OBS & GYNAE WK 1 Flashcards
what are the structures of the pelvic cavity, division between greater and lesser
ovaries
uterine tubes
uterus
superior part of vagina
structures of the perineum
inferior part of vagina
perineal muscles
bartholin’s glands
clitoris
labia
what is the perineum and forms what pouches
shallow space between diaphragm and skin
recto-uterine aka pouch of Douglas - if woman is upright, this is the lowest point of peritoneum, so blood collecting there
vesico-uterine - men
broad ligament of the uterus and its function
double layer of peritoneum
helps maintain the uterus in its correct midline position
round ligament of the uterus
formed from embryological remnant
passes thru deep inguinal ring to attach to the superficial tissue of the female perineum
3 layers of the uterus and their function
contracts during labour
during menstrual cycle
implantation of zygote occurs in body of uterus
peri
myo
endometrium
implantation of zygote occurring outside of the body of uterus causes what?? presentation
ectopic pregnancy
common sites = fallopian tube, ampullary
more pain than bleeding
dizziness
SOB
pallor
guarding
most common and normal position of the uterus
anteverted and anteflexed = most common
retroverted and retroflexed = normal variation
uterus is held in position by 3 levels of support, what are they??
uterosacral ligaments
endopelvic fascia
muscles of pelvic floor eg. levator ani
where exactly does fertilisation occur?
ampulla - of fallopian tube
salpingectomy
salpinx is Greek for “tube”
removal of uterine tube
HSG
hysterosalpingogram
radiopaque dye
is uterine tube open or not?
ovary - location and shape
almond sized and shape
develop on posterior abdo wall
what hormones are secreted by ovaries??
secrete oestrogen and progesterone in response to:
FSH
LH
4 parts of the fornix
anterior
posterior
2 x lateral
upper end of the vagina, where it meets the cervix
vagina
muscular tube
cervical screening, what part is sampled??
squamo columnar junction aka transformation zone is sampled
use a speculum
vaginal digital examination, what structures can be palpated
ischial spines - bony landmarks of pelvis
position of uterus can be palpated
palpation of adnexae (uterine tubes and ovaries)
levator ani muscle - what muscle type, function, and supplied by what nerve??
skeletal muscle
voluntary control
dual nerve supply
pudendal nerve+perineal
S3,4,5
perineal body
why is it important
bundle of collagenous and elastic tissue
LOCATED DEEP TO SKIN
gives strength to pelvic floor
if damaged during childbirth -> prolapse
bartholin’s gland aka greater vestibular gland - what do they secrete
infection - enlarged bartholin’s gland = infection
The Bartholin’s glands secrete fluid that acts as a lubricant during sex.
where are the bed of breasts found? how do breasts attach to skin
ribs 2-6
deep fascia
4 quadrants of the breast
upper - outer and inner
lower - outer and inner
lymphatic drainage - where do most lymph from breast drain to??
ipsilateral axillary lymph nodes -> supraclavicular
axillary node clearance - 3 levels?? all in relation to pec minor
I - inferior and lateral to pec minor
II - deep to pec minor
III - superior and medial to pec minor
blood supply to breast
axillary
internal thoracic
ovarian cycle
Follicular
Ovulation
Luteal
uterine cycle
Menstrual
Proliferative
Secretory
corpus luteum
mass of cells that forms in an ovary. It produces the hormone progesterone during early pregnancy. It is a temporary organ that appears every menstrual cycle and disappears if fertilization does not occur.
doughnut shape
proliferative
piano key appearance
secretory
dense round clusters
menstrual
decidual change
stromal cells become round, and pink
in response to prolonged progesterone exposure
‘hairpin’ structures
atrophy of endometrium
post-menopausal
AUB - causes
abnormal uterine bleeding:
pregnancy / miscarriage
endometritis
bleeding disorders
infection / inflammation
Methods of assessing the endometrium
TVUS
>4mm thickness
DUB - most common cause
anovoluntary cycles
CL does not form
endometrial polyps
common
may have bleeding or discharge
molar pregnancy
2 types:
complete/partial mole
non-viable fertilised egg
complete - snowstorm appearance, swollen villi
only paternal DNA is present
no foetus
partial - both maternal and paternal DNA is present
non-viable foetus
leiomyoma
aka fibroids
group of benign smooth muscle tumors commonly present in premenopausal women.
endometriosis
microscopic vs macroscopic
micro - haemorrhage, inflammation, fibrosis
macro -
inflammation
chocolate cyst
fibrous adhesions
complications of endo
pain
cyst formation
infertility
higher risk of malignancy
ovarian tumours - solid vs cystic, benign vs malignant
solid - firm
mix of cystic and firm is more worrying
cystic -
ovarian tumours - classification, which one is the most common
epithelial - most common
germ cell
stromal
metastatic
miscellanous
serous carcinoma
high vs low grade
endometriod carcinoma
mostly low grade and early stage
what staging is used for cervical / endometrial cancer??
