Obs n Gobs Flashcards
What is the nerve supply to the bladder and urethra?
Parasympathetic: S2-4, promotes urination (detrusor contraction)
Sympathetic: T12-L2, stops urination (detrusor relaxation)
Somatic: (voluntary nervous system) Pudendal nerve allows voluntary urination
What is the pressure balance in urination?
Bladder pressure (detrusor and intra-abdominal pressure) VS Urethral pressure ( urethral muscle tone and pelvic floor)
What are the components of the pelvic floor?
Pelvic bones, ligaments (cardinal and uterosacral), pelvic floor muscles (levator ani and coccygeus), pudendal nerve
What are the risk factors of a prolapse:
Age (decreased oestrogen, poor tone) Multiparity Obesity Retroverted uterus Chronic cough Pelvic masses
50% parous women have a prolapse
What are the symptoms of a prolapse?
“Something coming down”
Urinary incontinence or frequency (stress incontinence due to altered urethrovesical angle)
UTI (due to incomplete bladder emptying)
Constipation of difficulty defecating
What are the types of prolapse?
What are the grades of prolapse?
Posterior:
- Rectocoele = rectum
- Enterocoele= small intestine
Anterior
- Cystocoele= bladder
- Vault = vagina in on itself (hysterectomy)
Uterine= uterus
1-3 with 2 at the introitus
Investigations for a prolapse:
Examination
+ any examinations for urinary symptoms (e.g. urine dip)
Management of a prolapse:
1st line: Lifestyle modification: weight loss, smoking cessation and physiotherapy– pelvic floor exercises
2nd line: Pessaries (ring or shelf) + topical oestrogen to prevent vaginal ulceration
3rd line: Surgical repair or hysterectomy
Types of incontinence
Urge: Detrusor overactivity Stress: Sphincter weakness Overflow: Retention Fistula Neurological: MS or nerve damage Functional
What is the aetiology of urinary incontinence?
Previous surgery Childbirth (stress) Diabetes- neuropathy, renal impairment, polyuria/dipsia, reduced immunity and increased infection Recurrent UTI Idiopathic (urge)
What are the risk factors of urinary incontinence?
Age Parity Obesity Smoking Previous surgery
What is the clinical presentation of an overactive bladder?
Urgency Urge incontinence Frequency Nocturia At orgasm Key in the door/ handwash triggers
What is the clinical presentation of a sphincter weakness incontinence?
Involuntary leakage with increased intraabdominal pressure- coughing, laughing, lifting, straining, exercise
What are the investigations for incontinence?
- HISTORY AND EXAMINATION (prolapse)!!
Frequency volume chart (bladder diary)
MSU urinalysis (infection, stones, diabetes, renal disease, carcinoma)
Residual urine measurement (in and out catheter, USS bladder)
ePAQ questionnaire (lifestyle and symptom questionnaire)
Urodynamics
Cystoscopy/ cystogram with contrast
What is the management for stress incontinence?
1st line: weight loss, smoking cessation, pelvic floor exercises (physiotherapy), modify fluid intake, adjunctive pads or toileting aids
2nd Line: Surgery- slings, tension free vaginal tapes
3rd Line: Duloxetine if surgery denied
What is the management for urge incontinence?
1st line: weight loss, smoking cessation, stop caffeine, modify fluid intake, adjunctive pads or toileting aids, bladder retraining
2nd line: medication-
anticholinergics (blocks Ach, blocks parasympathetic NS, blocks detrusor contraction)- oxybutynin, tolterodine
Mirabegron- beta 3 adrenergic receptor agonist, relaxes smooth muscle (detrusor)
3rd line: botox injections
Further: cystoplasty , catheters, bypass (urostomy)
What is the normal duration of a menstrual cycle?
21-38 days (mean 28), 60-80ml blood loss
What is primary vs secondary amenorrhoea?
Primary: menstruation not started
If no secondary sexual characteristics: 14
Otherwise: 16
Secondary: previously normal menstruation caesed for >6 months
What is Kallman’s syndrome?
Hypogonadotropic Hypogonadism
GnRH secreting cells did not migrate to forebrain,
have absence in puberty and anosmia (can’t smell)
craniofacial defects
What are the causes of PRIMARY amenorrheoa?
Constitutional variances/ delays, iatrogenic (drug use- dopamine antagonists)
Anorexia, depression, high exercise levels
Kallman’s, Hypothalamic Hypogonadism, Hyperprolactinaemia (causing reduced GnRH), space occupying lesions, pituitary adenoma, sarcoidosis etc.
Hypo/hyperthyroidism (reduced GnRH) Congenital adrenal hyperplasia (CAH) (deficient in sex steroids)
Turner’s syndrome/ other gonadal dysgenesis, Androgen insensitivity (defective androgen receptor, XY but failure to develop male characteristics), PCOS
Imperforate hymen, tranverse vaginal septum
What are the causes of SECONDARY amenorrheoa?
Menopause, pregnancy, lactation, iatrogenic (drug use- dopamine antagonists)
Anorexia, depression, high exercise levels
Sheehan’s, Hypothalamic Hypogonadism, Hyperprolactinaemia (causing reduced GnRH), space occupying lesions, pituitary adenoma, sarcoidosis etc.
Hypo/hyperthyroidism, Cushing’s (reduced GnRH)
PCOS, adrenal tumours, POF, Asherman’s syndrome, cervical stenosis
What is Sheehan’s syndrome?
Damaged pituitary gland following labour (pituitary necrosis), often caused by hypoxia- PPH or low BP
Presents with hypothyroidism, amenorrhoea,
What is Asherman’s syndrome?
