symptoms
Severe (twisting) abdominal pain, nausea and vomiting, shoulder tip irritation if peritoneal irritation
61
Ovarian torsion management
laparoscopic surgery to untwist ovary - if necrotic remove
62
pre-eclampsia vs severe pre-eclampsia vs eclampsia
pre-eclampsia - hypertension + proteinurea
severe preeclampsia - hypertension + proteinurea + end organ effect
Eclampsia - hypertension + proteinurea + seizures
63
What end organ effects occur in severe pre-eclampsia
Headache/visual disturbance/papilledema
clonus
Liver tenderness/abnormal enzymes
64
treatment for pre-eclampsia
stabilize BP - labetalol/nifedipine
fluid restriction +output monitoring
assess foetal wellbeing
delivery via induction/caesarean as required
65
Risk factors of pre-eclampsia
Chronic hypertension
previous pre-eclampsia
Type I or type II diabetes mellitus
Chronic kidney disease
Autoimmune disease
66
Pre-eclampsia symptoms
Headache
Visual disturbance: such as blurring or flashing lights
Swelling of the arms, legs and face
Nausea and vomiting
Abdominal pain
67
what medicine is used to prevent the onset of pre-eclampsia
Aspirin 150mg once daily
68
what is HELLp sydrome
Haemolysis
Elevated liver enzymes
low platelets
69
eclampsia treatment
seizure onset = magnesium sulfate IV and caesarean/delivery once mum is stable
70
Ultrasound findings in PCOS and their pathophysiology
immature follicles which have had their ovulation phase arrested. This occurs due to an elevated baseline of LH and lack of LH surge
71
What hormone changes are seen in PCOS
Elevated LH - follicles are not released due to lack of surge
Hyperinsulinemia - excess glucose causes androgen production
Elevated testosterone - prevents follicles from growing normally
72
Polycystic ovarian syndrome (PCOS) risk factors
Obesity
Diabetes mellitus
Family history of PCOS
Premature adrenarche (early onset of pubic hair)
73
Polycystic ovarian syndrome (PCOS) Symptoms
Hirsutism: excessive hair growth in women
Infertility
Acne
Menstrual cycle disturbance
Obesity and weight gain
74
PCOS investigations
ultrasound - Multiple small follicles of similar size around the periphery of the ovaries, resembling a “string-of-pearls”
Testosterone (total and free): raised in PCOS
75
PCOS diagnostic criteria
Rotterdam criteria (2/3 required)
Imaging: polycystic ovaries on ultrasound
Abnormal periods
Hyperandrogenism: clinical and/or biochemical changes
76
What is the Rotterdam criteria for PCOS
(2/3 required)
Imaging: polycystic ovaries on ultrasound
Abnormal periods
Hyperandrogenism: clinical and/or biochemical changes
77
PCOS Treatment
conservative: Weight loss, regular exercise and diet
Medicine: Combine pill - regulated period OR clomiphene - promotes fertility
78
What is a uterine prolapse
Uterine prolapse is where the uterus itself descends into the vagina.
