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MBBS Y5 > Obstetrics and Gynaecology 1 > Flashcards

Obstetrics and Gynaecology 1 Flashcards

1
Q

What is a Miscarriage?

A

Loss of pregnancy before 24 weeks gestation

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2
Q

What is an EARLY vs LATE Miscarriage?

A

Early miscarriage: 13- wksLate miscarriage: 13-24 wks

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3
Q

What percentage of pregnancies end up as Miscarriages?

A

30%

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4
Q

What are the RF for Miscarriages? (5 things)

A
  1. Age (both maternal + paternal like 35+)2. Black ethnicity3. Obesity4. Infection (e.g appendicitis)5. Anti-phospholipid syndrome
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5
Q

What is the single most common cause of Miscarriages in 1st trimester?

A

Chromosomal abn

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6
Q

What should you sus in with all women with bleeding in early pregnancy?

A

Miscarriage

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7
Q

What are the classifications of Miscarriages? (5 things)

A
  1. Missed2. Threatened3. Inevitable4. Incomplete5. Complete
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8
Q

What is a Missed Miscarriage?

A

Asymptomatic miscarriage

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9
Q

What is a Threatened Miscarriage?

A

Ongoing viable pregnancy w Bleeding

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10
Q

How long do symptoms of Threatened Miscarriage last?

A

Days / weeks

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11
Q

What is an Inevitable Miscarriage? (2 things)

A
  1. Non-viable pregnancy w Bleeding2. Pregnancy tissue still in uterus
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12
Q

What will an Inevitable Miscarriage become? (2 things)

A

Incomplete OR Complete miscarriage

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13
Q

What is the difference between INCOMPLETE and COMPLETE Miscarriage?

A

Incomplete: still has some products of conception left (seen in US)Complete: all products of conception have been expelled + bleeding STOPPEDPlus Cervical Os still Open in Incomplete

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14
Q

What are the CF of Miscarriages? (2 things)

A
  1. Bleeding2. Abd pain
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15
Q

What is the blood like in Miscarriage?

A

Usually low volume

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16
Q

What are the CF of Miscarriage if there is Excessive bleeding? (4 things)

A

Haemodynamic instability:1. Pale2. Tachycardia3. Hypotension4. Tachypnoea

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17
Q

What are the CF of Miscarriage @ Abd examination? (2 things)

A
  1. Distension2. Localised tenderness
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18
Q

What are the CF of Miscarriage @ Speculum examination? (3 things)

A
  1. Products of conception in Cervical canal2. Bleeding3. Cervical os (Open / Closed)
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19
Q

What is the Cervial Os like in a MISSED Miscarriage?

A

Closed

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20
Q

What is the Cervial Os like in a THREATENED Miscarriage?

A

Closed

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21
Q

What is the Cervial Os like in an INEVITABLE Miscarriage?

A

Open

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22
Q

What is the Cervial Os like in an INCOMPLETE Miscarriage?

A

Open

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23
Q

What is the Cervial Os like in a COMPLETE Miscarriage?

A

Closed

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24
Q

When is the only times the Cervical Os is OPEN in a Miscarriage? (2 things)

A
  1. Inevitable2. IncompleteOpeN iN iN
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25
Q

What are the CF of Miscarriage @ Bimanual examination? (2 things)

A
  1. Uterine tenderness2. Adnexal masses / collections
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26
Q

What are some other Differential Dx of Miscarriage? (3 things)

A
  1. Ectopic preg2. Hydatidiform mole3. Cancer (cervical / uterine)
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27
Q

Where should pt with sus Miscarriage be investigated?

A

EPAU

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28
Q

What investigation gives you a Definitive Dx of Miscarriage?

A

Transvaginal US

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29
Q

What will you NOT see in a Transvaginal US that will give you a Dx of Miscarriage?

A

Fetal Cardiac Activity

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30
Q

What weeks will you check for Fetal Cardiac Activity to check for Miscarriage Dx?

A

5.5 – 6 wks gestation

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31
Q

How can you calculate the weeks of gestation using US?

A

Crown Rump Length (CRL)

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32
Q

What are the measurements for a definitive Dx of MISSED Miscarriage? (2 things)

A
  1. CRL: 7+ mm2. NO Fetal Cardiac Activity(both together)
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33
Q

Can you make a Dx of Missed Miscarriage if you have NO Fetal Cardiac Activity but the CRL is LESS than 7mm?

A

No, you have to repeat US 7 days later to confirm

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34
Q

What are the measurements for a definitive Dx of Empty Sac Miscarriage (aka Anembryonic Pregnancy? (2 things)

A
  1. Mean Sac Diameter (MSD): 25+ mm2. NO Yolk Sac / Embryonic Pole (Fetal pole in pic)(both together)
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35
Q

Can you make a Dx of Empty Sac Miscarriage (aka Anembryonic Pregnancy if you have NO Yolk Sac / Embryonic Pole but the MSD is LESS than 25mm?

A

No, you have to repeat US 10-14 days later to confirm

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36
Q

What investigation can be done if US is not immediately available for Miscarriage?

A

Serum b-HCG blood test (helps Dx viable n non-viable pregnancy)

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37
Q

What other investigations can you do for bleeding women? (3 things)

A
  1. FBC2. Blood group + Rhesus status3. Triple swabs + CRP (esp if pyrexial)
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38
Q

What is the Tx of for Threatened Miscarriages? (2 things)

A
  1. Analgesia2. Vaginal micronised progesterone (400mg twice daily) (NICE 2021)
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39
Q

Who should have Vaginal Micronised Progesterone according to NICE 2021?

A

Woman who is:1. Pregnant (confirmed by scan)2. Bleeding3. Had a previous miscarriage(All 3)

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40
Q

What does Vaginal Micronised Progesterone do?

A

Helps preserve Threatened Miscarriage into Live Birth

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41
Q

If Fetal Cardiac Activity is confirmed while on Vaginal Micronised Progesterone, what should you do?

A

Continue VMP until 16 wks

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42
Q

What should you give if any type of Miscarriage pt (even threatened) is 12+ wks and Rhesus Negative?

A

Anti-D immunoglobulin

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43
Q

What is FIRST LINE management of Miscarriages?

A

Expectant (conservative) management (aka jus wait n let it come out naturally)

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44
Q

Who should be offered Expectant management of Miscarriage?

A

6- wks gestation w bleeding but NO pain

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45
Q

How long should you trial Expectant management for Miscarriages for?

A

7-14 days

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46
Q

If you do Expectant management of a miscarriage, and symptoms resolve within 7-14 days, what should the pt do next?

A

Pregnancy test @ 3 wks (if positive come bk)

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47
Q

What are the Advantages of Expectant Management of Miscarriage? (3 things)

A
  1. Can go home2. No meds side fx3. No anaesthetic / surgery risk
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48
Q

What are the Disadvantages of Expectant Management of Miscarriage? (4 things)

A
  1. Unpredictable timing2. Heavy bleeding + Pain @ passing POC (products of conception)3. Might not work4. Might need transfusion
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49
Q

What are the CI for Expectant management for Miscarriages? (4 things)

A
  1. Infection2. Increased risk of haemorrhage (e.g coagulopathy)3. Hx of bad pregnancies4. Pt doesn’t want to
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50
Q

What are the MEDICAL management options for Miscarriages? (3 things)

A
  1. Misoprostol (vaginal / oral) (vaginal is preffered)2. Analgesia (PRN)3. Anti-emetics (PRN)
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51
Q

What is Misoprostol? (2 things)

A
  1. Synthetic prostaglandin that stimulates Cervical Ripening + Uterine contractions2. Used as Medical management for miscarriages
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52
Q

What should you give 24-48 hours before Misoprostol?

A

Mifepristone

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53
Q

What is Mifepristone?

A

Anti-progestational steroid (blocks progesterone)(progesterone helps pregnancy, remember dat lecturer said its PRO-GEST-erone)

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54
Q

What should you do after giving Misoprostol?

A

Pregnancy test @ 3 weeks

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55
Q

What happens if Pregancy test @ 3 wks after Misoprostol is still Positive?

A

Specialist review

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56
Q

What are the Advantages of Medical Management of Miscarriage? (2 things)

A
  1. Can go home2. No anaesthetic / surgery risk
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57
Q

What are the Disadvantages of Medical Management of Miscarriage? (3 things)

A
  1. Meds side fx: D+V2. Heavy bleeding + Pain @ passing POC (products of conception)3. Might not work (might need emergency surgical intervention)
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58
Q

What should you do if Expectant and Medical Management of Miscarriages fail?

A

Surgical management

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59
Q

What are the 2 main options for Surgical management of Miscarriages?