Uterine adhesions
How do you investigate/ manage amenorrhoea?
Investigate: Bloods: LH, FSH, Testosterone, SHBG (low in PCOS), prolactin, TFT
Karyotyping
MRI (head and neck)
Pelvic USS
Treat underlying conditions!
What are the three arms of PCOS? (Rotterdam Criteria)
2/3 needed for clinical diagnosis
Hyperandrogenism
((((Oligomenorrhoea)))) Anovulation- marked by low day 21 progesterone
Polycystic ovaries on USS (12 or more follicles)
What is the clinical presentation of PCOS?
Oligomenorrhoea Hirsutism Infertility Obesity Metabolic syndrome (htn, t2dm)
What are some long term consequences of PCOS?
Infertility T2DM Gestational DM CVD Endometrial cancer
What is the management of PCOS?
WEIGHT LOSS!!!!!!
Smoking cessation
Manage t2dm (metformin), htn, dyslipidaemia, sleep apnoea
COCP (reduced risk of unopposed oestrogen on endometrium (ca risk))
Fertility:
Clomifene
Ovarian drilling
Metformin for fertility
What are the appropriate investigations for PCOS?
- LH:FSH ratio (elevated)
- Testosterone (elevated)
- Day 21 progesterone (reduced)
- SHBG (reduced)
- Fasting or random glucose
- Prolactin (would indicate hyperprolactinaemia as a cause of amenorrhoea)
- BMI + clinical exam
What is menorrhagia?
Heavy periods
What are the causes of pathological menorrhagia?
thyroid disease haemostatic disorders- e.g. VWD Anticoagulant therapies (e.g. warfarin, heparin)
fibroids
uterine or cervical polyps
adenomyosis, endometriosis
Investigations for menorrhagia?
Bloods: Hb, clotting profile, anaemia, TFT, beta HCG
TV USS: fibroids, ovarian mass, polyps
Endometrial biopsy
What is the management of menorrhagia?
Symptomatic.
- Mirena coil
- Antifibrinolytics; Tranexamic acid
NSAIDs: Mefenamic acid
COCP
POP (tricyclic)
Norethisterone
GnRH agonists
Polypectomy, Fibroidectomy, endometrial resection/ablation, Hysterectomy
What is dysmenorrhoea?
Painful periods
What are the causes of dysmenorrhoea?
Primary:
Idiopathic
Excess prostaglandins
Secondary: Adenomyosis Endometriosis Polyps Fibroids PID
Management of Dysmenorrhoea?
Investigate with USS
NSAIDs (inhibit prostaglandins): Paracetamol, cocodamol, mefenamic acid
COCP
Mirena coil
Manage any secondary causes
What are the causes of intra-menstrual bleeding (IMB)?
Normal: mid cycle fall in oestrogen (spotting)
Polyps Carcinoma- cervical, uterine OCP Infection- cervicitis, vaginitis, chlamydia IUCD
What are the causes of post-coital bleeding (PCB)?
!!!!!!! CERVICAL CANCER !!!!!!!
Cervical trauma
Cervicitis, vaginitis, chlamydia
What is an ectropion?
Soft glandular columnar epithelium from inside cervical os is seen on surface of cervix
Normal- caused by hormonal changes, pill
Causes vaginal discharge or PCB
What are the causes of post-menopausal bleeding (PMB)?
!!!!!!!! ENDOMETRIAL CANCER !!!!!!!!!
Oestrogen withdrawal (HRT)
Endometrial or cervical polyps
Vaginitis (atrophic
SE of pessaries
What is normal menopause?
Cessation of menstruation after the age of 45 years old as a result of ovarian exhaustion
Describe progression of menopause
Climacteric phase: transition from reproductive to non reproductive states.
Erratic ovulation and menstruation starts, as ovaries become irregularly responsive to pituitary hormone stimulation, and number of follicles decline.
Once menopause is reached, ovaries “fail” and no longer respond, and there is diminished oestrogen production.
Low oestrogen–> reduced negative feedback to pituitary–> increased LH and FSH.
What are the symptoms of menopause?
EARLY:
Hot flushes, insomnia, irritability, mood swings, lethargy, anxiety, depression, reduced libido, dyspareunia, and failure to achieve orgasm
LONG TERM:
Loss of collagen from skin (drier and wrinkled), hair loss, breast tissue loss (replaced with fatty tissue, and breasts shrink).
Vaginal dryness, thin vaginal walls (increased infection risk), prolapse
Incontinence
Osteoporosis (decreased oestrogen causes calcium loss, raised fracture risk), fractures
CVD- strokes and heart attacks
What investigations can you do in ?Menopause?
LH and FSH (risen)
Mammography
DEXA
Investigate as IMB or PMB (endometrial biopsy)
What is the management of menopause?
HRT- combined oestrogen and progesterone (omit prog. if post hyterectomy as no risk of endometrial cancer as a result of unopposed oestrogen) e.g. tibolone (oral), patches, implant
Testosterone for libido
What are the causes and diagnosis and management of premature menopause/ POI/ POF?
Iatrogenic: chemo/radiotherapy, oophrectomy, hysterectomy
Idiopathic
Infection- mumps, pelvic TB
Autoimmune conditions
Raised FSH + LH, low oestrogen
Managed with HRT until 51y/o (+testosterone for libido)
+ care with CV and osteoporosis risk
Manage fertility- donor egg
What are the benefits of HRT?
Improved symptoms- hot flushes, psych symptoms, loss of libido
Lower risk of fracture and osteoporosis, bowel ca
Slows collagen loss
What are the disadvantages of HRT?
Bleeding (regular or irregular)
Headaches, fluid retention, breast tenderness, PMS
!!!! 2-4x increased risk of thromboembolic disease!!!!