Figo
3 layers of gastrulation
endo
meso
ectoderm
female embryological development
male embryological development, what gene is present ??
SRY gene
ambisexual / biopotential phase
mesonephric duct
para-mesonephric duct
female congenital abnormalities
double uterus / vagina
unicorn ate / bicornate uterus
septated uterus
male congenital abnormalities
persistent müllerian duct syndrome
Polymenorrhoea
frequent periods
<21 days cycle
Menometrorrhagia
prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal.
Oligomenorrhoea
irregular cycle
>35 days
what structures do you need to see for a good biopsy
squamous epithelium
endocervical gland
cervicitis
inflammation
can lead to infertility
HSV infection
cervical polyp
common
inflammatory localised outgrowth. May bleed if ulcerated
CIN - caused by what HPV types? histology
common
caused by HPV 16 and 18 infection
may show koilocytosis
nuclear abnormalities
excess mitotic activity
cervical cancer
invasive squamous carcinoma
keratin present
genital warts are caused by which HPV types
low risk
thickened papillomatous squamous epithelium w cytoplasmic vacuolation (koliocytosis)
3 stages of CIN
I - BASAL 1/3rd of epithelium
II - abnormal cells extend to middle 1/3rd
III - abnormal cells occupy full thickness of epithelium
2nd most common female cancer worldwide?? where does it develop from??
invasive squamous carcinoma
from pre-existing CIN - preventable by cervical screening
symptoms of invasive carcinoma
abnormal bleeding - post coital, post menopausal
pelvic pain
haematuria / urinary infections
ureteric obstruction
spread of squamous carcinoma - 3
local
lymphatic
haematogenous
grading of squamous carcinoma
well differentiated
moderately differentiated
poorly differentiated
undifferentiated / anaplastic
CGIN
cervical glandular intraepithelial neoplasia
HIGH GRADE always
worrying, must be removed
pre invasive phase of endocervical adenocarcinoma
endocervical adenocarcinoma
young women
HPV 18
VIN, VaIN, AIN
vulvar intraepithelial neoplasia - often history of CIN or VaIN
vaginal intraepithelial neoplasia
anal intraepithelial neoplasia
VULVAR PAGET’S DISEASE
crusting rash, often sharp
painful / itchy
tumour cells in epidermis, has mucin
primary / secondary
Most important prognostic factor for vulvar invasive squamous carcinoma
spread to inguinal lymph nodes
capacity and consent in young ppl - what guidelines??
under 13 cannot give consent to sexual activity, must be 16 and over for consent
gillick competence - consenting to medical treatment without parents’ permission
fraser guidelines
2 functions of the ovary
produce gametes termed oogenesis
produce steroids, mainly oestrogens and progestogens
structure of the ovary - 2, what is the outer shell called?
medulla - has loose connective tissue, arteries, veins
cortex - scattered ovarian follicles, outer shell is called tunica albuginea, over the layer of tunica a, it is called germinal epithelium
what is oogenesis and folliculogenesis
oogenesis = development of oocytes, female germ cells, from oogonia
folliculogenesis:
growth of follicle which consists of the oocyte and support cells
follicular development
pre-antral follicles (flat cells become cuboidal, primordial follicles) -> antral follicles -> mature Graafian follicle
where are primary follicles formed
after ovulation, the follicle transforms into a _____ _______
why is this important
corpus luteum - body which is yellow in colour
secretes oestrogen and progesterone, helping uterus prepare for implantation
what 3 layers make up the uterine wall
inner - endometrium
myometrium
outer - perimetrium
endometrium is divided into 2 what??
SF
SB
2 PARTS OF CERVIX
supravaginal part - lined by simple columnar
intravaginal - lined by stratified squamous non-keratinised epithelium
4 layers of vagina
-non-keratinised stratified squamous epithelium
-lamina propria
(stratified and lamina together is called mucosal layer)
-fibromuscular
-adventitia - outer
causes of bleeding?
miscarriage
ectopic
molar
implantation bleeding
cervical/vaginal causes
miscarriage classification
threatened (risk to pregnancy)
Inevitable (pregnancy can’t be saved)
incomplete (part of pregnancy is already expelled)
complete (uterus empty on scan)
missed miscarriage
septic
recurrent
what is miscarriage and what symptoms
loss of early pregnancy
positive urine pregnancy test
amenorrhea
period type cramps
causes of miscarriage
chromosomal abnormality
APS - immune cause
infections - rubella, CMV
uncontrolled diabetes
ix and mx of miscarriage
FBC, serum hCG, ultrasound
conservative - watch and wait
medical - can take tablets at home
MVA / surgical
anti-d
NICE guidance for threatened miscarriage
micronised progesterone
recurrent miscarriage ??