A
  1. Manual vacuum aspiration (under LOCAL) (if 12- wks)2. Evacuation of Retained Products of Contraception (ERPC) (under GENERAL)
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60
Q

Who is Manual vacuum aspiration more suitable for?

A

Parous women (given birth b4)

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61
Q

What are the Indications for Surgical management of Miscarriage? (3 things)

A
  1. Haemodynamically unstable2. Infected tissue3. Gestational trophoblastic disease
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62
Q

What are the Advantages of Surgical management of Miscarriage? (2 things)

A
  1. Planned procedure (helps pt cope)2. Pt unconscious (under general)
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63
Q

What are the Disadvantages of Surgical management of Miscarriage? (7 things)

A
  1. Infection (endometriosis)2. Bleeding3. Ashermen’s syndrome (scar tissue aka adhesions form inside uterus)4. Uterine perforation5. Bowel / bladder damage6. Retained POC (products of contraception)7. Anaesthetic risk
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64
Q

What is given before Surgical management of Miscarriage and why?

A

Misoprostol, to soften cervix

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65
Q

When can sexual intercourse resume after a miscarriage?

A

Once symptoms have completely settled

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66
Q

When can a pt start trying to conceive again after a miscarriage?

A

@ 4-8 wks bc that’s when menstruation will resume

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67
Q

What is a Recurrent miscarriage according to RCOG?

A

3+ consecutive pregnancies that end in miscarriage of fetus before 24 weeks gestation

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68
Q

What is the epidemiology of Recurrent Miscarriages?

A

1-2% women

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69
Q

What are the RF for Recurrent Miscarriages? (3 things)

A
  1. Age2. No. of previous miscarriages3. Lifestyle (smoking / alcohol / caffeine)
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70
Q

The risk of miscarriage increases after each miscarriage… what is the risk of a 4th miscarriage after the 3rd one?

A

40%

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71
Q

What are the causes of Recurrent Miscarriages? (7 things)

A
  1. Antiphospholipid syndrome2. Genetic factors (parental / embyronic chromosomal abn)3. Endocrine factors (DM / Thyroid / PCOS)4. Anatomical factors (uterine abn / cervical weakness)5. Infection (any severe infection / bacterial vaginosis)6. Inherited thrombophilia7. Idiopathic (esp older women)
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72
Q

What happens in Antiphospholipid syndrome?

A

Blood clots more

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73
Q

How can you get Antiphospholipid syndrome? (2 things)

A
  1. Randomly2. Secondary to SLE
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74
Q

What percentage of Recurrent Miscarriage women have Antiphospholipid syndrome?

A

15%

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75
Q

What is the live birth rate for women with Antiphospholipid syndrome with no pharma intervention?

A

10% :( , but dw is treatable

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76
Q

What percentage of Recurrent Miscarriage couples have a Parental chromosomal abn being carried by one of the parents?

A

2-5%

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77
Q

What Parental chromosomal abn can be carried that cause Recurrent Miscarriages? (2 things)

A
  1. Balanced reciprocal2. Robertsonian translocation
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78
Q

If DM and Thyroid disease are WELL controlled @ conception / during pregnancy is that calm?

A

Yh

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79
Q

What Uterine abn can cause Recurrent Miscarriages? (6 things)

A
  1. Asherman’s syndrome (adhesions of uterus)2. Fibroids3. Septate uterus (partition thru uterus)4. Unicornuate uterus (single horned uterus)5. Bicornuate uterus (heart shaped uterus)6. Didelphic uterus (double uterus)
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80
Q

How can Cervical weakness cause Recurrent Miscarriages?

A

Cervix effaces and dilates before term

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81
Q

When does Cervical weakness cause Miscarriage?

A

2nd trimester

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82
Q

How can Bacterial vaginosis cause Recurrent Miscarriages?

A

Infection in 1st trimester –> 2nd trimester miscarriage

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83
Q

How is the Bacterial vaginosis cause of Recurrent Miscarriages prevented against?

A

Screening in 1st trimester + Tx if appropriate

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84
Q

What are the Inherited Thrombophilias that cause Recurrent Miscarriages? (4 things)

A
  1. Factor V Leiden2. Prothrombin gene mutation3. Protein C/S deficiencies4. Antithrombin 3 deficiency
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85
Q

When do Inherited Thrombophilias cause Miscarriages?

A

2nd trimester

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86
Q

How do Inherited Thrombophilias cause Miscarriages?

A

Thrombosis of uteroplacental circulation

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87
Q

When should investigations be started for Recurrent Miscarriages? (2 things)

A
  1. After 3+ 1st trimester miscarriages2. After 1+ 2nd trimester miscarriages
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88
Q

What different types of investigations can be done for Recurrent Miscarriages? (3 things)

A
  1. Blood tests2. Genetic tests3. Imaging
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89
Q

What blood tests can be done for Recurrent Miscarriages? (2 things)

A
  1. Antiphospholipid antibodies2. Inherited thrombophilia screen
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90
Q

How is a diagnosis of Antiphospholipid syndrome confirmed with blood tests? (3 things)

A

2 positive tests at least 12 weeks apart for either:1. Lupus Anticoagulant2. Anticardiolipin Antibodies3. Anti-B2-Glycoprotein Antibodies

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91
Q

What is checked for in an Inherited Thrombophilia Screen for Recurrent Miscarriages? (4 things)

A
  1. Factor V Leiden2. Prothrombin gene mutation3. Protein C/S deficiencies4. Antithrombin 3 deficiency
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92
Q

What genetic tests can be done for Recurrent Miscarriages? (2 things)

A
  1. Cytogenic analysis2. Parental peripheral blood karyotyping
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93
Q

What does Cytogenic analysis check for in Recurrent Miscarriages?

A

Chromosomal abn

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94
Q

What tissue is Cytogenic analysis done on in Recurrent Miscarriages?

A

Products of conception

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95
Q

When is Cytogenic analysis done for Recurrent Miscarriages?

A

After 3rd miscarriage + all ones after that

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96
Q

When should you do Parental peripheral blood karyotyping for Recurrent Miscarriages?

A

When Products of conception testing shows unbalanced structural chromosomal abn

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97
Q

Who is Parental peripheral blood karyotyping done on?

A

Both partners

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98
Q

What imaging can be done for Recurrent Miscarriages?

A

Pelvic US

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99
Q

What is a Pelvic US checking for in Recurrent Miscarriages?

A

Uterine anatomy

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100
Q

If you sus uterine abn in Pelvic US, what further investigations should you do to confirm Dx? (3 things)

A
  1. Hysteroscopy2. Laparoscopy3. 3D Pelvic US
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101
Q

What should patients with Recurrent Miscarriages be referred for?

A

Specialist treatment

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102
Q

How should you manage a couple with abn Parental karyotypes?

A

Refer to clinical geneticist (genetic counselling)

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103
Q

Will surgical correction of Uterine abn (like septated uterus) change the pregnancy outcome?

A

No (no evidence on this so far)

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104
Q

Will surgical correction of Cervical weakness change pregnancy outcome?

A

Yes

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105
Q

What is the surgical treatment for Cervical weakness?

A

Cervical cerclage (suture used to close cervix)

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106
Q

What are the indications for Cervical cerclage? (3 things)

A
  1. Poor obstetric Hx (3+ 2nd trimester miscarriages)2. Cervical shortening on US (25-mm before 24 wks + Hx of 2nd trimester miscarriage)3. Symptomatic + Premature Cervical dilatation + Exposed Fetal membranes in vagina
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107
Q

What are the complications of Cervical Cerclage? (3 things)

A
  1. Bleeding2. Membrane rupture3. Stimulating uterine contractionsTherefore need senior involvement n counselling b4 decision
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108
Q

What should you offer women with Hx of 2nd trimester miscarriages + Sus cervical weakness who have NOT had Cervical cerclage?

A

Serial Cervical Sonographic Surveillance

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109
Q

What is the treatment for Recurrent Miscarriages caused by Antiphospholipid Syndrome? (2 things)

A
  1. Low dose aspirin2. LMWH
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110
Q

What is the treatment for 2nd trimester Recurrent Miscarriages caused by Inherited Thrombophilias?

A

Heparin

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111
Q

What can you offer a woman with Unexplained Recurrent Miscarriages?

A

Preimplantation genetic screening + IVF (no evidence on this tho)

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112
Q

What is Heavy Menstrual Bleeding?

A

Excessive menstrual loss which interferes with a woman’s quality of life

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113
Q

What percentage of women experience Heavy Menstrual Bleeding?

A

3%

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114
Q

What age group of women are most affected by Heavy Menstrual Bleeding?

A

40-51 years old

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115
Q

What is the mnemonic used to divide the different causes of Heavy Menstrual Bleeding?