Slight increase of breast cancer (not in POI)
Risks of unopposed oestrogen (endometrial ca)
What is the difference between OCP and HRT?
Supraphysiological (OCP) dose VS Physiological (HRT) dose
OCP therefore causes FSH and LH suppression, and HRT does not (therefore not contraceptive)
What is the presentation and how do you diagnose POF?
Clinical presentation: secondary amenorrhoea, infertility
Diagnosis: <40y/o, 4 months amenorrhoea + FSH > 25 in 2 separate samples over 1 month
Explain the Hypothalamic-Pituitary-Gonadal Axis
Hypothalamus (GnRH)–+++-> Pituitary (FSH or lh)–+++-> Ovary (Oestrogen)–+++—> Pituitary (LH, and suppresses FSH) ((((ovulation)))–++-> Ovary (CL Progesterone) —> Hypothalamus less GnRH
https://www.researchgate.net/figure/Representation-of-the-hypothalamus-pituitary-gonadal-axis-positive-and-negatives_fig4_258056691
Explain the relationship between oestrogen and LH in the menstrual cycle
Oestrogen (produced by GCs) stimulates LH after it reaches a certain threshold, after ovulation, no GC, no oestrogen, no LH.
What is the action of Progesterone in the menstrual cycle?
Progesterone, produced by CL after ovulation, maintains endometrial lining and supports implantation and early pregnancy
What is the action of FSH in the menstrual cycle?
FSH, produced in the pituitary, stimulated by GnRH, causes follicle development.
Stimulates oestrogen production from GCs
Oestrogen negatively feeds back to pituitary to reduce FSH to prevent multiple follicle development
What is the action of oestrogen in the menstrual cycle?
Oestrogen, produced in GCs, stimulated by FSH.
Causes endometrial prolferation.
Stimulates LH production from pituitary after a certain threshold
What is the action of LH in the menstrual cycle?
LH, produced by pituitary, stimulated by GnRH and rising oestrogen levels
Causes follicle rupture (ovulation), maintains corpus luteum
What is the action of progesterone in the menstrual cycle?
Progesterone, produced by the corpus luteum (following ovulation)
Maintains endometrial lining and primes it for implantation of an embryo
Negatively feeds back to the hypothalamus, reducing GnRH production and FSH and LH (which maintain the corpus luteum), therefore CL regression and progesterone decrease–> menstruation
How does hCG effect the menstrual cycle?
Produced by implanted embryo, hCG maintains CL, and therefore progesterone, stopping uterine shedding.
What is the definition of a miscarriage?
Pregnancy loss before 24 weeks
What are common causes of miscarriage?
- chromosomal abnormalities causing incompatibility with life (e.g. aneuploidy)
- abnormal foetal development
- maternal illness (e.g. APS, infection, thrombophilia)
- trauma
What is a threatened miscarriage?
bleeding, with closed os and foetal heartbeat present
25% miscarry
What is an inevitable miscarriage?
bleeding (++) with open os
What is an incomplete miscarriage?
some, but not all product of conception have passed
What is a missed miscarriage?
Foetus dies but still inside, close to asymptomatic
Closed os, no foetal heart
confirmed with USS
How do you manage a miscarriage?
Conservative: watch and wait, analgaesia.
Misoprostol
Surgical evacuation
How do you manage medical TOP?
Mifepristone (+ misoprostol)
or surgical evacuation
What are the risk factors for an ectoptic pregnancy?
- previous ectopic
- structural/ tubal damage (eg. PID/ previous surgery)
- endometriosis
- IUCD
- Progesterone only pill
- subfertility
- IVF
- Adhesions (Asherman’s)
- Infection (current or previous)
- Unsuccessful/ reversed tubal ligation
What is the presentation of an ectopic pregnancy?
Severe abdominal pain (usually unilateral- due to tubal distention or rupture)
PV bleeding
Amenorrhoea
Cervical excitation
What investigations should you conduct for a suspected ectopic pregnancy?
TV USS
beta hCG/ urine pregnancy test
Assess haemodynamic stability: FBC, blood pressure, O2 sats
serum progesterone (identifies failing pregnancy)
What is the management for an ectopic pregnancy?
Conservative: only if woman is stable and has bHCG <1500
Surgical: Salpingotomy, Salpingectomy (if tubal)
Medical: Methotrexate (teratogenic so should have effective contraception afterwards)
What is gestational trophoblastic disease?
Abnormal cells arising from trophoblastic tissue, greater proliferation and hCG secretion.
Non-malignant: Hydatidiform mole
Malignant: Invasive mole (only in uterus), choriocarcinoma (metastatic)
What are the risk factors of gestational trophoblastic disease?
previous GTD
extremes of age
Explain the pathophysiology of gestational trophoblastic disease
Molar pregnancy:
- Complete mole (no foetal tissue, increased risk of choriocarcinoma, 46 chromosomes), 2 sperm + empty ovum, or duplicated single sperm + empty ovum
- Partial mole (contains foetal tissue, 69 chromosomes), 2 sperm + 1 ovum
Choriocarcinoma:
- Choriocarcinoma, malignant trophoblastic tissue, can arise from molar pregnancy or germ cells.
What is the presentation of gestational trophoblastic disease?
irregular vaginal bleeding hyperemesis hyperthyroidism (as hCG mimics TSH) LARGE FOR DATES early pregnancy failure Blood--> raised hCG USS--> snowstorm appearance, grape like clusters
What is the management of gestational trophoblastic disease?