3 or more pregnancy losses
or 2 losses if over age 35
APS link
ALIFE 2 trial
ix and gold standard for ectopic
FBC, G&S, ultrasound
TVS = GOLD STANDARD
management for ectopic
conservative
medical - methotrexate
surgical - laparoscopic salpingectomy
PUL
pregnancy of unknown location
amenorrhoea and abdo pain
M6 MODEL
molar pregnancy - pathology
grape like clusters = pathology
overgrowth of placental tissue w chorionic villi swollen w fluid rich in hCG
ix and mx for molar pregnancy
uss
*surgical - uterine evacuation
implantation bleeding
fertilised egg implants in endometrial lining
bleeding is light or brownish
Chorionic Haematoma
Pooling of blood between the chorion, a membrane surrounding the embryo, and the uterine wall
self-limiting
HG - clinical presentation
Hyperemesis Gravidarum
VOMITING - 1st trimester
- Dehydration, ketosis, electrolyte and nutritional disbalance
- Weight loss, altered liver function
- Signs of malnutrition
- Emotional instability, anxiety, severe cases can cause mental health issues e.g. depression
mx of HG
PUQE score - mild moderate severe
- Rehydration IV infusion, electrolyte replacement
Parenteral antiemetic:
- First line: cyclizine, prochlorperazine
- Second line: metoclopramide
what do u give to rhesus-negative women??
anti-d, to prevent iso-immunisation (may result in hemolytic disease of the fetus and newborn)
definition of infertility
2 types ??
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child
Either primary (couple never conceived) or secondary (couple previously conceived, although pregnancy may not have been successful e.g. miscarriage, ectopic pregnancy)
what surge do you look at before ovulation?
assessing ovulation
LH surge
around day 21
regular cycles are suggestive of ovulation
confirm by mid-luteal serum progesterone > 30 mmol/L
azoospermia
no sperm in ejaculate
investigations in females - what do you do to check for uterine abnormalities
and for tubal patency testing ??
ULTRASOUND
Hysterosalpingogram (HSG) = if no known risk factors for tubal or pelvic pathology, or if laproscopy contraindicated
Diagnostic laproscopy - if possible tubal/pelvic disease, known previous pathology, history suggestive of pathology or previously abnormal HSG
REVISED ROTTERDAMN DIAGNOSTIC CRITERIA = 2 OF…..
oligo/amenorrhoea
polycystic ovaries - 12 or more 2-9mm follicles, increased ovarian volume
clinical and biochemical signs of hyperandrogenism
causes of female infertility
Anovulatory infertility
PCOS
causes of male infertility
- Low testicular volume
- Reduced secondary sexual characteristics
klinefelter’s, cystic fibrosis
what is the first line for ovulation induction??
Clomifene citrate/letrozole
gonadotrophin injections and laparoscopic ovarian diathermy are other options
ART - eligibility for this ??
assisted reproductive technology
female <40 yrs
3 cycles treatment max
non-smokers
no biological child
no illegal substances
female BMI 18.5-30
stable relationship
Methods of abortion??
medical - most use this method, before 23+6 wks
mifepristone and one dose of misoprostol
surgical - vacuum aspiration, up to 12 wks, under local anaesthetic only up to 10 wks
dilatation and evacuation
assessment of gestation
up to how many ___ + ___ gestation is fine for self administration
clinical
ultrasound
up to 11+6 weeks
EMAH
early medical abortion at home
must have had misoprostol before in hospital or clinic
surgical abortion
cervical priming via misoprostol
up to 13 + 6 weeks
what drug is taken at the time of abortion
antibiotic prophylaxis
VTE prophylaxis
contraception after abortion
pretty much all methods of contraception are safe and effective when started after an abortion.
coil
_______ initiates follicular growth。
what 2 hormones stimulate the ovarian follicles to secrete oestrogen
FSH
FSH and LH
when and what happens in the menstrual phase ??
first 5 days of cycle
in ovaries:
FSH influence allows primary follicles -> secondary follicles
in uterus:
fall in oestrogen and progesterone -> release of prostaglandins causing uterine spiral arterioles to constrict
stratum functionalis of endometrium sloughs off leaving the thin stratum Basilis
pre-ovulatory phase
secondary follicles -> oestrogen
oestrogens released into circulation -> growth of endometrium
ovulatory phase
day 14 OF CYCLE
oestrogen -> GnRH release
increase in LH and FSH
postovulatory phase
most constant phase and lasts for 14 days
corpus luteum -> progesterone, oestrogen = fertilisation
P+O -> GROWTH AND COILING OF ENDOMETRIAL GLANDS
Pre-menstrual disorders
impact on daily life
symptoms include - breast tenderness, headache, weight gain, fatigue, mood swings, depression, anger
mx of ovulation suppression
GnRH agonists
mx for heavy menstrual bleeding
1 = mirena coil
2 = tranexamic acid
COC
causes of heavy menstrual bleeding
fibroids - benign
polyps
adenomyosis
coagulopathy
malignancy