79
What is a vault prolapse
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina
80
What is a rectocele
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
81
what is a cystocele
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
82
Types of uterine prolapse
uterine
vault
rectocele
cystocele
83
Grades of uterine prolapse
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
84
vault prolapse treatment
colposuspension
85
rectocele prolapse treatment
posterior wall repair
86
cystocele prolapse treatment
anterior wall repair
87
risk factors for vaginal prolapse
vaginal delivery
Instrumental delivery
prolonged delivery
menopause
Obesity
constipation
chronic respiratory condition
(increased intraabdominal pressure)
88
vaginal prolapse presentation
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
89
Vaginal prolapse conservative management
pessary
pelvic floor exercise
weight loss
90
Vaginal prolapse medical management
Oestrogen cream to prevent irritation and maintain vaginal tissue health
91
What are fibroids
benign tumours of uterine smooth muscle (leiomyoma)
92
What hormone are fibroids sensitive to
oestrogen
93
Where is an intramural fibroid
within the uterine muscle
94
where is a subserosal fibroid
outside of the uterus
95
where is a submucosal fibroid
just below the uterine endometrium
96
what is a pedunculated fibroid
fibroid on a stalk
97
Fibroid presentation
Asymptomatic
potentially
Heavy periods/long periods
abdominal pain worse on menstruation
bloating
pain on intercourse
98
Investigation for fibroids
hysteroscopy - submucosal
pelvic ultrasound if large
MRI - prior to surgery
99
Medicinal management of fibroids
mirena coil/combined pill
100
Surgical fibroid management
endometrial ablation
resection during hysteroscopy
hysterectomy
101
What is red degeneration of fibroids
ischaemia, infarction and necrosis of fibroids
102
when does red degeneration of fibroids occur
during pregnancy to large fibroids
103
pathophysiology of red degeneration of fibroids
during pregnancy, fibroids grow rapidly (due to oestrogen) and blood supply is kinked during uterine expansion. fibroids become ischaemic
104
red degeneration of fibroids symptoms
abdominal pain
low grade fever
tachycardia
vomiting
105
what is a functional ovarian cyst
a fluid filled sac caused by fluctuation in hormones during the menstrual cycle
106
In what women are ovarian cysts concerning
post menopausal women
107
diagnostic criteria for PCOS
anovulation
hyperandrogenism
polycystic (string of pearl ovaries) on ultrasound
108
Presentation of ovarian cysts
asymptomatic
maybe
pelvic pain
bloating
palpable mass
abdominal fullness
109
Types of functional cyst
follicular (most common)
corpus luteum
110
what causes a follicular cyst
failure of follicle to rupture and release egg
111
what causes a corpus leuteum cyst
the corpus leuteum fails to breakdown in early pregnancy and fills with fluid
112
Risk factors for malignant ovarian cyst
post menopausal
increased age
obesity
HRT
Smoking
BRAC1 BRAC2
113
symptoms of malignant ovarian cyst
bloating
loss of appetite/early satiety
weight loss
urinary symptoms
114
management of functional ovarian cyst
less than 5cm = do nothing - spontaneously resolves
5cm to 7cm = gynae referral and annual ultrasound
7cm + = consider surgery as difficult to determine malignancy
115
what are functional ovarian cysts
fluid filled sac's caused by the fluctuation in hormones due to periods (benign)
116
when do malignant ovarian cysts occur
post-menopause
117
diagnostic criteria for PCOS
String of pears/multipls cycts
anovulation
hyperandrogenism
118
Presentation of ovarian cyst
asymptomatic
maybe
pelvic pain, bloating, abdominal fullness palpable mass
119
Types of functional ovarian cyst
follicular
corpus leuteum
120
what is a follicular cyst and what does it look like on an ultrasound
follicle fails to rupture and release egg
has thin walls and no internal structures
121
what is a corpus luteal cyst and when is it seen?