Molar pregnancy:
- remove tissue via suction
- monitor hCG levels
Choriocarcinoma:
- methotrexate based chemotherapy
Explain the background and presentation of Lichen Sclerosus
Potentially autoimmune conditions (often seen with vitiligo and thyroid disease)
Mostly in post-menopausal women
Thin vulval epithelium with loss of collagen
Presents with pruritis and soreness, pink-white papules with come together to form white patches with fissures.
figure of 8 presentation (around vulva and anus)
increased risk of vulval cancer
What is the management of lichen sclerosus?
Observe as it can be premalignant
Ultra-potent topical steroids: Clobetasol Propionate cream
Explain the cervical screening programme
Smears every 3 years from 25-50,
Every 5 years from 50-64
What is Cervical Intra-epithelial Neoplasia (CIN)?
inc. pathophys, grading, risks and management
Pre-invasive phase of cervical cancer
Atypical cells in the squamous epithelium of the cervix (dyskaryotic, increased mitosis and large nuclei)
Graded I-III depending on extent of neoplasia
1/3 women with CIN will develop cervical cancer
Commonly caused by HPV inserting viral DNA into cells, smoking, HIV, OCP/ multiple sexual partners without barrier contraception
Managed by LLETZ (large loop excision of the transformation zone)
What is the clinical presentation of cervical cancer?
Most common cancer in women <35
Often picked up at screening
POST COITAL BLEEDING
watery discharge
weight loss, post-menopausal bleeding, bowel distrubance, fatigue, loss of appetite, general malaise etc.
What investigations are carried out for a ?cervical cancer?
Smear Colposcopy Chlamydia screening Punch biopsy CT for staging
What is a triple swab?
Vaginal swabs- screening for chlamydia, gonorrhoea, bacterial and fungal infections
2 x endocervical (chlamydia + gonorrhoea)
1 x high vaginal (bacterial + fungal)
What is the management for cervical cancer?
LLETZ (large loop excision of the transformation zone)
Cone excision (remove cervix)
Hysterectomy (simple or total +- pelvic lymph nodes)
Chemo/radiotherapy
What cells are involved in cervical cancer?
+ what staging
squamous cell carcinoma
FIGO staging- dependant on extent of spread (only in primary organ, adjacent organs, lymph nodes, other organs)
What cells are involved in endometrial cancer?
+ what staging
glandular/ secretory epithelium- adenocarcinoma FIGO staging (only in primary organ, adjacent organs, lymph nodes, other organs)
What are the risk factors and pathophysiology for endometrial cancer?
+ protective factors?
- UNOPPOSED OESTROGEN
- Obesity (adipose tissue is oestrogenic)
- Nulliparity
- HRT
- Tamoxifen
- PCOS
Protective:
COCP
Smoking
What is the clinical presentation of endometrial cancer?
- post menopausal women
- post menopausal bleeding
(heavy periods in pre-menopausal women)
How do you investigate ?endometrial cancer?
Transvaginal USS to assess endometrial thickness (<4mm is okay)
Endometrial biopsy
Hysteroscopy
What is the management of endometrial cancer?
Hysterectomy± pelvic lymph nodes removal
Radiotherapy
progesterone
What cells are involved in vulval cancer?
Squamous epithelial
What is the aetiology + presentation + management of vulval cancer?
HPV or lichen sclerosus
can present as VIN initially (Vulval Intra-epithlial Neoplasia)
Itching, soreness, bleeding, lump, pain on urination
manage with surgery ± radiotherapy
What cells are involved in ovarian cancer?
Epithelial (serosal)
What is the aetiology and risk factors/protective factors of ovarian cancer?
Epithelial cell tumours (mostly), some stromal/granulosa, germ cell tumours
Aetiology: increased exposure to oestrogen,
!!!!!!! more ovulation !!!!!!!
Risk Factors:
- Early menarche
- Late menopause
- Nulliparity
- IVF
- Family history (BRCA genes)
Protective Factors:
- OCP
- Multiple pregnancies
- Breast feeding
- Hyterectomy ± bilateral salpingoophrectomy
- Tubal ligation
What is the clinical presentation of ovarian cancer?
Older women: approx 75-85 y/o
Often very late presenting
General symptoms:
- IBS like bloating
- Abdominal pain/ discomfort
- Bowel obstruction
What investigations should be done in ?ovarian cancer?
- CA125 (50% positive predictive value) (normal value 35, value above 250 is a referral)
- USS
What is the management for ovarian cancer?
- Surgery (oophrectomy, bowel resection)
- Chemotherapy
- Palliative care
What is endometriosis?
uterine tissue outside the uterus
driven by oestrogen, and therefore is hormonally effected
found commonly:
- pouch of douglas (retrograde menstruation)
- ovaries
- tubal
- bowel
- peritoneum
- points of scar tissue
What are the pathophys theories of endometriosis?
Retrograde menstruation Endometrial metoplasia (cells change into endometrial cells)
What is the presentation of endometriosis?
In women of reproductive age, cyclical presentation of pain, pain is worst a few days before period
- Dysmenorrhoea
- Menorrhagia
- Deep dyspareunia
- Sub-fertility (can damage reproductive structures)
- Dyschezia (pain on defecation)
- Pain improves during pregnancy
How do you diagnose endometriosis?
- Laparoscopy
- Elevated Ca125 (nonspecific, caused by irritation of peritoneum)
- Trialled management works
What is the management of endometriosis?
Analgaesics (NSAIDs: ibuprofen, naproxen, mefenamic acid)
Tranexamic acid for bleeding
Two Pharmacological Approaches:
1. Abolish cycles
- Monophasic and then triphasic COCP/ POP (3 months
back to back with 1 week break)
- Also consider Depot Provera, Implant, Mirena/ Copper
- Medroxyprogesterone/ Norethisterone
- Invoke glandular atrophy
- GnRH analogues + HRT add back (tibolone)
Surgical
- endometrial ablation
- hysterectomy
What is adenomyosis?
