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Phase 2 > Obstetrics and Gynaecology > Flashcards

Obstetrics and Gynaecology Flashcards

1
Q

What is endometriosis?

A

chronic inflammatory condition characterised by the ectopic growth of endometrial tissue outside the uterine cavity

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2
Q

What are 4 current aetiological theories for endometriosis pathogenesis?

A
  1. Retrograde menstruation → backflow of menstrual blood containing endometrial cells
  2. dysfunctional immune response resulting in ineffective clearing of menstrual effluent
  3. peritoneal metaplasia → differentiation into endometrial tissue
  4. lymphatic or haematogenous dissemination of endometrial cells
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3
Q

How does endometriosis cause pain and symptoms?

A
  • ectopic endometrial tissue responds to oestrogen causing cyclic proliferation and shedding
  • local inflammation and fibrosis
  • invasion of pelvic organs including nerves
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4
Q

Where are common locations for endometriotic implants to occur?

A
  • ovaries (most common)
  • pelvic organs → uterine tubes, bladder, cervix, retrouterine pouch
  • peritoneum
  • extrapelvic organs eg lungs
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5
Q

What are the three common types of lesions in endometriosis?

A
  1. superficial peritoneal endometriosis
    • powder burn lesions on ovaries, serosa and peritoneum
    • may also appear as white plaques, scarring, red implants, serosa vesicles
  2. ovarian cysts (endometrioma)
    • chocolate cysts forming from mestrual beeding in the ovaries
  3. deep infiltrative endometriosis
    • nodules extending more than 5mm beneath the peritoneum involving the uterosacral ligaments, vagina, bowel, bladder or ureters
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6
Q

what are the classical, key features of endometriosis and when do they occur? (D’s)

A
  1. Dysmenorrhea → especially new onset after years of pain free menses
  2. dyspareunia → deep pain that varies with position
  3. dysuria → more specific with menstruation
  4. dyschezia + nausea, bloating, diarrhoea
  5. Depression → sadness and unhappiness with period
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7
Q

What are signs of endometriosis?

A
  1. uterosacral and rectovaginal tenderness
  2. uterosacral nodulatrity on internal palpation
  3. adnexal massess
  4. premenstrual or postmenstrual bleeding
  5. infertility
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8
Q

What are the stages of endo severity and how are they measured?

A
  • Based on density and depth of implantations and adhesions
    1. Minimal
    2. Mild
    3. Moderate
    4. Severe
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9
Q

what are some DDx for endometriosis?

A
  1. Adenomyosis → growth of endometrial tissue within the myometrium -> bleeding
  2. PID
  3. Malignancy
  4. Ovarian Cyst
  5. irritable bowel syndrome
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10
Q

What are the 4 components of medical management of endometriosis?

A
  1. Analgesia with NSAIDS
  2. Hormonal management → induce decidualisation of the endometrium resulting in atropy
    • OCP fist line
    • Progestins
    • Mirena → to control severe bleeding as well
  3. GnRH agonists → suppress HPG axis
  4. Danazol → high androgen, low oestrogren environment to inhibit endometrial growth
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11
Q

What are 4 indications for surgical management of endo?

A
  1. pain refractory to medical management
  2. endometriomas
  3. severe invasive disease
  4. sub-fertility
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12
Q

What is the surgical procedure for endo management?

A
  1. laparoscopic excision and ablation of implants

2. hysterectomy +/- salpingo -oophorectomy → if fertility not desired

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13
Q

what are sequelae of endometriosis?

A
  1. infertility
  2. risk of transformation into malignancy
  3. ectopic pregnancy
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14
Q

when is the peak incidence of cervical cancer?

A

35-44 years old

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15
Q

What are risk factors for cervical cancer?

A
  1. multiple sex partners
  2. younger age of first intercourse
  3. cigarette smoking
    • HPV infection
      - multiparity
      - immunosupression
      - Hx of STIs
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16
Q

what are the three stages of precursor lesion in cervical cancer, and the depth of cervix involvement?

A
  1. CIN I or LSIL: mild dysplasia → 1/3 of the basal epithelium
  2. CIN II or HSIL: Moderate dysplasia → 2/3 of basal epithelium
  3. CIN III or HSIL: severe dysplasia → >2/3 of basal epithelium → name called carcinoma in situ
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17
Q

What does CIN stand for?

A

Cervical intra-epithelial lesion

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18
Q

What does LSIL and HSIL stand for?

A
  • Low grade squamous intra-epithelial lesion

- High grade squamous intra-epithelial lesion

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19
Q

What are the 5 stages of confirmed cerivcal cancer?

