Obstetrics and Gynaecology Flashcards
What views form the mainstay of mammography
Medic-lateral oblique view and craniocaudal view
What additional views may be useful in mammography?
Coned view
Magnification view
True lateral
Extended craniocaudal
What are the indications for ordering a mammogram?
If aged over 40 with suspected pathology
If aged under forty with a strong clinical suspicion of cancer or a family history risk >40%
What signs of disease may be identified on mammography?
Dominant mass
Asymmetry
Architectural distortion
Calfcifications
What are some typical features of a malignant soft tissue mass in the breast? (4)
Irregular and ill-defined
Spiculated (spikey appearance)
Dense
Distortion of surrounding tissues
What are some common features of a benign soft tissue mass in the breast?
(3)
Smooth/lobulated
Normal density
Halo sign (radiolucent ring around mass)
Ultrasound can be useful in distinguishing what breast pathologies?
Solid from cystic mass
Can suggest benign from malignant masses
When is ultrasound considered before mammography?
First line for women under the age of forty
What is ‘triple assessment’ in the investigation of breast cancer?
Clinical examination
Imaging (mammography usually)
FNA cytology
What indication is there for the use of MRI in breast imaging?
(4)
Recurrent disease
Implants present
Indeterminate lesion following triple therapy
Screening in high-risk women
What imaging technique can be used to determine malignant involvement of the sentinel node in breast cancer?
Lymphoscintigraphy
Outline the process of the Breast Screening Programme in the UK
Women aged 50-70 invited every three years for mammography
5-10% are recalled for further investigations to optimally catch cancer in the DCIS stage or <15mm size to improve outcomes
What is the point of cytology investigations in breast cancer?
Allows for microscopic examination of a thin layer of cells obtained by FNA/smear of nipple discharge or skin scrape of nipple
Describe the cytological appearance of a typical benign breast mass
Low/moderate cellularity
Cohesive cells
Cells uniform in size
Cells uniform in chromatin pattern
Describe the cytological appearance of a typical malignant breast mass
High cellularity
Loss of cohesion
Nuclear pleomorphism
Hyperchromasia
How are cytological samples from breast tissue scored?
C1 - unsatisfactory C2 - benign C3 - atypical (probably benign) C4 - suspicious C5 - malignant
Commonly breast lumps will turn out to be cysts. How are cysts treated?
Aspiration is curative
The fluid drained from breast cysts is discarded unless _________ or ___________.
Fluid is blood-stained
There is residual mass
What are some potential complications of FNA of a breast mass?
Pain Haematoma Fainting INfection Pneumothorax (rare)
Describe the normal structure of the adult breast
Each breast has 8-10 lobes
Within each lobe are many smaller lobules
Each lobule ends with a small bulb that can produce milk
Describe the pre-pubescent structure of the breast
15-25 lactiferous ducts with varying degrees of branching and no lobules.
How does breast anatomy change during puberty?
Hormone responsive tissues lead to proliferation of tissues forming lobules and lobes. Most significantly after pregnancy
Describe the lymphatic drainage of the breast
Drain lymph fluid from the breast tissue into nodes in the axilla and behind the sternum
List six common benign breast pathologies
Fibrocystic change Fibroadenomatous change Intraduct papilloma Fat necrosis Duct ectasia Microcalcifications
What structures may arise from fibrocystic change?
Hint = FACAD
Fibrosis Adenosis Cystis Apocine metaplasia Ductal epithelial hyperplasia
What is a fibroadenoma of the breast?
Benign proliferation of epithelial and storml tissue producing a mobile, painless lump in reproductive age females
List two less common forms of benign adenoma of the breast
Tubular and lactating
What is fat necrosis?
Lipid-filled cysts giving the clinical and morphological appearance of carcinoma. Causes by trauma and history should give suspicion
What is the principal symptom of ductal ectasia?
Nipple discharge
What are microcalcifications?
Tiny deposits of calcium in the breast tissue. Very common and often seen on mammograms. Majority are harmless but may be pre-cancerous
List types of malignant breast disease
Phyllodes tumour
Breast carcinoma
Paget’s Disease of the Nipple
What is Phyllodes tumour?
Very rare malignant breast tumour (can also be benign)
Leaf-like pattern on biopsy
What are the potential symptoms of breast carcinoma?