Presence of endometrial tissue in the myometrium
What is the presentation of adenomyosis?
- dysmenorrhoea
- menorrhagia
More commonly in older women of reproductive age after childbirth, RF is multiparity
Cyclical pain- worst during cycle
What is the management of adenomyosis?
Tranexamic acid, NSAIDs/ COX inhibs (ibuprofen, naproxen, mefenamic acid, paracetamol)
COCP POP IUD
Surgical
- ablation
- hysterectomy
What are uterine fibroids?
Uterine Leiomyomas
Benign smooth muscle tumours of the uterus (of the myometrium)
Oestrogen dependant- don’t occur and shrink after menopause
What are the risk factors of fibroids?
- Afro-Caribbean
- COCP (gives oestrogen)
- Family history
What is the clinical presentation of fibroids?
- Menorrhagia ± anaemia
- Sub fertility
- Miscarriage
- Pain (torsion of pedunculated fibroid)
- Abdominal mass
What investigations are carried out in ?fibroids or ?polyps?
USS
Hysteroscopy
Endometrial biopsy
What is the management of uterine fibroids?
GnRH analogues (shrinks fibroids and induced amenorrhoea) not long term due to demineralisation and fracture risk
Myomectomy
Uterine artery embolisation
Hysterectomy
What are endometrial polyps?
endometrial growths into uterine cavity, usually benign
(can be precancerous)
Thought to be oestrogen sensitive, grow in high levels of circulating oestrogen
Fibrous tissue core surrounded by columnar epithelium
Occurs due to dysregulated apoptosis and growth
What are the risk factors for endometrial polyps?
Peri- or post-menopausal
hypertension
obesity
tamoxifen
What is the presentation of endometrial polyps?
peri/postmenopausal women
- irregular bleeding
- intramenstrual bleeding
- excessively heavy periods
- post menopausal bleeding
- infertility/ miscarriages
What is the management of endometrial polyps?
GnRH analogues
Polypectomy + histology
What are ovarian cysts + how do you assess risk?
common, usually follicular or CL cysts
mostly benign <5cm
Risk assessment using RMI (risk of malignancy index):
Ca125 x USS score x Menopausal status
USS score: 1-3 based on findings
Menopausal Status: 1-3, 1=pre, 3=post
What are the types of ovarian cyst?
Functional: CL or follicular, can cause pain or bleeding if
rupture/ failure to rupture during ovulation
Endometrioma: chocolate cyst, cyst filled with old blood
Serous cystadenoma: most common in 30-40y/o, 30%
malignant
Mucinous cystadenoma: most common 30-50y/o, 5%
malignant, filled with mucus
Fibroma: benign small fibroid, sometimes presents with
pleural effusion, and ascites (Meig’s)
Teratoma (Dermoid cyst): arise from primitive germ cells
What is the clinical presentation of ovarian cysts?
chronic pain, dull ache, cyclical
dyspareunia
abdominal mass
Rupture/ torsion (Ovarian or cyst):
- acute pain (unilateral)
- vomiting
- rupture: tenderness, guarding, peritonism,
discharge/bleeding
What investigations should be done in ?cyst rupture/torsion?
FBC (WCC, CRP)
Ca125
TVUSS/ MRI
What is the management for ovarian cyst torsion/ rupture?
conservative, analgaesia
surgical laparoscopic correction- resection, oophrectomy, ovary fixation
Preserve fertility
Send to histology
What is Pelvic Inflammatory Disease (PID)?
Infection of the upper reproductive tract
What is the aetiology of PID?
Acending infection from endocervix from endogenous vaginal bacteria (anaerobes), STIs (25% are chlamydia or gonorrhoea), uterine instruments (e.g. hysteroscopy etc.) , postpartum
What are the risk factors and protective factors of PID?
rf: STIs, multiple new sexual partners, recent birth, recent use of uterine instruments
protective: barrier method contraception, Mirena, COCP
What is the clinical presentation of PID?
CERVICAL EXCITATION, ADNEXAL TENDERNESS
Lower abdominal pain Deep dyspareunia Vaginal discharge IMB/ PCB Fever/ malaise Subfertility Ectopic pregnancy/ miscarriage Abscess
What investigations should you carry out in ?PID?
Triple swabs
Examination for cervical excitation and adnexal tenderness
FBC, CRP, Blood cultures, beta hCG
What is the management of PID?
analgaesia
remove IUD
Ab: Ceftriaxone, Doxycycline, Metronidazole, Azithromycin
What investigations are carried out for ?subfertility?
Male: Semen analysis: motility, morphology
What is the definition of subfertility ?
Inability to conceive after 2 years of regular unprotected sexual intercourse
How long is it until the IUD is an effective mechanism of contraception?
Immediate
How long is it until the Progesterone Only Pill (POP) is an effective mechanism of contraception?
2 days
How long is it until the COCP, IUS, implant, Depot is an effective mechanism of contraception?
7 days
What is the management of varicella zoster exposure in pregnancy?
Check previous maternal exposure
If unsure or no; test for VZ immunoglobulins
Give VZ vaccine (an give within 10 days of exposure) (infectious 2 days before rash, until vesicular rash crusts over)
How do you manage Group B Strep in pregnancy?
