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Phase 3a Medicine - Riona > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is the cervix and upper 1/3rd of the vagina supported by? (2)

A

Carinal and uterosacral ligaments

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2
Q

What is the middle 1/3rd of the vagina supported by?

A

Endofascial condensation (endopelvic fascia)

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3
Q

What is the lower 1/3rd of the vagina supported by? (2)

A

Levator ani muscles and perineal body

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4
Q

Define urethrocoele

A

Prolapse of the lower anterior vaginal wall involving the urethra only

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5
Q

Define cystocoele

A

Prolapse of the upper anterior vaginal wall involving the bladder (if urethra involved - cystourethrocoele)

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6
Q

Define enterocoele

A

Prolapse of the upper posterior vaginal wall (usually contains loops of small bowel)

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7
Q

Define apical prolapse

A

Prolapse of uterus, cervix, upper vagina

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8
Q

Define rectocoele

A

Prolapse of the lower posterior wall of vagina, involving anterior wall of rectum

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9
Q

What are the 5 stages of pelvic organ prolapse?

A

0 - no descent of pelvic organs during straining
1 - leading surface of prolapse <1cm above hymenal ring
2 - leading surface of prolapse from 1cm above to 1cm below hymenal ring
3 - leading surface ≥1cm below hymenal ring, not complete
4 - vagina completely everted

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10
Q

Give 3 causes of prolapse

A
  • vaginal delivery and pregnancy
  • congenital factors
  • menopause
  • chronic predisposing factors
  • iatrogenic
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11
Q

Give 2 chronic predisposing factors to prolapse

A

Increased intra-abdominal pressure

  • obesity
  • chronic cough
  • constipation
  • heavy lifting
  • pelvic mass
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12
Q

Give 3 symptoms of prolapse

A
  • dragging sensation
  • lump sensation
  • worse at end of day/standing
  • bleeding
  • discharge
  • interference with sex
  • urinary symptoms
  • bowel symptoms
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13
Q

Give 3 examinations for prolapse

A
  • abdominal exam
  • bimanual exam
  • Sims speculum
  • PR
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14
Q

Give 2 investigations for prolapse

A
  • pelvic USS
  • urodynamic testing
  • assessments for fitness for surgery
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15
Q

How is prolapse prevented?

A

Recognition of obstructed labour and avoidance of a prolonged second stage
Pelvic floor exercises after birth

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16
Q

What are the 3 aspects of management for prolapses?

A

General, pessaries, surgery

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17
Q

What is the general management for prolapses? (3)

A

Lose weight
Physiotherapy
Smoking cessation

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18
Q

What does pessary management for prolapse involve?

A

Ring or shelf, change 6-9 monthly

HRT/topical oestrogen

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19
Q

Give 3 different surgical managements for prolapses

A

Uterine - hysteropexy, hysterectomy
Vaginal vault - sacropopexy, sacrospinous fixation
Vaginal wall - anterior and posterior repairs, mesh
Stress incontinence - tape, colposuspension

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20
Q

What is urodynamic stress incontinence?

A

Involuntary leakage of urine on effort, exertion, sneezing or coughing. Often due to urethral sphincter weakness.

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21
Q

Give 3 causes of urodynamic stress incontinence

A

Vaginal delivery and pregnancy
Obesity
Age
Previous hysterectomy

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22
Q

What is the mechanism for urodynamic stress incontinence?

A

1) Increased intra-abdominal pressure (e.g. cough) causes the bladder to be compressed and bladder pressure to increase.
2) Normally, the bladder neck is also compressed and pressure also increases.
3) If pelvic supports are weak the bladder neck can slip below the pelvic floor, and therefore isn’t compressed - no pressure increase.
4) Bladder pressure > urethral pressure = incontinence

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23
Q

Give 2 symptoms of urodynamic stress incontinence

A

Stress incontinence
Urgency
Frequency
Urge incontinence

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24
Q

How is urodynamic stress incontinence examined?

A

Sims’ speculum
Abdominal exam
Cough

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25
Q

What are the investigations for urodynamic stress incontinence?

A

Urine dipstick

Cystometry

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26
Q

What are the 4 domains of management for urodynamic stress incontinence?

A

General, conservative, drugs, surgery

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27
Q

What is the general management for urodynamic stress incontinence?

A

Lose weight
Treat chronic coughs
Decrease excessive fluid intake

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28
Q

What is the conservative management for urodynamic stress incontinence?

A

Pelvic floor muscle training

Vaginal cones/sponges

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29
Q

What is the drug management for urodynamic stress incontinence?

A

Duloxetine

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30
Q

What type of drug is duloxetine

A

Serotonin and noradrenaline reuptake inhibitor

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31
Q

What is the surgical treatment for urodynamic stress incontinence?

A

TVT
TOT
Burch colposuspension
Injectable periuretheral bulking agents

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32
Q

Define overactive bladder

A

Urgency with/without urge incontinence, usually with frequency or nocturia, in absence of proven infection

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33
Q

Define detrusor overactivity

A

Urodynamic diagnosis characterised by involuntary detrusor contractions during filling phase which may be spontaneous/provoked

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34
Q

Give 2 causes for overactive bladder

A

Idiopathic
Iatrogenic
Detrusor overactivity

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35
Q

What is the mechanism for overactive bladder?