Hard lump
FIxed mass
Tethering to skin
Peau d’orange dimpling of the skin
List some common risk factors for breast carcinoma
Family history (BRCA1/2 genes) Hormonal treatment Obesity Lack of physical activity Alcohol
How is breast carcinoma classified?
Non-invasive (ductal or lobular carcinoma in situ)
Invasive (ductal or lobular carcinoma and special types)
List some special types of invasive breast carcinoma
Hint = TMMM
Tubular
Mucinous
Medullary
Metaplastic
What is in situ carcinoma of the breast?
Does not form a palpable tumour and is not detected clinically and is not metastatic. Progression to invasive stage is dependent on grade.
Outline the risk of progression of in situ carcinoma of the breast?
Low grade = 30% risk in 15 years
High grade = 50% risk in 8 years
What is the most common subtype of breast cancer?
Invasive ductal carcinoma (75% of cases)
How is suspected breast cancer investigated?
Triple assessment with clinical examination, imaging and cytology (usually core biopsy or FNA)
Histology can report if the tumour is oestrogen or progesterone receptor positive
What effect on mortality from breast cancer has the national screening programme had?
30% reduction in mortality
How is breast cancer treated?
4
Either mastectomy or breast-conservation surgery +/- lymph nodes)
Radiotherapy
Anti-hormonal therapy
Chemotherapy
What is Paget’s Disease of the Nipple?
Results from intraepithelial spread of an intraductal carcinoma causing large-pale staining cells to cause painful/itchy scaling and redness of the nipple with ulceration nnd serious discharge
What common pathology is Paget’s disease of the nipple sometimes mistaken for?
Eczema
What is the most common clinical-pathological abnormality of the male breast?
Gynaecomastia
What is the structural cause of gynaecomastia?
Increased subareolar tissue bilaterally
What underlying conditions may cause gynecomastia?
5
Hyperthyroidism Cirrhosis of the liver Chronic renal failure Hypogonadism Hormone therapies (inc marijuana and TCAs)
What serious male breast pathology accounts for <1% of all breast malignancies?
Carcinoma of the male breast
What targeted therapy for breast carcinoma is available with the HER-2 mutation?
Trastuzumab (anti-HER-2)
Outline antihormone therapy for breast carcinoma
If oestrogen receptors present then given tamoxifen in premenopausal women or other aromatase inhibitors (e.g. anastrozole) if postmenopausal
What three glands all contribute to the production of seminal fluid?
Bulbourethral gland
Prostate
Seminal vesicles
How many sperm are typically each male ejaculate?
20-200 million sperm / mL
What are the functions of Leydig cells?
Produce testosterone in the interstitium of of the testes
Outline the cell life of a sperm
Spermatogonium form first primary and then secondary spermatocytes. Before being moved into the lumen of the seminiferous tubules, they are called spermatids and then finally new sperm are called spermatozoa before they migrate to the epididymus and are then mature sperm
Where do all the seminiferous tubules coalesce?
Rete testes
What are the functions of the Sertoli cells?
5
Form the blood-testis barrier Physical movement of sperm towards lumen Nutrition of the sperm Removal of waste products from sperm Removing of excess cytoplasm
The optimum temperature of sperm is two degrees below that of the core body temperature. How does the body achieve this lower temperature?
Counter-current heat exchange
Afferent testicular arterial blood is cooled by a dense network of venous vessels called the pampiniform plexus.
What factors may affect spermatogenesis?
Testis temperature Endocrine Loss of blood-testis barrier Immunological reactions Environmental factors Medication
How may the blood-testis barrier be compromised?
Trauma
What environmental factors may affect spermatogenesis?
Occupation e.g. welders, plastic manufacturing, pesticide use
Smoking
Radiation
What medications can have an effect on spermatogenesis?
Anti-hypertensives
Anti-depressants
Chemotherapy
What are the systemic effects of androgens?
Deepening of the voice
Increase in sebaceous gland activity
Protein anabolism
Growth of pubic hair
Describe the dual role of oestrogen in the female menstrual cycle
Low levels of oestrogen gives a negative feedback for most of the menstrual cycle
High levels give a positive feedback during days 12-14 of the cycle, therefore stimulating GnRH from the hypothalamus and LH (surge) and FSH from the anterior pituitary
What is the function of the luteinising hormone surge in the menstrual cycle?