A

Palm-Coein

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116
Q

What does the PALM bit of the Palm-Coein mnemonic mean?

A

Structural causes of Heavy Menstrual Bleeding:P – PolypA – AdenomyosisL – Leiomyoma (Fibroid)M – Malignancy / hyperplasia

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117
Q

What does the COEIN bit of the Palm-Coein mnemonic mean?

A

Non-structural causes of Heavy Menstrual Bleeding:C – CoagulopathyO – Ovulatory dysfunctionE – EndometrialI – IatrogenicN – Not yet classified

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118
Q

What are the main risk factors for Heavy Menstrual Bleeding? (2 things)

A
  1. Age2. Obesity
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119
Q

What are the CF of Heavy Menstrual Bleeding? (3 things)

A
  1. Bleeding2. Fatigue3. SOB (if associated anaemia)
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120
Q

What are you looking for @ examination of Heavy Menstrual Bleeding patient? (4 things)

A
  1. Pallor (anaemia)2. Palpable uterus / pelvic mass3. Inflamed cervix / cervical polyp / tumour4. Vaginal tumour
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121
Q

What are you suspecting if a Heavy Menstrual Bleeding patient has an irregular uterus @ examination?

A

Fibroids

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122
Q

What are you suspecting if a Heavy Menstrual Bleeding patient has a tender uterus / cervical excitation @ examination? (2 things)

A
  1. Adenomyosis2. Endometriosis
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123
Q

What are the differential diagnoses for Heavy Menstrual Bleeding? (9 things)

A
  1. Pregnancy2. Endometrial / cervical polyps3. Adenomyosis4. Fibroids5. Malignancy / endometrial hyperplasia6. Coagulopathy7. Ovarian dysfunction8. Iatrogenic causes9. Endometriosis
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124
Q

What are the CF of Endometrial / cervical polyps? (3 things)

A
  1. Intermenstrual bleeding2. Post-coital bleeding3. NOT associated w dysmenorrhea (painful periods)
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125
Q

What are the CF of Adenomyosis? (2 things)

A
  1. Dysmenorrhea2. Bulky uterus (@ exam)
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126
Q

What are the CF of Fibroids? (2 things)

A
  1. Hx of pressure symptoms (e.g urinary frequency)2. Bulky uterus (@ exam)
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127
Q

What is the most common Coagulopathy to cause Heavy Menstrual Bleeding?

A

Von Willebrand’s disease

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128
Q

What are the CF of Von Willebrand’s disease? (5 things)

A
  1. HMB since menarche2. PPH Hx3. Surgical / dental related bleeding (bleeding gums)4. Easy bruising / epistaxis5. Bleeding disorder FHx
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129
Q

What should you consider for pt w Von Willebrand’s disease?

A

Warfarin (anti-coagulant)

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130
Q

What are the most common causes of Ovarian dysfunction? (2 things)

A
  1. PCOS2. Hypothyroidism
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131
Q

What are the iatrogenic causes of HMB? (2 things)

A
  1. Contraceptive hormones2. Copper IUD
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132
Q

What percentage of all HMB does Endometriosis represent?

A

Less than 5%

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133
Q

What investigations should you do for HMB? (5 things)

A
  1. Urine pregnancy test2. FBC3. TFT4. Hormone tests (e.g if sus PCOS)5. Coag screen (+ check for Von Willebrand’s) if sus
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134
Q

Why should you do a FBC for HMB?

A

Anaemia presents after 120ml menstrual blood loss

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135
Q

When should you do a TFT for HMB?

A

If has other signs of hypothyroidism

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136
Q

What imaging should you do for HMB?

A

Transvaginal US

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137
Q

What is a Transvaginal US useful for?

A

Checking endometrium / ovaries

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138
Q

When should you for a Transvaginal US in HMB? (2 things)

A
  1. Uterus / pelvic mass palpable @ exam2. Pharmacological tx failed
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139
Q

When should you do a Cervical smear in HMB?

A

If hasn’t had routine ones done

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140
Q

What investigation should you for HMB if sus infection?

A

High vaginal / endocervical swabs

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141
Q

What biopsy can be done for HMB?

A

Pipelle endometrial biopsy

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142
Q

When should you do a Pipelle endometrial biopsy in HMB? (3 things)

A
  1. Persistent intermenstrual bleeding2. 45+ age3. Pharmacological tx failed
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143
Q

When should you do a Hysteroscopy / Endometrial biopsy for HMB?

A

US identifies pathology / is inconclusive

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144
Q

What is the aim of management of HMB?

A

Improve woman’s quality of life (rather than specific reduction in blood loss volume)

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145
Q

When considering HMB management options, what should you discuss with the patient?

A

Impact on fertility

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146
Q

What is the management approach for HMB when there is no sus pathology?

A

3 tiered approach

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147
Q

What is the 3 tiered approach for HMB?

A
  1. Levonorgestral-releasing intrauterine system (LNG-IUS)2. Tranexamic acid / Mefanamic acid / COCP3. Progesterone only: Oral Norethisterone / Depo / Implant
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148
Q

What does Levonorgestral-releasing intrauterine system (LNG-IUS) also act as?

A

Contraceptive

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149
Q

How long is Levonorgestral-releasing intrauterine system (LNG-IUS) licenced for treatment?

A

5 years

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150
Q

How does Levonorgestral-releasing intrauterine system (LNG-IUS) work? (2 things)

A
  1. Thins endometrium2. Shrinks fibroids
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151
Q

What does the woman’s choice to use Tranexamic acid / Mefanamic acid / COCP depend on?

A

Her wishes for fertility

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152
Q

When should Tranexamic acid be used?

A

Only during menses to reduce bleeding

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153
Q

Does Tranexamic acid have an effect on fertility?

A

No

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154
Q

What is a pro for using Mefanamic acid?

A

Is an NSAID = offers analgesia for dysmenorrhoea

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155
Q

When should Mefanamic acid be used?

A

Only during menses to reduce bleeding

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156
Q

Does Mefanamic acid have an effect on fertility?

A

No

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157
Q

Does Oral Norethisterone work as a contraceptive?

A

No

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158
Q

Do Depo / Implant progesterone work as a contraceptive?

A

Yes

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159
Q

What are the main Surgical management options for HMB? (2 things)

A
  1. Endometrial ablation2. Hysterectomy
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160
Q

What are some other Surgical management options only for HMB caused by fibroids? (2 things)

A
  1. Myomectomy2. Uterine artery embolization
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161
Q

What is Endometrial ablation?

A

Lining of uterus obliterated

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162
Q

Who is Endometrial ablation suitable for?

A

Women who no longer wish to conceive

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163
Q

By how much does Endometrial ablation reduce HMB?

A

Up to 80%

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164
Q

Where can Endometrial ablation be performed?

A

Outpatient using local anaesthetic

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165
Q

What is the only definitive treatment for HMB?

A

Hysterectomy

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166
Q

What does Hysterectomy offer? (2 things)

A
  1. Amenorrhoea2. End to fertility
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167
Q

What are the types of Hysterectomy performed? (2 things)

A
  1. Subtotal (partial)2. Total
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168
Q

What is Subtotal (partial) Hysterectomy?

A

Removal of uterus but NOT cervix

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169
Q

What is Total Hysterectomy?

A

Removal of uterus and cervix

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170
Q

What openings can Hysterectomy be performed via? (2 things)

A
  1. Abdominal incision2. Vagina
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171
Q

What is the most common gynaecological disorder?

A

Dysmenorrhoea

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172
Q

What is Dysmenorrhoea?

A

Painful periods

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173
Q

What are the pathophysiological steps of Dysmenorrhoea? (5 steps)

A
  1. Absence of fertilisation2. Corpus luteum regresses3. Decline in oestrogen + progesterone prod4. Endometrial cells release Prostaglandin5. Excess prostaglandin release –> primary dysmenorrhoea
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174
Q

What are main actions of Prostaglandins on the uterus? (2 things)

A
  1. Spiral artery vasospasm (–> ischaemic necrosis + endometrium shedding)2. Increased myometrial contractions
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175
Q

What are the RF for primary dysmenorrhoea? (5 things)

A
  1. Early menarche2. Long menstrual phase3. Heavy periods4. Smoking5. Nuliparity
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176
Q

Where is the pain of dysmenorrhoea?

A

Lower abd / pelvic pain

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177
Q

Where can the pain of dysmenorrhoea radiate to? (2 things)

A
  1. Lower back2. Ant thigh
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178
Q

What is the quality of the pain of dysmenorrhoea?

A

Crampy

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179
Q

How long does the pain of dysmenorrhoea last for and when does it occur?

A

48-72 hours during menstrual period

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180
Q

When is the pain of dysmenorrhoea worse?