A

1) Detrusor contractions large enough to make bladder pressure > urethral pressure
2) Leakage, urge incontinence
3) Can be spontaneous, due to a rise in intra-abdominal pressure, or due to a trigger (tap, key in door)

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36
Q

Give 3 symptoms of an overactive bladder

A 
Urgency
Urge incontinence
Frequency
Nocturia 
Stress incontinence
Leakage at night/orgasm
Childhood enuresis
Faecal urgency
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37
Q

What are the investigations for overactive bladder?

A

Urinary diary

Cystometry

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38
Q

What are the 3 main treatment options for overactive bladder?

A

Conservative
Drugs
Surgery

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39
Q

What does conservative management of overactive bladder involve? (2)

A 
Advice (decreased fluid intake, avoiding caffeine)
Bladder training (delay voiding)
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40
Q

What does drug management of overactive bladder involve? (3)

A

Anticholinergics
Oestrogens
Botulinum toxin A

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41
Q

How do anticholinergics work in overactive bladder?

A

Block muscarinic receptors that mediate detrusor smooth muscle contractions

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42
Q

How does botulinum toxin A work in overactive bladder?

A

Blocks neuromuscular transmission, injected into detrusor

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43
Q

What does surgical management of overactive bladder involve?

A

Neuromodulation and sacral nerve stimulation (S3 nerve route)
Clam augmentation oleocystoplasty

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44
Q

Give 3 investigations for urinary symptoms

A 
Frequency volume chart/bladder diary
Urinanalysis/dip stick
Residual urine measurement
Questionnaire
Urodynamics
45
Q

What is the detrusor muscle innervated by?

A

Sacral roots, parasympathetic

46
Q

What is endometriosis?

A

The presence and growth of endometrial tissue outside of the uterine cavity

47
Q

What is endometriosis dependent on?

48
Q

When does is endometriosis repressed? (2)

A

After menopause

During pregnancy

49
Q

Where does endometriosis most often occur?

A

Uterosacral ligaments
Ovaries
Pouch of Douglas

50
Q

What is an endometrioma?

A

Chocolate cyst/accumulated blood in ovaries

51
Q

Give 2 causes of endometriosis

A

Retrograde menstruation

Mechanical, lymphatic, blood bourne, metaplastic

52
Q

Give 3 symptoms of endometriosis

A 
Chronic cyclical pelvic pain
Dysmenorrhoea before menstruation
Deep dyspareunia 
Subfertilty
Dyschezia during menses
Menstrual problems
53
Q

Give a finding on examination in endometriosis

A

Tenderness and/or thickening behind uterus/in adnexa

Immobile uterus

54
Q

Give 2 investigations for endometriosis

A

Laparoscopy +/- biopsy
Transvaginal USS
MRI
CA125 levels

55
Q

Give 3 medical treatments for endometriosis

A 
Analgesia
COCP
Progestogen
GnRH analogues
Danazol (androgenic)
IUD
56
Q

Give 2 surgical treatments for endometriosis

A

Laparoscopic laser ablation/diathermy
Adhesiolysis
Hysterectomy +/- BSO

57
Q

Give 2 ways in which endometriosis can cause infertility

A 
Immune factors
Oocyte toxicity
Adhesions
Tubal dysfunction
Ovarian dysfunction
58
Q

What are fibroids?

A

Benign tumours of the myometrium

59
Q

What factors make fibroids more common?

A

Near the menopause
Afro-Caribbean
Family history

60
Q

What factors make fibroids less common?

A

Parous
COCP
Progestogen injections

61
Q

When do fibroids regress?

A

Menopause (not necessarily in pregnancy)

62
Q

Give 2 symptoms of fibroids

A

Menstrual problems (menorrhagia, intermenstrual loss)
Dysmenorrhoea
Bladder symptoms
Subfertility

63
Q

Give 2 complications of fibroids

A

Torsion
Degenerations (red, cystic, hyaline)
Malignancy
Pregnancy problems

64
Q

What are the investigations for fibroids?

A

USS, MRI, laparoscopy

Hysteroscopy

65
Q

What are the medical treatments for fibroids?

A

GnRH agonists

Transexamic acid, NSAIDs, progestogens

66
Q

How long can one take GnRH agonists for, why, and what can be done to extend this?

A

~6 months
Bone density decreases, side effects
Take HRT too

67
Q

What are the surgical treatments for fibroids?

A

Hysteroscopic resection
Myomectomy
Hysterectomy

68
Q

Give a less common management of fibroids

A

Uterine artery embolisation

Ablation

69
Q

What is adenomyosis?

A

The presence of endometrium and underlying storm in myometrium

70
Q

How does adenomyosis occur?

A

Endometrium grows into myometrium

71
Q

What are the symptoms of adenomyosis?

A

Painful, regular, heavy periods

72
Q

What are the treatments for adenomyosis?