Causes an ovum to be expelled from a mature Graffian follicle to allow it to be fertilised and begin pregnancy
What structure is formed from the union of an ovum and a sperm cell?
A zygote
What are the systemic effects of oestrogen?
5
Affects the following processes:
Protein metabolism Carbohydrate metabolism Lipid metabolism Water and electrolyte balance Blood clotting
What proportion of women are affected by morning sickness?
80-85% of women
At what point in the pregnancy does morning sickness usually get better by?
16 weeks gestation
Morning sickness is worse in conditions where human chorionic gonadotropin is higher. Name two examples of these conditions.
Twin pregnancy
Molar pregnancy
What is a molar pregnancy?
When a non-viable egg (the product of the first meiotic division of the oocyte) implants into the uterine wall and become a growth (not a foetus) with swollen chorionic villi
What is the most severe clinical form of morning sickness?
Hyperemesis gravidarum
How is cardiac output affected during pregnancy?
Increases by 30-50%
What mechanism results in an increase in cardiac output in pregnancy? What worrying but benign symptom can arise as a result?
Heart rate increases from 70bpm to 90bpm (palpitations are common)
What happens to blood pressure during the second trimester?
Decrease
The drop in blood pressure in the second trimester is due to a number of mechanisms, name some.
(4)
Expansion of the uteroplacental circulation
A fall in systemic vascular resistance
Reduction in blood viscosity
Reduction in angiotensin sensitivity
When does BP usually return to normal?
Third trimester
Urine output increases during pregnancy; wy?
Renal plasma flow increases by 25-50%
GFR increases by 50%
Bladder capacity is reduced in the third trimester due to expanded uterus
Why are UTIs more common in pregnancy?
Increased urinary stasis
Physiological hydronephrosis provides easier path of infection
What complications are associated with UTI in pregnancy?
Pylonephrosis
Pre-term labour
Anaemia is common during pregnancy; why?
Dilutional effect of plasma volume increasing with no compensation of iron stores
What is the lower tolerated limit of iron levels in pregnancy before supplementation is started?
Iron supplements given if Hb is lower than 110 at booking
Progesterone acts centrally to affect a reduction in CO2 levels. Outline some effects of the reductions of CO2
(5)
Increased tidal volume Increased respiratory rate Increased oxygen consumption by 20% Plasma PO2 is unchanged Hyperaemia of respiratory mucous membranes
What conditions are screened for during a first visit scan?
Ensures viable pregnancy
Identifies multiple pregnancy
Downs Syndrome Screening
What conditions are screened for during a second-trimester scan?
Major structural abnormalities
If something is spotted on the second-trimester scan, what more comprehensive investigation may be offered?
Detailed anomaly scan
Outline the changes to the pelvis during pregnancy?
Pubic symphysis stretches
When are pregnant women most likely to report extreme fatigue?
First and third trimester
Oesophageal reflux is common; what mechanism underlies this?
Progesterone reduces peristalsis
What changes occur in the thyroid during pregnancy?
Iodine is excreted to the foetus and therefore enlarges and can cause goitre
Why is infection more likely during pregnancy?
General state of immunosuppression (physiological) to avoid rejecting the foetus
Describe the changes in the breast that occurs during pregnancy?
Increased size and vascularity
Increased areola and nipple pigmentation
Colostrum like fluid may be expressed from the end of the first trimester
Describe the cardiovascular changes during the intrapartum period
Autotransfusion (500mls of blood into circulation due to contractions)
Pain increases heart rate and blood pressure
How does the cardiovascular system adjust in the postpartum period?
Returns to normal by three months
What two ways do contraceptive clinical trials report their failure rates
The Pearl Index
The LIfe Table Analysis
What is the definition of the Pearl Index?
Defined as the number of contraceptive failures per 100 women-years of exposure
What is the definition fo the Life Table Analysis?
Provides a cumulative failure rate for a given time period of exposure
What are the two hormones contained in the combined oral contraceptive pill?
Ethinyl estradiol
Synthetic progesterone
What is the most common drug regimen for the combined oral contraceptive pill?
Taken for 21 days with a pill-free week
What is the mode of action of the combined oral contraceptive pill?