A

Stage 0 = carcinoma in situ
Stage 1 = confined to cervix
stage 2 = disease beyond cervix but not to pelvic wall or lower 1/3 vagina
stage 3 = disease to pelvic wall or lower 1/3 vagina
stage 4 = invades bladder, rectum or metastasis

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20
Q

what are the clinical features of cervical cancer?

A
  1. abnormal vaginal bleeding
    • postcoital
    • heavy or irregular menstrual bleeding
  2. blood stained or purulent discharge
  3. dyspareunia (painful sex)
  4. pelvic pain
  5. bladder or bowel dysfunction
  6. ulceration or induration of the cervix on speculum exam
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21
Q

what are 4 complications of local invasion of pelvic organs by cervical cancer?

A
  1. compression of ureters → hydronephrosis → KF and uraemia
  2. rectum, bladder and vagina involvement
  3. compression of pelvic veins/lymphatics → lymphedema
  4. fistula formation → rectovaginal, vesicovaginal, urethrovaginal
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22
Q

What monitoring/follow up needs to be done on women post LLETZ procedure for cervical cancer?

A
  1. Test of cure
  2. CST in 12 months for LBC
  3. CST in 24 months for LBC
  4. If all normal, back to CST every 5 years
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23
Q

What are complications of LLETZ procedure?

A
  • GA - risks
  • infection
  • bleeding
  • 5% of cases lesion can persist
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24
Q

What are the indications for a LLETZ procedure?

A
  • HSIL

- abnormal cells on colposcopy

25
Q

What are indications for cone biopsy?

A

Glandular cells on CST
TZ grade 3
Adenocarcinoma in situ

26
Q

What are antepartum risk factors for PPH?

A
  1. previous PPH
  2. grand multiparity
  3. placenta previa
  4. antepartum haemorrhage
  5. overdistension of the uterus
    • macrosomia
    • multiple pregnancy
    • polyhydramnios
  6. fibroids
  7. coagulopathy
  8. chorioamnionitis
27
Q

What are intrapartum risk factors for PPH?

A
  1. prolonged labour
  2. mismanaged stage 3 of labour
  3. syntocinon augmentation
  4. assisted delivery → vaccum, forceps, operative retained placenta
  5. distended bladder → not voiding during labour
  6. lower genital tract trauma
  7. uterine inversion or rupture
28
Q

what are the 4 T causes of PPH?

A
  • TONE → 70%
    • uterine atony is most common cause of PPH
    • associated with uterine muscle exhaustion, overdistension, drug-induced hypotonia, infection, distortion of uterus
    • normally prompt myometrial contraction is required
    • atony results in brisk postpartum bleeding, boggy, flaccid uterus
  • Trauma → 20%
    • episiotomy
    • lacerations
    • uterine inversion or rupture
  • Tissue → 10%
    • retained placenta → not delivered within 30mins
    • retained fragments
    • invasive placenta
  • Thrombin → 1%
    • maternal coagulopathy
      • pre-existing disorders
    • iatrogenic or obstetric disorders
      • sepsis
      • Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP)
29
Q

what are the two methods for managing the third stage of labour, and which one is most effective at preventing PPH?

A
  1. Expectant management
    • await placental separation
    • leave cord uncut
    • spontaneous delivery of the placenta
    • oxytocin given after placental delivery
  2. active management
    • oxytocin given with delivery of the anterior shoulder
    • cord clamped and cut early
    • controlled cord traction to remove placenta
    • most effective at reducing PPH, anaemia and need for blood transfusion by 50%
30
Q

what are the 6 steps of management of PPH?

A
  1. Call for assistance
  2. determine cause of bleeding
    • placenta out and intact?
    • fundus firm or boggy?
    • genital tract intake?
    • blood clotting?
  3. IV access and fluid resuscitation + administeration of syntocinon
    • may need blood transfusion
  4. further methods for controlling bleeding
    • drug therapy
      • ergometrine
      • misoprostol
      • prostaglandin F2 alpha
    • bimanual compression of uterus
    • bakri tamponade balloon
  5. if bleeding continues → internal iliac artery ligation, uterine artery embolisation, emergency hysterectomy
  6. care following PPH
    • IDC, fluid balance, continue IV syntocinon, observation and monitoring
31
Q

What are the names of the 5 drugs used to control PPH?

A

1) syntocinin
2) ergometrine
3) misoprostol
4) prostaglandin 2 alpha
5) transexemic acid

32
Q

What is the MOA and SE of Syntocinin?