corpus luteum fails to break down and fills with fluid
seen in early pregnancy
122
Risk factors for malignant ovarian cyst
increased age
post menopausal
Obesity
Smoking
HRT
BRCA1/BRCA2
123
symptoms of malignant ovarian cyst
bloating
loss of appetite/early satiety
weight loss
urinary symptoms
124
Management of ovarian cyst (size dependant)
less than 5cm - will spontaneously resolve
5-7cm - scan every year
7cm+ consider surgery due to inability to tell if malignant
125
processing/management/follow up of cervical smear test HPV results
If HPV +ve check for dysplasia + colposcopy
If HPV -ve repeat in 3 years
126
Management of high grade cervical dysplasia
Loop electrosurgical excision
127
Management of low grade cervical dysplasia
recheck in 6 months
128
Cervical cancer Initial symptoms
post coital bleeding, menorrhagia + vaginal discharge
129
Cervical cancer severe symptoms
Loss of appetite, weight loss, early satiety, single swollen leg, pelvic pain, faecal/urinary incontinence
130
Pathophysiology/histology of cervical cancer
squamous cell carcinoma caused by dysplasia caused by HPV infection (type 16/18)
131
Risk factors for cervical cancer
risky sexual activity eg. multiple partners/not using condoms
Smoking
HIV
132
Staging of dysplasia
1 - mild - 1/3 of epilthelium - will return to normal
2 - moderate - 2/3 epithelium - may progress to cancer
3 - severe - very likely to become cancer
133
Treatment of cervical cancer
Cone biopsy (if small enough)
Hysterectomy if invades uterus
Chemo/radiotherapy
134
Endometrial cancer histology
adenocarcinoma
135
what is endometrial hyperplasia + treatment
precancerous thickening of the endometrium
Most return to normal - if not progestogens eg mirena coil/methyprogesterone
136
Risk factors for endometrial cancer
Unopposed oestrogen:
No pregnancies
early onset of menstruation
increased age
late menopause
Obesity
PCOS
137
What effect does smoking have on endometrial cancer deveopment
protective - reduces unopposed oestrogen
138
Presentation of endometrial cancer
post coital bleeding
intermenstrual bleeding
abnormal discharge
Anaemia
139
Staging of endometrial cancer
1 - uterus only
2 - cervix
3 - ovaries/lymph nodes
4 - bladder/beyond pelvis
140
Management of endometrial cancer
hysterectomy
radiotherapy
chemotherapy
Progesterone to slow progression
141
Investigations for endometrial cancer
transvaginal ultrasound/pipelle biopsy
142
Ovarian cancer histology
epithelial, germ cell or metastasis from elsewhere
143
Ovarian cancer risk factors
60+
BRCA1/BRCA2
increased number of ovulations eg. no pregnancy/ early onset of menstruation
Obesity
Smoking
144
Investigation for ovarian cancer
CA125 blood test
Pelvic ultrasound
CT to establish staging
145
what does a snowstorm appearance on ultrasound indicate
a hydatidiform mole/ molar pregnancy
146
Ovarian cancer management
surgery/chemotherapy
147
what can cause a raised CA125 blood test
Endometriosis
fibroids
liver disease
Ovarian cancer
148
Vulval cancer histology
Squamous cell carcinoma
149
Vulval cancer risk factors
75+
immunosupression
HPV
Lichen sclerosis
150
Vulval cancer presentation
Vulval lump - irrecular mass/fungating lesion
ulceration
bleeding
pain/itching
151
investigation of vulval cancer
Biopsy + sentinel node biopsy
CT for staging
152
what is lichen sclerosis
an autoimmune inflammatory disease affecting the labia, perineum and perianal skin
153
lichen sclerosis Presentation
itching
soreness (worse nocturnally)
Skin tightness
Pain on intercourse
erosions/fissures
154
Lichen sclerosis appearance (poem)
Porcelain white,
shiny and tight,
slight raise
155
what is koebners phenomenon
symptoms made worse by friction
156
Management of lichen sclerosis
potent topical steriods
157
Complications of lichen sclerosis
Vulval cancer (squamous cell carcinoma)
sexual dysfunction
narrowing of urethral/vaginal opening
158
what is a molar pregnancy
a tumour that grows in the uterus like a pregnancy (a hydatidiform mole)
159
What is a complete mole
2 sperm fertilise an empty egg - no foetal material will form
160
what is an incomplete mole
2 sperm fertilise a normal egg - foetal material will form
161
what is the appearance of a hydatidiform mole on ultrasound
snowstorm appearance
162
Symptoms of a hydatidiform mole/molar pregnancy
Pregnancy on Crack
Severe morning sickness
Very high HCG
Thyrotoxicosis
vaginal bleeding
uterine enlargement
163
Management of molar pregnancy
evacuation of uterus
monitor HCG and if does not decrease - chemotherapy