A

At menses onset

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181
Q

What other symptoms can come w dysmenorrhoea? (5 things)

A
  1. Nausea2. Dizziness3. Malaise4. Vomiting5. Diarrhoea
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182
Q

What signs might you find @ examination of a pt w dysmenorrhoea?

A

Uterine tenderness

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183
Q

What is special about diagnosing primary dysmenorrhoea?

A

It is a diagnosis of exclusion: so you have to exclude causes of SECONDARY dysmenorrhoea

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184
Q

What are the causes of secondary dysmenorrhoea to exclude? (4 things)

A
  1. Endometriosis2. Adenomyosis3. Pelvic inflamm disease4. Adhesions
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185
Q

What investigations are needed for primary dysmenorrhoea dx?

A

None

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186
Q

What scenarios would make you do some investigations in sus primary dysmenorrhoea? (2 things)

A
  1. Pt = high risk for STI –> do high vaginal swab / endocervical swabs2. Pelvic mass palpated @ exam –> transvaginal US (TVS) for further investigation
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187
Q

What is the aim of management in primary dysmenorrhoea?

A

Symptomatic improvement (bc ders no pathology to treat)

188
Q

What lifestyle advice would you give a pt w primary dysmenorrhoea?

A

Stop smoking

189
Q

What is the FIRST line pharmacological tx for primary dysmenorrhoea? (2 things)

A
  1. NSAIDs (ibuprofen / naproxen / mefenamic acid)2. +/- paracetamol
190
Q

Why do NSAIDs work to treat primary dysmenorrhoea?

A

They inhibit prostaglandin production (which we said is the cause of primary dysmenorrhoea)

191
Q

What is the SECOND line pharmacological tx for primary dysmenorrhoea?

A

Trial of hormonal contraception (3-6 month trial)

192
Q

What pill is used first line for hormonal contraception trial tx of primary dysmenorrhoea?

A

Monophasic combines oral contraceptive pill

193
Q

What else can be used for hormonal contraception trial tx of primary dysmenorrhoea?

A

Intrauterine system (e.g Mirena coil)

194
Q

What are some non pharmacological tx options for primary dysmenorrhoea? (2 things)

A
  1. Local heat application (water bottles / heat patch)2. Transcutaneous Electrical Nerve Stimulation (TENS)
195
Q

How do you classify Amenorrhoea?

A

Primary and Secondary

196
Q

What is Primary Amenorrhoea? (2 things)

A

Failure to start menses (aka no menarche) in:1. 16+ yr w secondary sexual characteristics (e.g pubic hair / breast dev)2. 14+ yr w NO secondary sexual characteristics

197
Q

What is Secondary Amenorrhoea?

A

Periods stop for 6+ months (after menarche obv)

198
Q

What is Oligomenorrhoea? (2 things)

A
  1. Irregular periods w intervals of 35+ days2. +/- Less than 9 periods / year
199
Q

What are the titles of the causes of Amenorrhoea? (3 things)

A
  1. Hypothalamic causes2. Pituitary causes3. Ovarian / Genital causes
200
Q

How does clartation of the Hypothalamus cause Amenorrhoea? (3 steps)

A
  1. Reduced GnRH secretion2. Reduces pulsatile release of LH + FSH from Ant Pit3. Anovulation
201
Q

What are the Hypothalamic causes of Amenorrhoea? (3 things)

A
  1. Anorexia nervosa2. Extreme exercise3. Stress
202
Q

How does clartation of the Pituitary gland cause Amenorrhoea? (2 steps)

A
  1. Reduced release of LH + FSH from Ant Pit2. Anovulation
203
Q

What are the Pituitary causes of Amenorrhoea? (3 things)

A
  1. Prolactinoma2. Pituitary adenoma3. Sheehan’s syndrome
204
Q

How do Prolactinomas cause Amenorrhoea? (4 steps)

A
  1. High levels of prolactin released2. Prolactin inhibits GnRH sec3. Reduces pulsatile release of LH + FSH from Ant Pit4. Anovulation
205
Q

What is Sheehan’s syndrome?

A

Post-partum pituitary necrosis (secondary to massive obstetric haemorrhage)

206
Q

What are the Ovarian / Genital causes of Amenorrhoea? (3 things)

A
  1. PCOS2. Ovarian failure3. Ashermann’s syndrome
207
Q

Does PCOS more commonly cause Amenorrhoea or Oligomenorrhoea?

A

Oligomenorrhoea

208
Q

What is Ovarian failure?

A

Premature ovarian insuffiency (aka menopause before age of 40)

209
Q

What are the CF of Ovarian failure?

A

Menopause symptoms like hot / night sweats

210
Q

What do hormone profile tests show in Ovarian failure? (2 things)

A
  1. Low oestrogen2. High FSH
211
Q

What is Ashermann’s syndrome?

A

Damage to basal layer of endometrium –> intrauterine adhesions

212
Q

What causes Ashermann’s syndrome?

A

Damage to uterus from Surgical management of miscarriage

213
Q

What are the most common causes of Oligomenorrhoea? (7 things)

A
  1. PCOS2. Contraceptive / hormonal tx3. Perimenopause4. Hypo / Hyperthyroidism5. DM6. Eating disorders / excessive exercise7. Medications
214
Q

How can Hypothyroidism cause Oligomenorrhoea? (4 steps)

A
  1. Decreased T3/T42. TRH upregulated3. Stimulates Prolactin secretion4. LH / FSH inhibited
215
Q

How can Hyperthyroidism cause Oligomenorrhoea? (4 steps)

A
  1. High T3/T42. Increased Sex Hormone Binding Globulin (SHBG)3. Reduced ratio of free / bound oesteadiol4. LH spike not triggered
216
Q

What medications can cause Oligomenorrhoea? (2 things)

A
  1. Anti-psychotics2. Anti-epileptics
217
Q

What investigations should you do for Amenorrhoea / Oligomenorrhoea? (5 things)

A
  1. Pregnancy test2. Bloods3. Karyotyping4. US5. Progesterone challenge test
218
Q

What bloods should you do for Amenorrhoea / Oligomenorrhoea? (4 things)

A
  1. TFT2. Prolactin3. FSH / LH / Oestradiol / Progesterone / Testosterone4. 17 hydroxyprogesterone (to check for Congenital adrenal hyperplasia)
219
Q

Why would you do Karyotyping for Amenorrhoea / Oligomenorrhoea?

A

If sus genetic abn

220
Q

Why would you do US for Amenorrhoea / Oligomenorrhoea?

A

To visualise ovaries / pelvic anatomy

221
Q

What is the Progesterone challenge test?

A

Giving progesterone to see if bleeding will start

222
Q

What does the Progesterone challenge test show? (2 things)

A
  1. If bleeding starts: suggests adeq levels of oestrogen but NO ovulation = PCOS2. If no bleeding: suggests LOW levels of oestrogen / outflow obstruction
223
Q

What are the titles of Tx for Amenorrhoea / Oligomenorrhoea? (7 things)

A
  1. Regulating periods2. Hormone replacement3. Symptom control4. Lifestyle advice5. Tx underlying disorder (aka thyroid disease)6. Improving fertility (clomifene / metformin / IVF)7. Surgery
224
Q

How do you Regulate periods to treat Amenorrhoea / Oligomenorrhoea? (2 things)

A
  1. COCP / POP2. Intrauterine system (IUS) (for irregular periods)
225
Q

What is another benefit of using COCP / POP to treat Amenorrhoea / Oligomenorrhoea?

A

Keeps lining of womb thin –> reduces long term risk endometrial cancer

226
Q

Who should receive Hormone replacement as Tx for Amenorrhoea / Oligomenorrhoea?

A

Women w Ovarian Failure

227
Q

What is Hormone replacement tx for Amenorrhoea / Oligomenorrhoea?

A

Cyclic hormone replacement therapy w Oestrogen (+ progesterone if they have a uterus)

228
Q

What are the benefits of Hormone replacement as treatment in Amenorrhoea / Oligomenorrhoea? (3 things)

A
  1. Treats menopause symptoms2. Decreases CVS risk3. Maintains bone density (prevents osteoporosis)
229
Q

What is also recommended alongside Hormone replacement tx for Amenorrhoea / Oligomenorrhoea?

A

Calcium + Vit D supplementation

230
Q

What types of Symptom control are available for Amenorrhoea / Oligomenorrhoea? (2 things)

A
  1. Excessive hair growth (from PCOS): Certain COCP types e.g Yasmin2. Acne: Abx / topical tx
231
Q

What Lifestyle advice options could you give for Amenorrhoea / Oligomenorrhoea? (2 things)

A
  1. Eating disorders / excessive exercise: sort it out m82. PCOS: weight loss
232
Q

What are the Surgical Mx options for Amenorrhoea / Oligomenorrhoea? (2 things)

A
  1. Trans-sphenoidal removal of Pit tumour2. Surgery for genital tract abn
233
Q

What is Endometrial cancer?