- risk factors
- investigations
- management
Risk Factors of vertical GBS transmission:
- Previous GBS+ve
- Intrapartum fever >38
- Current preterm labour
- Prolonged rupture of membranes
Investigations:
- Vaginal and rectal swab at 35-37 week IF previous GBS+ve
Management: If +ve cultures or risk factors present
- IV penicillin
What is the management of a missed miscarriage?
vaginal misoprostol
What is assessed at the booking visit?
+ when is it?
<10 weeks
BMI
Blood pressure
Urinalysis (for proteinuria)
Blood test:
FBC + serum Ab (Rhesus status)
Infection: rubella immunisation, syphillis, HIV, Hep B
Haemoglobin electrophoresis (sickle cells)
Glucose tolerance test (if at risk of GD)
History:
Age (risks)
History of current pregnancy (LMP)
Past obstetric history
Past gynae history
Past medical history + drug history
Family history
Full social history (inc. domestic violence and FGM)
What is assessed at the dating scan?
+ When is it?
8-14 weeks
Dating + due date using crown-rump length
Multiple pregnancies
Nuchal translucency measurements
What is assessed at the abnormality scan?
+ When is it?
18-20 weeks
Structural abnormalities
Placental lie
What is the screening for Down’s syndrome?
<14 weeks: 75% sensitivity
- USS nuchal translucency (raised indicated cardiac abnormality)
- PAPP-A (low indicated chromosomal abnormality)
- bHCG (raised in Down’s)
> 15 weeks:
- AFP (reduced)
- uE3 (unconjugated oestriol) (reduced)
- Inhibin A (raised)
- bHCG (raised)
If positive: CVS (quicker) or Amniocentesis (safer and more accurate)
What is assessed at 28 week antenatal check up?
Bloods: FBC, Rhesus status
Urine BP
- given Anti-D*
- offer pertussis vaccine*
What is the antenatal care from 34 weeks onwards?
Check ups every 2 weeks to assess:
- birth plan: vaginal or c-section, analgaesia etc.
- Urine and BP
- growth plotting (symphisiopubic height)
36w: check foetal presentation and placental lie
When is Anti-D prophylaxis given?
28 weeks and 34 weeks
What is assessed at a 41 week scan?
offered membrane sweep and induction of labour
When are the extra antenatal checks for nulliparous women?
25+31 weeks
- Urine and BP
- growth plotting (symphisiopubic height)
What are the risk factors for cord presentation?
Premature rupture of membranes Long umbilical cord Polyhydramnios Multiple pregnancy Abnormal foetal lie (e.g. breech) Placenta praevia Multiparity CPD
What is cord prolapse and why is it worrying?
Umbilical cord descends ahead of the foetus
Causes cord compression or spasm–> foetal hypoxia and death
What is the management of cord prolapse?
Push presenting part of foetus back into uterus (to alleviate cord pressure)
Raise hips above head
Avoid handling cord
Tocolytics e.g. terbutaline
Emergency c-section
What is the diagnostic criteria for hyperemesis gravidarum?
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
What are risk factors for hyperemesis gravidarum?
Multiple pregnancies Trophoblastic disease Hyperthyroidism Obesity Nulliparity
What is the management of hyperemesis gravidarum?
Ginger
P6 Acupressure
Promethazine
Cyclizine
IV fluid correction
What are complications of hyperemesis gravidarum?
Wernicke’s encephalopathy
IUGR or preterm birth
Mallory-Weiss tear
What are the side effects of Entonox in labour?
Maternal nausea and vomiting
What are the side effects of opioids in labour?
+ give examples of the drugs
Maternal: prolonged first/second stage of labour, feelings of unease, euphoria/dysphoria
Foetal: Respiratory depression, diminished breast-feeding behaviours
e.g. pethidine, morphine IM, PCA fentanyl
What level do you insert an epidural?
L3/4
Epidural;
- Indications
- Contraindications
Indications: Maternal request Multiple delivery Instrumental deliveries Maternal hypertension
Contraindications:
Maternal refusal
Allergy
Local infection
What nerves and levels cause pain in labour?
L5-S4
Especially pudendal nerve: S2-4
What are the 4 elements of a CTG?
Baseline foetal heart rate
Foetal heart rate variability
Accelerations
Decelerations
What are the causes of antepartum haemorrhage?
Placental abruption Placenta praevia Vasa praevia Morbidly adherent placenta (accreta, increta, percreta) Uterine
Polyps Fibroids Vulval varicosities Vaginitis Cervicitis Carcinoma
How is an antepartum haemorrhage classified?
Bleeding >24 weeks
What are the risk factors and associations for placental abruption?
Pre-eclampsia/ hypertension
Smoking
Thrombophilia
Multiple pregnancy
Polyhydramnios
IUGR
PROM
Increasing maternal age
Abdominal trauma
IVF
What is the presentation of placental abruption?
Antepartum haemorrhage (could be hidden), blood dark red PAIN Tender, tense uterus- "woody" Normal foetal lie Foetal distress
What are the risk factors and associations with placenta praevia?
Multiparity IVF Dichorionic twins Uterine fibroids Endometriosis Previous c-section
Maternal age
Previous uterine surgery (inc TOP)
What is the antenatal management of placenta praevia?
Detect in 20-week anomaly scan + repeat USS at 36 weeks
Anti D prophylaxis !!
Planned c-section if within 2cm of the os
Normal delivery if not
What is the management of an antenatal haemorrhage?
ABCDE and management
Steroids if <34 weeks
Arrange emergency c-section
What is the presentation and management of vasa praevia?
Antenatal diagnosis by USS
Elective c-section (or emergency if not detected)
What is the presentation of placenta praevia?
!! Bleeding- small bleeds before- bleeding is not concealed, bright red
NO PAIN/ tenderness/ uterine tenseness
Likely abnormal foetal lie
What is the management of morbidly adherent placenta?