Prevents ovulation by altering FSH and LH (no surge)
Creates an inadequate endometrium and alters the quality of the cervical mucous preventing sperm penetration
How long does a woman need to abstain from sex/use other forms of contraceptive after starting the combined pill before the pill is sufficient to prevent conception?
7 days
Does the contraceptive effect remain during the pill-free week?
Yes
What is the longest period of time that a woman can use the combined oral contraceptive pill before they need a pill-free week?
Three months
List some non-contraceptive benefits of the combined oral contraceptive pill?
Regulates bleeding
Reduction in functional ovarian and endometrial cysts
Improves acne
Reduction in benign breast disease, rheumatoid arthritis, colon cancer and osteoporosis
What are the potential health risks associated with the use of the combined oral contraceptive pill?
VTE (3x increase in risk)
Increased MI risk in smokers
Increased risk of stroke in those susceptible to focal migraines
Breast and cervical cancer risk increased
What drug regimen is required for the progesterone-only pill?
Pill taken every 24hours (+/- 3hours per day)
What is the mode of action of the progesterone-only pill?
Cervical mucus rendered impenetrable by sperm
What is the depot medroxyprogesterone acetate (DepoProvera)? How is it given and in what regimen?
An aqueous solution of crystals of the progesterone complex given in 150mls deep IM injection every 12 weeks
What is the mode of action of the DepoProvera?
Prevents ovulation
Makes cervical mucous impenetrable
Renders endometrium unsuitable
What are the non-contraceptive advantages of the DepoProvera?
(3)
Good for forgetful pill-takers
70% of women become amenorrhoeic
Oestrogen free
What are some negatives of the DeproPorvera?
4
Delays return to fertility (up to one year)
Reversible reduction in bone density (up to one year)
Problematic bleeding is possible
Weight gain common
What are the modes of action of the subdermal implant?
Primary - inhibition of ovulation in 100% of women for three years regardless of weight
Secondary - inhibits sperm penetrance of cervical mucous
How is sterilisation achieved in women?
Filshie clips inserted laporiscopically
Outline the process of a vasectomy
Permanent division of the vas deferens under local anaesthetics
Why is vasectomy typically permanent?
Anti-sperm antibodies are implicated in low-rate of success of reversal procedures
Pain is a complication following a vasectomy; why is this?
Pain due to sperm granuloma formation
What is a sperm granuloma?
A mass of degenerating spermatozoa surrounded by macrophages
How is the termination of pregnancy medically carried out?
Mifepristone - switches off progesterone (which keeps the uterus from contracting)
Misoprostol is given 48 hours later to initiate uterine contraception and opens the cervix to expel the pregnancy
What are some potential complications of medical termination of pregnancy?
Failure
Haemorrhage
Infection
Prolonged bleeding
What is labour?
The process in which the foetus, placenta and membranes are expelled via the birth canal
When does the typical labour process begin?
At term (37-42 weeks gestation)
What is it called when a foetus is born at term, presenting by the vertex without medical intervention?
Spontaneous vaginal delivery
How is labour triggered?
Complex aetiology
Triggered by paracrine and autocrine signals from the mother, foetus and placenta.
What three key physiological changes must occur to allow expulsion of the foetus?
Cervix softens
Myometrial tone changes to allow for coordinated contractions
Progesterone decreases while oxytocin and prostaglandins increase
What are the two parts of the first stage of labour?
Latent first stage
Established first stage
What is the latent first stage of labour?
A period during which there are intermittent, irregular and painful contractions that bring cervical dilation up to 4cm
What is established first stage of labour?
Regular, painful contractions that result in progressive cervical dilatation up to 10cm
What is the typical length of the first stage of labour?
Primagravida - average of 8 hours (no more than 18 hrs)
Multigravida - average of 5 hours (no more than 12hrs)
What is stage two of labour?
The period of labour from full cervical dilation to the birth of the baby
What are the two parts of the second stage of labour?
Passive and active stages
Outline the passive second stage of pregnancy
Findings of full dilation of the cervix before or in absence of involuntary expulsive contractions
Outline the active second stage of pregnancy
Expulsive contractions requiring active maternal effort with a finding of full cervical dilatation. Presenting part is visible
How long does the second stage of pregnancy last?