A

Cancer of lining of uterus

234
Q

What type of cancer is Endometrial cancer usually?

A

Adenocarcinoma (80%)

235
Q

Endometrial cancer is an WHAT-dependant cancer? What does this mean?

A

Oestrogen-dependant cancerOestrogen stimulates the growth of endometrial cancer cells

236
Q

What is the precursor precancerous condition to Endometrial condition?

A

Endometrial hyperplasia

237
Q

What percentage of Endometrial hyperplasia goes on to become Endometrial cancer?

238
Q

What are the 2 types of Endometrial hyperplasia?

A
  1. Hyperplasia without atypia2. Atypical hyperplasia (more likely to progress to cancer)
239
Q

What is the Tx for Endometrial hyperplasia? (2 things)

A

Progestogens:1. Intrauterine system (e.g Mirena coil)2. Continuous oral progestogens (e.g levonorgestrel)

240
Q

What is the cause of Endometrial cancer?

A

Exposure to Unopposed oestrogen (aka oestrogen without progesterone)

241
Q

What are the RF for Endometrial cancer? (7 things)

A
  1. Age2. Early menarche / Late menopause3. Oestrogen only HRT4. Nuliparity5. Obesity6. PCOS7. Tamoxifen
242
Q

How does PCOS increase risk of Endometrial cancer?

A

Usually: Ovulation –> Corpus luteum formed –> CL produces Progesterone (which opposes oestrogen)In PCOS: Anovulation = so all this doesn’t happen

243
Q

How do you protect the Endometrium in women with PCOS? (3 things)

A
  1. COCP2. Intrauterine system (e.g Mirena coil)3. Cyclical progestogens (to induce a withdrawal bleed)
244
Q

Why is Obesity a RF for Endometrial cancer?

A

Adipose tissue (fat) = source of oestrogen

245
Q

How does Adipose tissue increase Oestrogen in body? (2 things)

A
  1. Adipose tissue contains Aromatase2. Aromatase converts androgens (aka testosterone) –> Oestrogen
246
Q

Why is Tamoxifen a RF for Endometrial cancer?

A

Has oestrogenic effect on Endometrial (while has anti-oestrogenic effect on breast tissue)

247
Q

What are the Protective Factors vs Endometrial Cancer? (4 things)

A
  1. COCP2. Mirena coil3. Increased pregnancies4. Smoking
248
Q

What is the main CF of Endometrial cancer that means it is Endometrial cancer unless proven otherwise?

A

Postmenopausal bleeding

249
Q

What percentage of Endometrial cancer pt have PMB?

250
Q

What percentage of women w PMB do NOT have Endometrial cancer?

251
Q

What other CF can Endometrial cancer present with? (4 things)

A
  1. Clear / white vaginal discharge2. Abn cervical smear3. Abd pain (advanced / metastatic)4. Weight loss (advanced / metastatic)
252
Q

What are you checking for in an Abd examination of sus Endometrial cancer?

A

Abd / pelvic masses

253
Q

What are you checking for in a Speculum examination of sus Endometrial cancer? (2 things)

A
  1. Vulval / vaginal atrophy2. Cervical lesions
254
Q

What are you assessing in an Abd examination of sus Endometrial cancer?

A

Size + axis of uterus b4 endometrial sampling

255
Q

What are some DDx that present similarly to Endometrial cancer (aka PMB)? (3 things)

A
  1. Vulval atrophy / pre-malignant vulval conditions2. Cervical polyps / cancer3. Endometrial hyperplasia / polyps / atrophy
256
Q

What is the FIRST line investigation for sus Endometrial cancer?

A

Transvaginal US

257
Q

What do the majority (96%) of Endometrial cancer pt show on the Transvaginal US?

A

Endometrial thickness of 5+ mm

258
Q

What investigation should you do if you see Endometrial thickness of 4+ mm in Transvaginal US?

A

Endometrial biopsy

259
Q

What other investigation can you do for sus Endometrial cancer apart from TUS and biopsy?

A

Hysteroscopy

260
Q

Once Endometrial cancer is confirmed, what investigation should you do next and why?

A

CT / MRI for staging

261
Q

What staging system is used for Endometrial cancer?

A

International Federation of Gynaecology and Obstetrics (FIGO)

262
Q

What are the stages of Endometrial cancer in the FIGO system? (4 stages)

A
  1. Stage 1: Confined to uterus2. Stage 2: Invades cervix3. Stage 3: Invades ovaries / fallopian tubes / vagina / lymph nodes4. Stage 4: Invades bladder / rectum / beyond pelvis
263
Q

What are the Tx options for Stage 1 and 2 Endometrial cancer?

A

Total abdominal hysterectomy (TAH) with Bilateral salpingo-oophorectomy (BSO)(aka removing uterus, cervix and adnexa)

264
Q

What are the Tx options for Stage 1 and 2 Endometrial cancer? (2 things)

A
  1. Maximal de-bulking surgery (if possible)2. Chemo + Radio
265
Q

What can be given to Endometrial cancer patients to slow progression of cancer?

A

Progesterone

266
Q

What is Endometriosis?

A

Condition where there is Ectopic endometrial tissue OUTSIDE uterus

267
Q

What is Adenomyosis?

A

Endometrial tissue in myometrium (muscle layer of uterus)

268
Q

What is the main age group for Endometriosis?

269
Q

Is the pathophysiology of Endometriosis clear?

270
Q

What is the Retrograde Menstruation theory for Endometriosis? (2 steps)

A
  1. Endometrial cells travel backwards from uterine cavity –> Fallopian tubes –> Pelvis / Peritoneum2. Endometrial cells seed + grow here
271
Q

What is another theory for Endometriosis pathophysiology?

A

Endometrial cells travel through lymphatic system (same way as cancer spreads)

272
Q

What is endometrial tissue sensitive to?

273
Q

During menstruation, what happens to the ectopic endometrial tissue?

A

Bleeds, just like normal endometrial tissue

274
Q

What does the bleeding of ectopic endometrial tissue cause? (2 things)

A
  1. Pain2. Bloating / distension @ ectopic sites
275
Q

What can repeated bleeding and inflammation at ectopic sites lead to?

A

Scarring –> Adhesions

276
Q

When are the symptoms of endometriosis reduced? (2 things)

A
  1. Pregnancy2. Menopause
277
Q

What are the RF for Endometriosis? (6 things)

A
  1. Early menarche2. FHx Endometriosis3. Short menstrual cycles4. Long duration of menstrual bleeding5. Heavy menstrual bleeding6. Defects in uterus / fallopian tubes
278
Q

What are the CF of Endometriosis?

A
  1. Pelvic / abdominal pain (cyclic)2. Dyspareunia (pain @ intercourse)3. Dysmenorrhoea4. Infertility5. Dysuria / Dyschezia6. Cyclic bleeding @ other sites (e.g haematuria)
279
Q

What examinations can you do for sus Endometriosis? (2 things)

A
  1. Bimanual examination2. Speculum examination
280
Q

What might you find @ examination of sus Endometriosis? (3 things)

A
  1. Endometrial tissue visible in vagina (esp post fornix)2. Fixed retroverted cervix3. Tenderness in vagina / cervix / adnexa
281
Q

What does an enlarged, tender, boggy uterus indicate?

A

Adenomysosis

282
Q

What are some DDx that present similarly to Endometriosis? (4 things)

A
  1. PID2. Ectopic pregnancy3. Fibroids4. IBS
283
Q

How does PID present similarly to Endometriosis? (3 things)

A
  1. Pelvic pain2. Dyspareunia3. Abn / heavy bleeding
284
Q

How does Ectopic pregnancy present similarly to Endometriosis? (4 things)

A
  1. Pelvic pain2. Dyspareunia3. Abn / heavy bleeding4. Collapse
285
Q

How does Fibroids present similarly to Endometriosis? (4 things)

A
  1. Pelvic pain2. Long duration of menstrual bleeding3. Heavy menstrual bleeding4. Bloating / feeling of a mass
286
Q

How does IBS present similarly to Endometriosis? (3 things)

A
  1. Abd pain2. Dyspareunia3. Bloating
287
Q

What is the GOLD standard investigation for sus Endometriosis?