A

MOA:

  • Stimulated uterine contractions → decreases blood flow to uterus.
  • rapid onset and assists in lactation

SE:

  • Usually none, contractions may be painful
  • high doses cause H2O intoxication due to antidiuretic effect
33
Q

What is the MOA and SE of ergometrine

A
  • ergot alkaloid causes generalised smooth muscle contraction

SE:

  • may entrap placenta
  • severe abdo pain
  • vomiting, nausea
  • headache
  • HTN
34
Q

What is the MOA and SE of misoprostol

A
  • synthetic PGE1 causes strong myometrial contractions
  • PR route

SE:

  • uterine rupture, diarrhoea
  • pain, nausea, vomiting
35
Q

What is the MOA and SE of PG2alpha

A

MOA:

    • transabdominal injection into the myometrium to induce contraction and control bleeding
    SE:
    • uterine rupture, headache, nausea, vomting, diarrhoea
    • observe for bronchospasm and arrhymia
36
Q

What is the MOA and SE of transexemic acid

A
  • antifibrinolytic that prevents plasmin formation to decrease bleeding

SE:

  • VTE
  • Anaphylaxis
37
Q

what are complications of PPH?

A
  1. iron deficiency anaemia
  2. hypotension and hemorrhagic shock
  3. pituitary infarction (sheehan Syndrome) → failure of lactation
  4. further surgical intervention, prolonged hospital stay, use of blood products
  5. need for hysterectomy to control bleeding → permanent sterilisation
38
Q

What are absolute contraindications for oestrogen contraceptive use?

A
  1. < 6 weeks postpartum or whilst breastfeeding
  2. Hx of migraine with aura
  3. AF, uncontrolled HTN, imapired cardiac function
  4. Hx of hormonal cancers
  5. current or Hx of DVT/PE
  6. positive antiphospholipid abs
  7. > 15 cigs per day if older than 35 years of age
39
Q

what are the 5 main categories of causes of female infertility and examples within each category.

A
  1. Ovarian
    • premature ovarian failure, menstrual cycle disorders, hyperprolactinaemia, thyroid disease, hypogondadism, PCOS, endocrine disorders
  2. Tubal → most common cause of infertility
    • PIF, endometriosis, Tubal adhesions/obstruction, Tubal hydrocele
  3. Uterine
    • anatomical abnormalities, fibroids, asherman syndrome, endometriosis
  4. cervical
    • insufficient cervical mucous, trauma
  5. psychiatric
    • vaginismus, sexual dysfunction
40
Q

what are the 4 main investigative assessments for female infertility?

A
  1. Hormone Studies
    • serum progesterone → should be increasing after ovulation
    • LH → should be predictive of ovulation
    • Androgens → if high applies negative feedback to HPO
    • FSH → elevated in ovarian insufficiency
    • TSH and prolactin
  2. Ovarian reserve testing
    • day 2-4 FSH → if elevated = poor reserve
    • clomiphene citrate challenge test (CCCT) → measures FSH and estradiol levels → if FSH or estradiol is elevated = poor response to injectable FSH in ART
    • antral follicle count on US
    • anti-mullerian hormone
  3. Imaging
    • HSG HyCoSys MRI → mri visualisation of uterine cavity and tubal patency
    • Laproscopy or hysterscopy
  4. cervical smear test
41
Q

Management of female infertility?

A
  1. manage lifestyle factors that increase risk of miscarriage
  2. many medical conditions that increase miscarriage risk
    • DM, Hypothyroidism, SLE and APS
  3. Induction of ovulation
    • Clomiphene citrate, Pulsatile GnRH, FSH/LH, Metformin
  4. Assisted reproductive technologies
    • IVF, intreuterine insemmination, egg donation
  5. Counselling
    • genetic testing and counselling
    • grief/supportive counselling
42
Q

what are the 6 categories of male infertility and examples?

A
  1. Spermatic
    • reduced count, impaired motility, reduced ejaculate volume
  2. testicular
    • prev. torsion, infection (mumps, Epidi-orc.) variocele, crytochoridism
  3. genetic
    • klinefelter syndrome (XXY), kallman syndrome
  4. endocrine
    • primary/secondary hypogonadism, thyroid disease, hyperprolactinaemia
  5. psychiatric
    • sexual dysfunction
  6. other
    • medications → anabolic steroids, chronic disease, smoking, alcohol, cannabis
43
Q

what are 4 types of investigations and examples for the assessment of male infertility?