Primigravida - expected pithing two hours of second stage commencement
Multigravida - expected within one hour of second stage commencement
What is the third stage of pregnancy?
Time from the birth of the baby to the expulsion of the placenta and membranes
What two methods of management of the third stage of labour?
Active and physiological
What is active management of the third stage of labour?
Use of uterotonic drugs
Deferred clamping and cutting of the cord
Controlled cord contraction after signs of placental separation
What is physiological management of the third stage of labour?
No routine use of uterotonic drugs
No clamping of the cord until pulsation has stopped
Delivery of the placenta by maternal effort
When is the diagnosis of prolonged third stage of labour made?
When the third stage of labour is not completed within thirty mins of active management or sixty mins of physiological management
What maternal vital signs are monitored throughout the labour process?
Blood pressure, pulse, temperature, respiration rate, oxygen saturation, urine output, urinalysis
How is foetal heart rate auscultated?
Intermittent with ah and held Doppler or continuously (cardiotocography) monitoring
How often is intermittent foetal heart rate auscultation done?
Stage one - every 15 mins
Stage two - every 5
When palpating the uterus for contractions, what timing and strength are optimal?
3-4 mins lasting approx. 40s-1min with moderate to strong strength
Outline the mechanism of delivery
HINT: DFILCRIL
Descent Flexion Internal rotation Crowning and extension of the head Restitution Internal rotation of the shoulders and head Lateral flexion
Outline the analgesic options in labour
Simple techniques - breathing, massage, TENS, water
Medications - entonox, opioids, remifentanil (patient controlled analgesia)
Procedures - epidural
What factors affect placental exchange of substances?
Size
Electrical change
Protein binding
Lipophilicity
Outline some potential mechanisms for teratogenicity
4
Folate antagonism
Neural crest disruption
Oxidative stress
Vascular disruption
What is the definition of maternal mortality?
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy from any cause related to or aggravated by the pregnancy or its management.
Not from accidental or incidental causes
What is the definition of maternal morbidity?
Severe health complications occurring in pregnancy and delivery not resulting in death
List four methods of measuring mortality
Maternal mortality ratio
Maternal mortality rate
Proportionate mortality ratio
Lifetime risk of maternal death
What is maternal mortality ratio?
Number of maternal deaths during a given time period per 100,000 live births during the same period
What is the maternal mortality rate?
Number of maternal deaths in a given time period per 100,000 women of reproductive age, woman-years of risk exposure in the same period
What does maternal mortality ratio represent in terms of risk?
Obstetric risk
What is the lifetime risk of maternal death?
Probability of maternal death during a woman’s reproductive life, usually expressed as odds
What does the lifetime risk of maternal death represent in terms of risk?
A measure of a woman’s risk of becoming pregnant as well as the risk of dying while pregnant
What is the proportionate mortality ratio?
Maternal deaths as a proportion of all female deaths of those of reproductive age in a given time period
What is the definition of direct deaths caused by pregnancy?
Defined as those related to obstetric complications during pregnancy, labour or puerperium (6 weeks)
What are the most common direct deaths caused by pregnancy?
Haemorrhage, sepsis, pre-eclampsia, obstetric labour or unsafe abortion
What proportion of maternal deaths are direct versus indirect?
87% ar direct
What are indirect deaths caused by pregnancy?
Those associated with a disorder, the effect of which is exacerbated by pregnancy
What are late maternal deaths?
Deaths which occur up to 42 days after the end of pregnancy but within one year
The Three Delays Model can account for some reasons why maternal deaths occur. What are the Three Delays?
Delay in…
Decision to seek care
Reaching care
Receiving care
What is the definition of a stillbirth?
Birth of a dead baby after 20-28 weeks of gestation or weighing more than 500g
What is the definition of early neonatal death?
Death of a baby within the first week of life
What is the definition of late neonatal death?
Death of a baby within the first 28 days of life
What is the definition of perinatal death?
Includes both stillbirth and neonatal mortality data
What is the definition of infant mortality?
Death of an infant within the first year of life
What is the definition of child mortality?
Death of a child within the first five years of life
What proportion of pregnancies are induced?
Approx. 1 in 5
What are the drawbacks of inducing labour?