A

Laparoscopy

288
Q

What are the typical findings of Endometriosis on Laparoscopy? (4 things)

A
  1. Endometriotic lesions (see pic)2. Chocolate cysts (endometriosis of ovaries)3. Peritoneal deposits4. Adhesions
289
Q

What are the benefits of doing a Laparoscopy for sus Endometriosis? (2 things)

A
  1. Take biopsy (for definitive dx)2. Surgically remove deposits (can improve symptoms)
290
Q

What other investigation can be done for sus Endometriosis?

A

Pelvic US(Usually unremarkable tho and will be referred to gynae for Laparoscopy)

291
Q

What does NICE recommend instead of using a staging system for Endometriosis?

A

Detailed documentation of endometriosis

292
Q

What are the 3 components of Mx of Endometriosis?

A
  1. Pain2. Hormonal3. Surgical
293
Q

How do you manage the pain of Endometriosis?

A

Analgesia / NSAIDS (follow analgesia ladder)

294
Q

What is a benefit of Hormonal Mx of Endometriosis?

A

Can be tried even before definitive Dx with laparoscopy

295
Q

What are the options for Hormonal Mx of Endometriosis? (5 things)

A
  1. COCP2. POP (Norethisterone)3. Depo-Provera injection4. IUD (Mirena coil)5. GnRH agonists
296
Q

How do COCP / POP / Depo / IUD work to manage Endometriosis? (3 steps)

A
  1. Suppresses ovulation2. Causes atrophy of endometriosis lesions3. Reduces symptoms
297
Q

How do GnRH agonists work to manage Endometriosis? (3 steps)

A
  1. Induce menopause-like state2. Female sex hormones reduced3. Reduces symptoms
298
Q

What are the side fx of using menopause-like inducing meds like GnRH agonists? (3 things)

A
  1. Hot flushes2. Night sweats3. Osteoporosis
299
Q

What are the Surgical Mx options of Endometriosis? (2 things)

A
  1. Laparoscopy2. Hysterectomy
300
Q

What can be done in Laparoscopic Tx of Endometriosis? (3 things)

A
  1. Excision2. Ablation3. Adhesiolysis
301
Q

What is the benefit of Laparoscopic Tx over Hormonal Tx of Endometriosis?

A

Laparoscopic Tx can improve fertility

302
Q

When is Hysterectomy a better option than Laparoscopic Tx of Endometriosis?

A

Beh relapses (which almost always occur after laparoscopic tx)

303
Q

What is PID?

A

Infection of Upper genital tract in females

304
Q

What organs does PID affect? (3 things)

A
  1. Uterus2. Fallopian tubes3. Ovaries
305
Q

What age group is PID most common in?

306
Q

What is the general cause of PID?

A

Spread of bac infection from vagina / cervix upwards

307
Q

What are the most common organisms that cause PID? (3 things)

A

STI’s:1. Neisseria gonorrhoea2. Chlamydia trachomatis3. Mycoplasm genitalium

308
Q

Which organism causes the most severe PID?

A

Neisseria gonorrhoea

309
Q

What are the RF for PID? (5 things)

A
  1. Sexually active (esp without protection)2. Recent partner change3. Age 15-244. Hx of STIs / PID5. IUD
310
Q

What are the CF of PID? (7 things)

A
  1. Fever (advanced)2. Pelvic / lower abd pain3. Dyspareunia (pain @ intercourse)4. Post-coital bleeding5. Abn discharge (purulent / foul smelling)6. Menstrual abn (menorrhagia / dysmenorrhoea)7. Dysuria
311
Q

What are the CF of PID @ examination? (4 things)

A
  1. Palpable mass2. Pelvic / cervical tenderness3. Inflamm cervix4. Purulent discharge
312
Q

What are some differential Dx that present similarly to PID? (4 things)

A
  1. Endometriosis2. Ectopic pregnancy3. Ruptured ovarian cyst4. UTI
313
Q

What investigations should be done for sus PID? (6 things)

A
  1. Endocervical (NAAT) swabs2. Full STI screen3. Urine dipstick / MSU4. Pregnancy test (to exclude ectopic pregnancy)5. Inflamm markers (CRP / ESR) (raised)6. Transvaginal US7. Laparoscopy
314
Q

What are you testing for in Endocervical (NAAT) swabs? (3 things)

A
  1. Gonorrhoea2. Chlamydia3. Mycoplasm genitalium
315
Q

What are you testing for in a Full STI screen? (5 things)

A
  1. HIV2. Syphilis3. Gonorrhoea4. Chlamydia5. Mycoplasm genitalium
316
Q

What is the point of a Urine dipstick / MSU in sus PID?

A

To exclude UTI’s

317
Q

When are Transvaginal US / Laparoscopy indicated in sus PID?

A

Severe cases where there is diagnostic uncertainty

318
Q

What is the point of Laparoscopy for investigating PID? (2 things)

A
  1. Observe gross inflamm changes2. Peritoneal biopsy
319
Q

What is the Tx for PID?

A

14 day broad spec abx course (w good anaerobic coverage)

320
Q

When should abx course for PID be started?

A

Immediately, even before swabs results are back

321
Q

What are the abx options for PID? (2 things)

A
  1. Doxycycline + Ceftriaxone + Metronidazole2. Ofloxacin + Metronidazole
322
Q

How should you manage pain in PID?

A

Paracetamol

323
Q

What are signs the pt has severe PID / needs further Tx? (3 things)

A
  1. Sepsis signs2. Pelvic abscess3. Pregnant
324
Q

What further treatment is given to patients with severe PID who are admitted?

325
Q

What is the Tx when a Pelvic abscess develops in PID?

A

Drainage (by interventional radiologist / surgeon)

326
Q

What are the complications of PID? (6 things)

A
  1. Sepsis2. Abscess3. Infertility (10%)4. Chronic pelvic pain5. Ectopic pregnancy6. Fitz-Hugh-Curtis syndrome
327
Q

Why is the risk of Ectopic pregnancy increased after having PID?

A

Bc narrowing + scarring of fallopian tubes

328
Q

What is Fitz-Hugh-Curtis syndrome? (2 steps)

A
  1. Inf of liver capsule (aka Glisson’s capsule)2. Leads to adhesions between Liver + peritoneum
329
Q

What are the CF of Fitz-Hugh-Curtis syndrome? (2 things)

A
  1. RUQ pain2. Referred R shoulder pain (if diaphragm irritated)
330
Q

What is used to visualise and treat adhesions of Fitz-Hugh-Curtis syndrome?

A

Laparoscopy (adhesiolysis)

331
Q

What is an Ectopic Pregnancy?

A

Pregnancy implanted outside uterus

332
Q

Where is the most common implantation site of an Ectopic pregnancy?

A

Fallopian tube

333
Q

What is the prevalence of Ectopic pregnancies in the UK?

A

1/80 pregnancies

334
Q

What are the RF for an Ectopic Pregnancy? (6 things)

A
  1. Previous EP2. Previous PID3. Previous of surgery to fallopian tubes4. IUD5. Age6. Smoking
335
Q

When do the CF of EP normally present?

A

6-8 weeks gestation

336
Q

What are the CF of EP? (4 things)

A
  1. Pain (lower abd / pelvic)2. Vaginal bleeding3. Amenorrhoea (aka missed period)4. Shoulder pain
337
Q

What are the CF of EP @ examination? (2 things)

A
  1. Lower abd / pelvic tenderness2. Cervical motion tenderness (pain @ moving cervix @ bimanual exam)
338
Q

What is the difference between Vaginal and Intra-abd bleeding in EP?

A
  1. Vaginal: Uterine cavity breakdown bc not enough β-HCG2. Intra-abd: Ruptured EP
339
Q

How will a pt present with a Ruptured EP?

A

Haemodynamically unstable

340
Q

Why might someone with EP present with Shoulder pain?

A

Blood in peritoneal cavity irritates diaphragm –> referred shoulder pain

341
Q

What are some differential Dx that present similarly to EP? (6 things)

A
  1. Miscarriage2. Ovarian cyst haemorrhage / torsion / rupture3. PID4. UTI5. Appendicitis6. Diverticulitis
342
Q

What is the first important investigation for sus EP?

A

Pregnancy test (β-HCG test)

343
Q

What investigation should be performed if the Pregnancy test in sus EP is positive?

344
Q

What should be offered if no pregnancy is seen on the Pelvic US?

A

Transvaginal US

345
Q

What is the term used to describe a positive pregnancy test but NO pregnancy seen on US?

A

Pregnancy of Uknown Location (PUL)

346
Q

What are the 3 main differentials of PUL?

A
  1. Very early intrauterine pregnancy2. Miscarriage3. EP
347
Q

What investigation should you do for PUL?

A

Serum β-HCG

348
Q

What Serum β-HCG levels are considered EP?

349
Q

What investigation should be done to confirm the diagnosis of EP when Serum β-HCG levels are 1500+?