A
  1. semen analysis
    • volume, sperm (conc. number, morph, motility, vitality), sperm chromatin and DNA assays, seminal fructose
  2. Hormone studies
    • prolactin, TSH, FSH,LH, testosterone
  3. Imaging
    • scrotum, prostate
  4. Genetic
    • karyotyping, CF gene testing
44
Q

management strategies for male infertility?

A
  • Management is dependent on cause but includes:
    1. modification of contributing lifestyle factors
    2. medical/surgical management of underlying disease
    3. assisted reproduction techniques
45
Q

what are abnormal features of CTG that require urgent action eg delivery/c-section?

A
  1. prolonged bradycardia → <100bpm for >5mins
  2. absent baseline variability <3bpm
  3. complicated variable decels with reduced baseline variability
  4. late decelerations with reduced variability
46
Q

What are features that are non-reassuring and warrant further Investigations? on CTG

A
  1. reduced variability 3-5bpm
  2. complicated varibale decels
  3. late decels
  4. prolonged decels
47
Q

what are features that are non-reassuring, but unlikely to be associated with foetal compromise if occurring in isolation and in a clear context? on CTG

A
  1. baseline 100-109
  2. absence of accelerations
  3. early decels
  4. variable decels without complicating features
48
Q

what are features of a reassuring, completely normal CTG?

A
  1. baseline 110-160
  2. Variability 5-25
  3. Accelerations 15x15
  4. No decel
49
Q

what are the 4 types of decels?

A
  1. Early decelerations → physiological
  2. variable decelerations → cord compression
  3. late decelerations → insufficient fetal blood flow usually during contraction
  4. prolonged decelerations → acute insult causing hypoxia
50
Q

what are the indications to take Foetal Cord Gases?

A
  1. prematurity
  2. vaginal breech delivery
  3. shoulder dystocia
  4. instrument delivery, expedited vaginal or emergency C-section
  5. intrapartum haemorrhage
  6. multiple birth
  7. low apgars
51
Q

What are contraindications to FBS?

A
  1. blood borne infection or active genital infection
  2. know foetal bleeding disorder
  3. gestation < 34 weeks
  4. non-vertex presentation
  5. clear evidence of acute compromise warranting clear delivery without delay
52
Q

What are the structural causes of bleeding? (PALM)

A
  1. Polyps
    • Endometrial or endocervical polyps
  2. Adenomyosis
    • Growth of endometrial tissue within the myometrium
  3. Leiomyoma
    • benign smooth fibromuscular tumours of the myometrium
  4. Malignancy
    • endometrial hyperplasia, endometrial cancer, cervical cancer
53
Q

What are the structural causes of AUB bleeding? (PALM)

A
  1. Polyps
    • Endometrial or endocervical polyps
  2. Adenomyosis
    • Growth of endometrial tissue within the myometrium
  3. Leiomyoma
    • benign smooth fibromuscular tumours of the myometrium
  4. Malignancy
    • endometrial hyperplasia, endometrial cancer, cervical cancer
54
Q

What are non-structural causes of AUB bleeding (COIEN)

A
  1. Coagulopathy
    • bleeding disorders
  2. Ovulatory disorders
    • dysfunction of the HPG axis resulting in variable timing and volume of bleeding
    • PCOS, thyroid disease, obesity, anorexia
  3. Endometrial disorders
    • usually diagnosis of exclusion in AUB
    • chronic endometritis
    • myometrial hypertrophy
  4. Iatrogenic
    • hormonal contraceptives
    • anticoagulant therapy
    • high dose corticosteroids
    • chemotherapy induced thrombocytopenia
  5. not otherwise classified
    • AV malformations
55
Q

What NSAID is used for dysmenorrhae due to abnormal uterine activity?

A

Mefenamic acid

56
Q

Antifibrinolytic drugs to treat menorrhagia?

A

transexamic acid

57
Q

What are 4 options for medical management of AUB?

A
  1. oral Fe supplementation
  2. Hormonal contraceptives
  3. NSAIDs → Mefenamic acid → for dysmenorrhea
  4. Antifibrinolytic drugs → transexamic acid at onset of bleeding
58
Q

What is the management of Acute profuse vaginal bleeding in a unstable patient?

A
  • IV fluid resus
  • tamponade with foley catheter
  • high dose IV Estrogen to promote rapid regrowth over denuded endometrium
59
Q

What is the management of Acute profuse vaginal bleeding in a stable patient?

A
  • High dose oral Oestrogen
  • High dose Progestins
  • Transexamic acid

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