Its less efficient and more painful
Risk of uterine “hyperstimulation” with prostaglandin/ oxytocin induction
Outline some indications for induction of labour
Diabetes
Post-dates (term +7 days)
Maternal health problems that necessitates delivery (e.g. treatment for DVT required)
Foetal reasons
What is induction of labour?
When an attempt is made to instigate labour artificially using medications or devices to “ripen the cervix” followed by an amniotomy
What is the Bishop’s Score?
A pre-labor scoring system to assist in predicting whether induction of labor will be required
Outline the process of induction of labour
Vaginal prostaglandin pessaries or a Cook balloon are used to ripen the cervix
Once the cervix is dilated and effaced, an amniotomy is performed (artificial rupture of membranes using an amniohook)
IV oxytocin can be used to achieve adequate contractions
What Bishops score is considered favourable for an amniotomy?
Seven or more
Labour can face several problems. One of these is suboptimal progress. What is progress? How is it assessed?
Progress is the descent of the foetal head through the maternal pelvis
Assessed by:
Cervical effacement
Cervical dilation
Define suboptimal progress.
Less than 0.5cm per hour for prima gravid women
Less than 1cm per hour for parous women
Passages and passenger of labour may be a problem. Give some clinical scenarios in which this may arise.
Cephalopelvic disproportion (rare - foetal head is in the right position but is too large to negotiate the maternal pelvis)
Malpresentation
Malabsorption
What is the most optimal position for birth?
Occipitoanterior (OA)
What position is incompatible with vaginal delivery?
Left or right occipitotransverse
Foetal distress is a risk in labour. How is it monitored?
Foetal heart rate
Cardiotocography
Foetal blood sampling (measures pH for hypoxaemia detection)
Foetal ECG
What situations may you advise against labour in?
Obstruction of birth canal Malpresentations Medical conditions Specific previous labour complications Foetal conditions
What percentages of pregnancies require assisted/instrumental delivery?
15%
What is caesarean section?
An essential procedure for the management of obstructed labour or foetal distress before the cervix is fully dilated
Caesarean section carries more risk than spontaneous vaginal delivery. What are they?
Increased risk of infection, bleeding, visceral injury, VTE
What is the advantage of Caesarian section in terms of collateral trauma?
Reduced risk of injury to the perineum and future complications with incontinence
List some third stage complications of labour
Retained placenta (requires surgery to retrieve it) Post-partum haemorrhage
What are the causes of postpartum haemorrhage?
Tone
Tissue
Thrombus
Tear
What is the most likely cause of postpartum haemorrhage?
Uterine atony (failure of autotransfusion of blood out of the uterus)
What is the spectrum of severity of tears associated with labour? How is the risk of this mitigated?
Graze all the way up to fourth-degree tears (full-thickness tear of the vagina through to anal canal)
Lateral episiotomy
In the post-partum period, the first midwife visit assess what?
Signs of abnormal bleeding
Observe for signs of infection (wound/endometritis/breast infection)
What are common problems identified with new mothers in the postpartum period?
Problems with feeding
Problems with bonding
Social issues (partner, other children, financial)
Contraceptive consideration
What is the definition of primary postpartum haemorrhage?
Blood loss of more than 500ml within the first 24 hours post-delivery
What is the definition of secondary postpartum haemorrhage?
Blood loss greater than 500mls from 24 hours post-delivery to 6 weeks
What bleeding pattern is normal postpartum?
Lochia is normal for 3-4 weeks postnatal and is described as “like a normal period or less”
Why is venous thromboembolism a risk in the postpartum period?
Pregnancy and the immediate postpartum period are hypercoagulable states
What clinical findings might indicate DVT/PE?
Unilateral leg swelling/tenderness/erythema
Dyspnoea
Chest pain
Unexplained tachycardia
How is the risk of VTE managed in the puerperium?
Early mobilisation following spinal aesthetic/ caesarian section
Treated with Low-Molecular Weight Heparin (LMWH)
What is the leading cause of maternal death?
Sepsis
If sepsis is suspected in a pregnant woman or in the postpartum period, what measures are taken?
Immediate and aggressive treatment with antibiotics and antipyretics, IV fluids too if shocked
Full spetic screen (blood cultures, low vaginal swab, mid-stream urine sample)
Referral to hospital
What psychiatric disorders are observed for in the puerperium?