A

Diagnostic laparoscopy

350
Q

What investigation should be done if Serum β-HCG levels are below 1500 and pt is stable?

A

Another Serum β-HCG after 48 hours

351
Q

What are the HCG levels expected to do every 48 hours in a VIABLE pregnancy?

A

Double every 48 hours

352
Q

What are the HCG levels expected to do every 48 hours in a Miscarriage?

A

Halve every 48 hours

353
Q

What should you do if the HCG levels doesn’t double / halve every 48 hours and was initially below 1500?

A

Can’t exclude EP so manage accordingly

354
Q

How could you exclude a differential of UTI in sus EP?

A

Urinalysis

355
Q

What are the Mx options for EP? (3 things)

A
  1. Expectant (await natural termination)2. Medical (methotrexate)3. Surgical (salpingectomy / salpingotomy)
356
Q

What are the criteria for Expectant Mx of EP? (6 things)

A
  1. Follow up possible to ensure successful termination2. EP needs to be unruptured3. Adnexal mass less than 35mm4. No visible heartbeat5. No significant pain6. HCG level below 1500
357
Q

What are the criteria for Medical (MTX) management of EP? (2 things)

A

Same as Expectant except:1. HCG level below 50002. Confirmed absence of IU pregnancy on US

358
Q

How does the Methotrexate work for Medical Mx of EP?

A

MTX = Anti-folate cytotoxic agent –> disrupts Folate dependant cell division of developing foetus

359
Q

How do you ensure the Methotrexate is working for EP Mx?

A

Measure HCG levels regularly (supposed to decline by 15+ % by day 5)

360
Q

What should you do if the HCG levels aren’t declining properly after you Methotrexate EP Mx?

A

Give repeat dose

361
Q

What are the Advantages of Medical Mx with MTX for EP? (2 things)

A
  1. Avoid surgical complications2. Pt can go home after injection
362
Q

What are the Side Fx of MTX as Medical Mx for EP? (9 things)

A
  1. N+V2. Stomatitis (mouth infamm)3. Abd pain4. Myelosuppression5. Renal dysfunction6. Hepatitis7. Vaginal bleeding8. Teratogenesis9. Failure of Tx
363
Q

What are the criteria for Surgical Mx of EP? (4 things)

A
  1. Pain2. Adnexal mass 35+ mm3. Visible heartbeat4. HCG level 5000+
364
Q

What is the most common surgical procedure for EP Mx?

A

Laparoscopic salpingectomy (remove ectopic + tube it’s in)

365
Q

When would you do a Salpingotomy instead of Salpingectomy for EP Mx? (2 points)

A
  1. If other tube is damaged bc infection / disease / surgery2. This is to preserve the EP tube to preserve future fertility
366
Q

If you do a Salpingotomy instead of Salpingectomy, what should you do you need to do?

A
  1. HCG follow up until it reaches below 52. To ensure no residual trophoblast
367
Q

What is the disadvantage of doing a Salpingotomy instead of a Salpingectomy for EP Mx?

A

Risk of recurrent EP in salvaged tube

368
Q

What are the Advantages of Surgical Mx of EP? (2 things)

A
  1. Reassurance that gonna be treated for defo2. High success rate
369
Q

What are the Disadvantages of Surgical Mx of EP? (2 things)

A
  1. Anaesthesia risk2. Damaging nearby structures3. DVT / PE / Haemorrhage / Infection4. Tx failure (salpingotomy)
370
Q

What do all Rhesus Negative women who receive Surgical Mx for EP need to be offered?

A

Anti-D prophylaxis

371
Q

What age group does Cervical Cancer tend to affect more?

A

Young women (in reproductive years)

372
Q

What is the most common type of Cervical Cancer?

A

Squamous cell carcinoma (80%)

373
Q

What is the second most common type of Cervical Cancer?

A

Adenocarcinoma

374
Q

What is the most common cause of Cervical Cancer?

375
Q

What is the pathophysiology of HPV causing Cervical Cancer? (4 points)

A
  1. HPV produces 2 proteins: E6 + E72. E6 inhibits p53 (tumour suppressor gene)3. E7 inhibits pRb (tumour suppressor gene)4. Therefore: HPV promotes cancer dev by inhibiting tumour suppressor genes
376
Q

What strains of HPV are responsible for 70% of Cervical Cancers? (2 things)

A
  1. Type 162. Type 18
377
Q

What are the RF for Cervical Cancer? (6 things)

A
  1. HPV (main)2. Smoking3. HIV4. COCP use for 5+ years5. High number of full-term pregnancies6. FHx
378
Q

What are the RF for catching HPV? (4 things)

A
  1. Early sexual activity2. High no. of partners3. Partners who have had more partners4. Not using condoms
379
Q

What are the CF of Cervical Cancer? (5 things)

A
  1. Asymptomatic (detected @ routine smear)2. Pelvic pain3. Dyspareunia (pain @ intercourse)4. Abn vaginal bleeding (intermenstrual / postcoital / post-menopausal)5. Vaginal discharge
380
Q

Why is it hard to diagnose Cervical Cancer from symptoms alone?

A

Symptoms are non-specific, and usually NOT caused by Cervical Cancer

381
Q

What investigation should be done for sus Cervical Cancer?

A

Speculum examination

382
Q

What can be done during a Speculum examination in sus Cervical Cancer and why?

A

Swabs to exclude infection

383
Q

What abn appearances of the cervix warrant an Urgent Cancer Referral for Colposcopy? (4 things)

A
  1. Ulceration2. Inflamm3. Bleeding4. Visible tumour
384
Q

What are you aiming to diagnose / exclude @ Colposcopy?

A

CIN aka Cervical Intraepithelial Neoplasia

385
Q
A

A grading system for the level of dysplasia (aka premalignant changes) in cervical cells

386
Q

What are the CIN grades?

A
  • CIN I = mild dysplasia* CIN II = moderate dysplasia* CIN III = severe dysplasia
387
Q

What does CIN I (aka mild dysplasia) mean? (2 things)

A
  1. Dysplasia affecting 1/3 thickness of epithelial layer2. Likely to return normal w/o tx
388
Q

What does CIN II (aka moderate dysplasia) mean? (2 things)

A
  1. Dysplasia affecting 2/3 thickness of epithelial layer2. Likely to progress to cancer if left untreated
389
Q

What does CIN III (aka severe dysplasia) mean?

A

Very likely to progress to cancer if untreated

390
Q

What are the aims of the screening programme for Cervical Cancer?

A

Pick up precancerous changes in cervix epithelium

391
Q

How often are the different age groups of women screened for Cervical Cancer?

A
  1. Age 25-49: every 3 years2. Age 50-64: every 5 years
392
Q

What are the exceptions to the Cervical Cancer screening program? (5 things)

A
  1. HIV pt: Screen anually2. 65+ yrs: Can request smear if not had one since 50 yrs old3. Hx of CIN: May require additional tests (e.g to test for cure after tx)4. Immunocompromised pt: Additional screening5. Pregnant: Must wait 12 wks post-partum
393
Q

What does the screening for Cervical Cancer involve?

A

Smear test

394
Q

How is a smear test done for Cervical Cancer screening?

A
  1. Speculum examination + collect cervical cells w small brush2. Cells sent to lab
395
Q

Who can do the smear test for Cervical Cancer screening?

A

Practice nurse

396
Q

What are smear samples tested for before the cells are examined?

A

High-risk HPV

397
Q

What happens next depending on the result of the High-risk HPV testing on the smear sample?

A
  • HPV negative = cells NOT examined –> continue routine screening* HPV positive = cells examined (cytology)
398
Q

What happens next depending on the cytology of the HPV positive smear?

A
  • Normal cytology: repeat HPV test after 12 months* Abn cytology: refer for colposcopy
399
Q

How are abn areas of cervix differentiated in Colposcopy?

A

Using stains

400
Q

What are the different stains used in Colposcopy? (2 things)

A
  1. Acetic acid2. Iodine
401
Q

What will you see in Colposcopy with Acetic Acid?

A

Abn cells = white (called acetowhite)

402
Q

What will you see in Colposcopy with Iodine?

A
  1. Healthy cells = brown2. (Abn areas won’t stain)
403
Q

How can you get a tissue sample during Colposcopy? (2 things)

A
  1. Punch biopsy2. Large Loop Excision of the Transformational Zone (LLETZ)
404
Q

What anaesthetic can LLETZ done under?

405
Q

What does LLETZ involve?

A

Using loop of wire w electrical current (diathermy) to remove abn epithelial cervix tissue

406
Q

What are the side fx of LLETZ? (3 things)

A
  1. Bleeding2. Abn discharge3. Increased risk of Preterm labour
407
Q

What should be avoided after LLETZ and why? (2 things)

A
  1. Intercourse2. Tampon use(to reduce infection risk)
408
Q

What staging system is used for Cervical Cancer?