Antenatal diagnosis via USS and MRI
Elective c-section at 36-37 weeks
±hysterectomy
What are the complications of an antepartum haemorrhage?
Maternal: DIC Hypovolaemic shock Sheehan's syndrome (pituitary necrosis following hypovolaemic shock) Post-partum haemorrhage
Foetal:
Hypoxia (+brain injury)
Demise
What is the classification of a postpartum haemorrhage?
Primary: haemorrhage within 24 hours of birth
Minor 500-1000ml
Major >1000ml
Secondary: haemorrhage from 24h-12 weeks of birth
What are the causes of PPH?
- Tone: atony++++++++
- Tissue: retained products (placenta)
- Trauma: uterus (rupture, inversion), surgical trauma
- Thrombin: DIC, haemophilia, sepsis, pre-eclampsia, ITP
What are the risk factors for PPH?
Previous PPH Antepartum haemorrhage Nulliparity Multiparity Clotting disorder (e.g. haemophilia)
Uterine malformations
Fibroids
Abnormal placentation
Polyhydramnios
Multiple pregnancy
During labour: Prolonged labour Macrosomia Shoulder dystocia Operative birth (c-section) Instrumental delivery Induction using oxytocin Prolonged syntocinon administration
What are the red flag signs of severe pre-eclampsia?
Severe headaches
Flashing lights
Papilloedema
HELLP - RUQ pain, low platelets, raised LFTs
Clonus/ hyperreflexia (precursor to seizures)
How do you manage pre-eclampsia?
Labetolol
± nifedipine, hydralazine
±magnesium sulphate
Delivery!
Aspirin from week 10-36 in second pregnancy!
What is pre-eclampsia?
Hypertension and proteinuria in pregnancy >20 weeks
What is eclampsia?
Proteinuria, hypertension + seizures in pregnancy
How do you manage eclampsia?
Magnesium sulphate
Delivery
What are the risks associated with pre-eclampsia and eclampsia?
Maternal:
- HELLP syndrome
- DIC
- Acute kidney injury
- ARDS (adult respiratory distress syndrome)
- Neurological complications
- Increased risk of htn/ CV disease in the future
Foetal:
- hypoxic brain injury
- Foetal growth retardation (IUGR)
- LBW
- Prematurity/ preterm birth
- SGA
What is the pathophysiology of pre-eclampsia?
Predisposition leads to poor vascularisation of the placenta
This causes placental ischaemia, and placenta releases thromboplastins (DIC) and renin (vasoconstriction)
This leads to hypertension (to preserve foetal nutrition), proteinuria and eventually seizures (+ foetal growth retardation)
What are symptoms in pre-eclampsia?
Headaches, visual disturbances
RUQ pain
Oedema
Rapid weight gain
What investigations would you do in ?pre-eclampsia?
Bloods: FBCs (Hb, platelets) U+Es (uric acid) LFTs (HELLP) Protein creatinine ratio (raised)
Urine dip
Blood pressure
Regular USS for foetal growth
What are differential diagnoses of pre-eclampsia?
Thrombotic thrombocytopenic purpura
Haemolytic uremic syndrome
Acute fatty liver
essential hypertension
What are the risk factors for pre-eclampsia?
Pre-existing hypertension Previous pre-eclampsia Family history of pre-eclampsia Maternal renal disease Obesity Diabetes (gestational or T2DM) Afrocaribbean Nulliparity Multiple pregnancy
What is cord prolapse and what are the risks?
When the cord is presenting and prolapses through the cervix
Causes vasospasm and foetal distress/ hypoxia
What are the risk factors of cord prolapse?
Obesity Multiparity Abnormal foetal lie PROM Long cord Polyhydramnios
What is the management of cord prolapse?
Alleviate pressure on cord- push foetus back into uterus
Elevate hips over head (e.g. trendelenberg)
Emergency caesarean
What are the risk factors for shoulder dystocia?
Macrosomia CPD Maternal diabetes Maternal obesity Prolonged labour
What is the management of shoulder dystocia?
McRoberts
Suprapubic pressure
Delivery of posterior arm
C-section
What are the complications of shoulder dystocia?
Maternal:
Trauma- 3rd or 4th degree tear
Psychological distress, PTSD
PPH
Foetal:
Hypoxic brain injury and cerebral palsy
Brachial plexus injury- Erb’s palsy
Clavicle fracture
Obstetric cholestasis:
- What is it
- Presentation
- Management
- Risks
Raised bile salts in blood
Presentation: Itching, mild jaundice, pale stools, dark urine, raised LFTs
Management: Ursodeoxycholic acid
Risks: Premature birth, foetal distress (meconium passage), and still birth
What are the risk factors for VTE in pregnancy?
Obesity Smoking Hypertension Pre-eclampsia Maternal age Prolonged labour Multiparity Immobilisation Cancer Trauma FH IVF
What is the management of VTE in pregnancy?
Dalteparin (LMWH)
What is SGA, IUGR and LBW?
SGA- foetus with size below the 10th centile
IUGR- foetus unable to meet genetically predetermined size
LBW- Baby born <2500g
What are the precipitating factors to preterm birth?
Premature rupture of membranes
Cervical weakness
Amnionitis
Preterm labour
What are the risk factors for preterm birth?
Pregnancy related:
- multiple pregnancy
- APH
Non-modifiable
- maternal age (extremes)
- previous PTB
- weak and short cervix
Modifiable
- Maternal infection- BV, UTI, pyelonephritis, appendicitis
What are the complications associated with preterm birth?
Developmental delay
Respiratory distress syndrome + chronic lung disease + pulmonary hypoplasia
Cerebral palsy
Visual impairment
How do you manage premature rupture of membranes?