A

IUD or COCP +/- NSAIDs

Hysterectomy

73
Q

What are endometrial polyps?

A

Small usually benign tumours

74
Q

What are the symptoms of endometrial polyps

A

Menorrhagia
Intermenstrual bleeding
Prolapse through cervix

75
Q

What is the management for endometrial polyps?

76
Q

What is the pathology of most endometrial carcinomas?

A

Adenocarcinoma of columnar endometrial gland cells

77
Q

Give 3 risk factors for endometrial carcinoma

A 
High ratio of oestrogen:progestogen
Obesity
PCOS
Nulliparity and late menopause
Oestrogen secreting tumours
Tamoxifen
78
Q

Give 1 protective factor for endometrial carcinoma

A

COCP

Pregnancy

79
Q

What is the premalignant stage to endometrial carcinoma?

A

Endometrial hyperplasia with atypia

80
Q

Give 2 symptoms of endometrial carcinoma

A

Post-menopausal bleeding
Inter-menstrual bleeding
Abnormal cervical smear

81
Q

What are the stages for endometrial carcinoma? (4)

A

1 - lesions confined to uterus
2 - also in cervix
3- invades through uterus
4 - further spread

82
Q

Give an investigation for endometrial carcinoma

A

USS +/- endometrial biopsy

83
Q

Give 3 managements for endometrial carcinoma

A

Hysterectomy and BSO
Lymphadenectomy
Radiotherapy

84
Q

What is the 5 year prognosis endometrial carcinoma?

A

85% at stage 1

85
Q

Explain the 3 stages of the menstrual cycle

A

Days 1-4: menstruation

  • endometrium shed as hormonal support withdrawn
  • myometrial contractions 😡

Days 5-13: proliferative phase

  • pulses of GnRH from hypothalamus stimulate LH and FSH release, which stimulate follicular growth
  • follicles produce oestradiol and inhibin, which suppress FSH secretion in a negative feedback loop
  • as oestradiol levels rise, a positive feedback effect causes sharp rise in LH
  • 36 hours after LH surge, ovulation
  • oestradiol causes endometrium to become proliferative

Days 14-29: luteal/secretory phase

  • follicle becomes CL, which produces oestradiol and progesterone
  • progesterone induces secretory changes in endometrium
  • if no fertilisation occurs, CL fails, causing oestrogen and progesterone to fall
86
Q

Give 2 features of a proliferative endometrium

A

Stromal cells proliferate

Glands elongate

87
Q

Give 3 features of a secretory endometrium

A

Stromal cells enlarge
Glands swell
Blood supply increases

88
Q

Define menorrhagia

A

Heavy menstrual bleeding in an otherwise normal cycle

89
Q

Define intermenstrual bleeding

A

Bleeding between periods

90
Q

Define irregular periods

A

Periods outside range of 23-35 days with range of >7 days

91
Q

Define postcoital bleeding

A

Bleeding after intercourse

92
Q

Define primary amenorrhoea

A

Periods never start

93
Q

Define secondary amenorrhoea

A

Periods stop for 6 months or more

94
Q

Define oligomenorrhoea

A

Infrequent periods (> every 35 days)

95
Q

Define post-menopausal bleeding

A

Bleeding 1 year after menopause

96
Q

Define dysmenorrhoea

A

Painful periods

97
Q

What is the clinical definition of menorrhagia?

A

Excessive menstrual blood loss that interferes with physical, emotional, social and material QOL

98
Q

What is the objective definition of menorrhagia?

A

> 80mL blood loss

99
Q

Give 2 causes of menorrhagia

A 
Subtle abnormalities of endometrial haemostasis or uterine PG levels
Fibroids
Polyps
Coagulation disorders
Adenomyosis
100
Q

Give 2 symptoms of menorrhagia

A

Flooding

Large clots

101
Q

Give 2 investigations for menorrhagia

A 
Haemoglobin
Coagulation and thyroid function 
Transvaginal USS
Endometrial biopsy
Hysteroscopy
102
Q

What is the first line medical treatment for menorrhagia?

103
Q

What is the second line medical treatment for menorrhagia? (3)

A

Antifibrolytics
NSAIDs
COCP

104
Q

What is the third line medical treatment for menorrhagia?

A

Progestogens

GnRH agonists

105
Q

What are the surgical treatments for menorrhagia? (5)

A 
Polyp removal
Fibroid removal/myomectomy
Endometrial ablation
Hysterectomy 
Uterine artery embolisation
106
Q

What are the two causes of irregular menstruation and IMB?

A

Anovulatory cycles

Pelvic pathology

107
Q

Who are more likely to have anovulatory cycles in irregular menstruation and IMB?

A

Just started menarche

Almost at menopause

108
Q

Give 2 investigations for irregular menstruation and IMB

A

Haemoglobin levels
Cervical smear
USS
Endometrial biopsy

109
Q

Give 2 drug treatments for irregular menstruation and IMB

A

IUS
COCP
Progestogens
HRT

Phase 3a Medicine - Riona (3 decks)

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