A

FIGO(International Federation of Gynaecology and Obstetrics)

409
Q

What are the FIGO stages of Cervical Cancer?

A
  • Stage 1: Confined to cervix* Stage 2: Invades uterus / upper 2/3 of vagina* Stage 3: Invades pelvic wall / lower 1/3 of vagina* Stage 4: Invades bladder / rectum / beyond pelvis
410
Q

What are the Mx options for CIN / Early stage 1A Cervical Cancer? (2 things)

A
  1. LLETZ2. Cone biopsy
411
Q

What is Cone biopsy?

A

Tx for CIN / Early Stage 1A Cervical Cancer

412
Q

What anaesthetic is Cone biopsy done under?

413
Q

What does Cone biopsy involve? (2 steps)

A
  1. Cone shaped piece of cervix removed w Scalpel2. Sample sent for histology to assess for malignancy
414
Q

What are the side fx of Cone biopsy? (5 things)

A
  1. Pain2. Bleeding3. Inf4. Scar formation w Stenosis of cervix5. Increased risk of Miscarriage / Premature labour
415
Q

What are the Mx options for Stage 1B / 2A Cervical Cancer? (4 things)

A
  1. Radical hysterectomy2. Removal of local lymph nodes3. Chemo4. Radio
416
Q

What are the Mx options for 2B - 4A Cervical Cancer? (2 things)

A
  1. Chemo2. Radio
417
Q

What are the Mx options for 4B Cervical Cancer? (4 things)

A
  1. Surgery2. Radio3. Chemo4. Palliative care
418
Q

What is the Surgical Mx option for 4B Cervical Cancer?

A

Pelvic extenteration

419
Q

What is removed in Pelvic exenteration? (7 things)

A

Most / All pelvic organs:1. Vagina2. Cervix3. Uterus4. Fallopian tubes5. Ovaries6. Bladder7. Rectum

420
Q

Why are early detection and screening programmes for Cervical Cancer so important? (2 points)

A
  • 5 year survival of Stage 1A: 98%* 5 year survival of Stage 4: 15%
421
Q

What chemo is used for Cervical Cancer?

A

Bevacizuman (Avastin)

422
Q

What is Bevacizumab (Avastin)?

A

Monoclonal antibody

423
Q

What types of Cervical Cancer is Bevacizumab (Avastin) used for? (2 things)

A
  1. Metastatic2. Recurrent
424
Q

What does Bevacizumab (Avastin) target?

A

Vascular Endothelial Growth Factor A (VEGF-A) –> responsible for new blood vessel dev(so dis tx stops dis)

425
Q

What vaccine is used to protect against HPV?

426
Q

When should Gardasil vaccine be given to people?

A

When they’re kids before they’re sexually active

427
Q

What strains of HPV does Gardasil protect against? (4 things)

A

6, 11, 16, 18

428
Q

What are the HPV strains 6, 11, 16 and 18 responsible for? (2 things)

A
  1. 6 + 11 = Genital warts2. 16 + 18 = Cervical Cancer
429
Q

What proportion of couples fail to conceive naturally?

430
Q

After trying to conceive for how long should investigations and referrals for infertility be started? (2 options)

A
  1. 12 months2. 6 months if: woman 35+ yrs
431
Q

What are the causes of infertility? (5 things)

A
  1. Sperm (30%)2. Ovulation (20%)3. Tubal (15%)4. Uterine (10%)5. Unexplained (20%)
432
Q

What is some general advice for infertility? (5 things)

A
  1. Woman takes 400mcg folic acid daily2. Have healthy BMI3. X Smoking / Alcohol4. Reduce stress (fx libido + relationship)5. Intercourse every 2-3 days
433
Q

What initial investigations should you do in primary care for infertility? (5 things)

A
  1. BMI2. Chlamydia screening3. Semen analysis4. Female hormone testing5. Rubella immunity in mother
434
Q

What does a LOW BMI suggest the cause of infertility is?

A

Anovulation

435
Q

What does a HIGH BMI suggest the cause of infertility is?

436
Q

What does Female hormone testing involve? (5 things)

A
  1. Serum LH + FSH2. Serum progesterone3. Anti-Mullerian hormone4. TFTs (if symptoms suggest dis)5. Prolactin (when symptoms of galactorrhoea / amenorrhoea)
437
Q

Why should you check Prolactin in infertility?

A

Hyperprolactinaemia causes anovulation

438
Q

Which day range is Serum LH + FSH checked?

439
Q

Which day is Serum progesterone checked?

A

Day 21(or 7 days b4 end of cycle if not 28 day cycle)

440
Q

What does High FSH suggest?

A

Poor ovarian reserve (aka number of follicles left in ovaries)

441
Q

What explains the High FSH in poor ovarian reserve?

A

Pit gland prod extra FSH in attempt to stimulate follicular dev

442
Q

What does Low LH suggest?

443
Q

What does a rise in Progesterone @ day 21 indicate? (2 things)

A
  1. Ovulation has occurred2. Corpus luteum formed + started secreting progesterone
444
Q

When in the cycle can Anti-Mullerian hormone be tested for?

445
Q

What is Anti-Mullerian hormone a marker for?

A

Most accurate marker of ovarian reserve

446
Q

What is Anti-Mullerian hormone released by?

A

Granulosa cells in follicles

447
Q

What does Low Anti-Mullerian hormone suggest?

A

Eggs are depleted

448
Q

What further investigations should you for infertility in Secondary care? (3 things)

A
  1. US Pelvis2. Hysterosalpingogram3. Laparoscopy + Dye test
449
Q

What are you looking for in a US Pelvis of infertility? (2 things)

A
  1. PCOS2. Structural abn in uterus
450
Q

What are you looking for in a Hysterosalpingogram of infertility?

A

Fallopian tube patency

451
Q

What are you looking for in a Laparoscopy + Dye test of infertility? (3 things)

A
  1. Fallopian tube patency2. Adhesions3. Endometriosis
452
Q

What is a benefit of a Hysterosalpingogram?

A

Can do Tubal cannulation during it –> opens up tube –> restores fertility

453
Q

What is a risk of having a Hysterosalpingogram?

454
Q

What precautions are taken with Hysterosalpingogram to reduce risk of infection? (2 things)

A
  1. Prophylactic abx2. Chlamydia + Gonorrhoea screening b4 hand
455
Q

What is a benefit of a Laparoscopy?

A

Can treat adhesions / endometriosis on the job

456
Q

What are the management options for infertility caused by ANOVULATION? (6 things)

A
  1. Weight loss (if overweight +/- PCOS)2. Clomifene3. Letrozole (instead of clomifene)4. Gonadotropins (if resistant to clomifene)5. Ovarian drilling (if PCOS)6. Metformin (for insulin sensitivity / obesity related to PCOS)
457
Q

What drug class in Clomifene?

A

Anti-oestrogen (selective oestrogen receptor modulator)

458
Q

What day range is Clomifene given?

A

Days 2-6 of menstrual cycle

459
Q

What are the physiological steps of Clomifene in restoring fertility? (4 steps)

A
  1. Stops negative feedback of oestrogen on hypothalamus2. Increased GnRH release3. Increased FSH + LH4. Ovulation
460
Q

What are the physiological steps of Ovarian drilling in restoring fertility? (3 steps)

A
  1. Multiple holes drilled in ovaries using diathermy / laser (@ laparoscopy)2. Womans hormone profile improved3. Regular ovulation
461
Q

What are the management options for infertility caused by TUBAL DEFECTS? (3 things)

A
  1. Tubal cannulation @ hysterosalpingogram2. Laparoscopy to remove adhesions / endometriosis3. IVF
462
Q

What is the management option for infertility caused by Uterine DEFECTS?

A

Surgery to correct polyps / adhesions / structural abn

463
Q

What are the management options for infertility caused by Sperm defects? (5 things)

A
  1. Surgical sperm retrieval2. Surgical correction of vas deferens obst3. Intra-uterine insemination4. Intracytoplasmic sperm infection (ICSI)5. Donor insemination
464
Q

What does Intra-uterine insemination involve? (2 steps)

A
  1. Collecting + separating high quality sperm2. Injecting them directly into uterus
465
Q

What does Intracytoplasmic sperm injection (ICSI) involve? (2 steps)

A
  1. Injecting sperm directly into cytoplasm of egg (which then becomes embyro)2. Embryo injected into uterus
466
Q

When is Intracytoplasmic sperm injection (ICSI) useful? (2 things)

A
  1. Sperm motility issues2. Low sperm count

MBBS Y5 (27 decks)

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