Admit Observe for signs of chorioamnionitis Oral erythromycin Steroids to mature foetal lungs Magnesium sulphate
What investigations should be done in premature labour?
Sterile speculum- to assess cervical dilation
Bedside fibronectin (indicates upcoming labour)
TVUSS to assess cervical length
What investigations should be done in premature rupture of membranes?
Sterile speculum- to assess cervix
Nitralazine stick (testing that it is amniotic fluid)
High vaginal swab (for GBS)
Assess maternal and foetal well-being regularly
What is the management of preterm labour?
Maternal steroids
Tocolytics- B2 agonists, ritodrine
Abx
What is the management for women at high risk of preterm labour?
Regular scans GBS testing Foetal fibronectin Cervical USS Cervical cerclage
What is the pueperium?
Delivery–> 6 weeks
What is ‘station’?
Level of the head in relation to the ischial spines
Above the spines (further in): -2 (2cm above)
At the spines: 0
Below the spines (further out): +2 (2cm below)
What are the characteristics of labour?
/
What is needed to “diagnose” labour?
Cervical effacement
Regular painful contractions
Mucus plug show or rupture of membranes
What is the first stage of labour?
From 4-10cm cervical dilation
How long should the first stage of labour take?
- How often contractions
Max 12 hrs.
Nulliparous: 1cm dilation per hour
Multiparous: 2cm dilation per hour
contractions every 3-5 min
lasting ~1 min
How long should the second stage of labour take?
- How often contractions?
Max 1hr. before intervention
Nulli: 40 min
Multi: 20 min
Every 30secs-2min
Lasts 90 seconds
What are the movements of the second stage of labour?
Head: flexed to extension
Rotation 90° from occipito-posterior to occipito-transverse
What is a partogram?
Assesses progression in labour
Monitors foetal: HR, head descent
Liquor colour
Cervical dilation
Maternal vital signs
What are the causes of failure to progress in labour?
Power;
- Inefficient uterine action-
Passage;
- Cephalo-pelvic Disproportion
Passenger;
- malpresentation
How do you manage malpresentation?
If breech: extracephalic version or c-section
If occipito-posterior: If prolonged first stage: c-section
If prolonged second stage: manual or ventouse rotation
If occipito-transverse: Usually with incomplete turning during decent- ventouse
If brow or face: c-section
What is the Bishop’s score?
Prelabouring scoring system to establish whether induction is necessary or not
What is included in the Bishop’s score?
Cervix texture: Soft (2), Medium (1), Firm (0)
Cervix length: <0.5 (3), <1 (2), <2 (1), >3 (0)
Cervix dilation: 5+ (3), 4-3 (2), 2-1 (1), <1 (0)
Foetal station: >0 (3), >-1 (2), >-2 (1), >-3 (0)
Foetal position: Anterior (2), Middle (1), Posterior (0)
How do you interpret the Bishop’s score?
Total /13
How do you interpret the Bishop’s score?
Total /13
<5: needs induction
5-9: Needs professional judgement
> 9: spontaneous labour
What are the methods of induction?
Prostaglandin E2 gel in the posterior fornix
Cervical sweeping
ARM and oxytocin infusion
What are the indications of induction of labour?
Gestation: 40-40+14
PROM
Maternal health problems; e.g. hypertension, pre-eclampsia, diabetes, cholestasis
IUGR
Foetal distress
What are the contraindications of induction of labour?
CPD Cord prolapse Vasa praevia Breech/transverse lie Active genital herpes 2+ c-sections or 1 classical c section Triplets +
What is polyhydramnios and how is it established?
Amniotic fluid index >95th percentile for gestational age
Calculated by measuring the vertical measurement of fluid pockets in 4 quadrants
What are the causes of polyhydramnios?
Idiopathic Foetal oesophageal dysfunction; CNS, diaphragm hernia, atresia Duodenal atresia (double bubble) Twin-twin transfusion Foetal hydrops Foetal anaemia Macrosomia Maternial diabetes Maternal lithium Maternal infection Foetal karyotype/ genetic abnormalities
What is foetal hydrops?
Oedema in 2 compartments of the foetus
e.g. scalp, ascites etc.
What are the causes of foetal hydrops?
Twin-twin transfusion Iron-deficiency anaemia Immune; Rh disease Congenital abnormality: e.g. Turners, Noonan's, Alpha thalassaemia
What investigations should you do in polyhydramnios?
Fasting glucose
Karyotyping
TORCH screen
What is the management of polyhydramnios?
Nothing
Indomethacin
Amnioreduction
Paediatric assessment of baby after birth- NG tube passed through to check for abnormalities inc fistulas
What are the risks associated with polyhydramnios?
Maternal:
- PPH (increased uterine contraction needed)
- Malpresentation
Foetal:
- Preterm labour
- Increased risk of congenital abnormality
What is Oligohydramnios?
+ how is it established?
Amniotic fluid index (AFI) < 5th percentile for gestational age
Vertical measurement of fluid space in four quadrants
What are the causes of oligohydramnios?
Placental insufficiency! Pre-eclampsia Premature rupture of membranes Renal agenesis Genetic/ chromosomal abnormalities Maternal infection
What are the risks of an amniocentesis?
- Miscarriage
- Infection
- Rhesus disease
- Club foot
What is the management of PPH as a result of atony?
Bimanual compression
Oxytocin infusion
Ergometrine slow IV/IM
Carboprost IM
Misoprostol rectal
Surgical: Balloon tamponade B-Lynch sutures Bilateral artery ligation (uterine or internal iliac) Hysterectomy