Baby blues
Postnatal depression
Puerperal psychosis
What are the “baby blues”?
Affects most women due to extreme hormonal changes around birth and usually lasts 1-3 days postnatally.
Does not affect functioning and requires no specific treatment
What is postnatal depression?
Can continue from baby blues or start later.
Classical depressive symptoms which may affect bonding and often requires treatment
What is puerperal psychosis?
Rare but serious psychiatric disorder of the postnatal period. Women can be a danger to themselves and their babies. Requires inpatient care
When do most pre-eclamptic seizures occur?
Most commonly occur in the post-natal period and may worsen over the several days following delivery
What is the definition of infertility?
Defined as the inability of the couple to conceive after 12 months of regular intercourse without the use of contraceptives
What is the chance of conception within one year of trying?
80% of couples in the general population will conceive within one year if the woman is aged less than forty and are not on contraception
What investigations are indicated in the case of difficulty conceiving?
Female partner: rubella immunity, chlamydia, TSH, mid-luteal progesterone (if periods are regular), full hormone profile (if periods are irregular)
Male partner: semen analysis
What pathologies may cause infertility?
Ovulatory disorder Tubal factors Endometriosis Male factor Sexual problems
Ovulatory disease may be treated by ovulation induction. Outline this process.
Clomifene (mimics oestrogen and stimulates gonadotropins to release)
Gonadotrophin therapy cycles (typically FSH)
What is azoospermia?
The absence of sperm in the semen
What investigations are indicated in the case of azoospermia?
Hormone profile (FSH, LH, testosterone, karyotyping and prolactin)
CF screen
What sexual problems may lead to infertility
Psychosexual problems
What treatment options are available to couples with sexual problems?
Psychosexual counselling
Artificial insemination
What option is available to couples with medically intractable infertility?
IVF treatment
What is the definition of miscarriage?
Termination / loss of pregnancy before 24 weeks gestation
What is the incidence of spontaneous miscarriage?
Approx. 15%
What are the categories of spontaneous miscarriage?
Threatened Inevitable Incomplete Complete Septic Missed
What is a threatened miscarriage?
Bleeding from the gravid uterus before 24 weeks gestation when there is a viable foetus and no evidence of cervical dilation
What is an inevitable miscarriage?
Abortion becomes inevitable when the cervix has begun to dilate
What is an incomplete miscarriage?
Only partial expulsion of the products of conception
What is a complete miscarriage?
Passed all the products of conception, cervix has closed and bleeding has stoppe
What is a septic miscarriage?
Following an incomplete abortion there is always a risk of ascending infection into the uterus and through the pelvis
What is a missed miscarriage?
Describes a pregnancy in which the foetus has died but the uterus has made no attempt to expel the products of conception
What are the common causes of spontaneous miscarriage?
5
Abnormal conceptus (chromosomal, genetic, structural)
Uterine abnormalities (congenital, fibroids)
Cervical incompetence
Maternal (increasing age, diabetes)
Unknown
How is threatened miscarriage managed?
Conservatively
How is inevitable miscarriage managed?
Heavy bleeding may need evacuation
How is missed miscarriage managed?
Conservative
Medical - prostaglandins (misoprostol)
Surgical evacuation
How is septic miscarriage managed?
Antibiotics and evacuation of uterus
What is the definition of ectopic pregnancy?
Pregnancy implanted outside the uterine cavity
Where is the most common site for an ectopic pregnancy to implant?
Fallopian tube
What are the risk factors of ectopic pregnancy?
PID
Assisted conception
Previous tubal surgery
Previous ectopic
How does ectopic pregnancy present?
Period of amenorrhoea (with a positive pregnancy test)
Other features include:
Pelvic pain
Vaginal bleeding
GI or urinary symptoms
What investigations are indicated in the case of ectopic pregnancy?
US scan - no intrauterine gestational sac, may see adnexal mass
Serum beta-HCG
Serum progesterone
What management is offered for ectopic pregnancy?
Medical - methotrexate
Surgical - laparoscopy (mostly), salpingectomy
What is antepartum haemorrhage?
Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby - associated with significant maternal mortality/morbidity
What are the common causes of antepartum haemorrhage?
Placenta praevia Placental abruption Local lesions Vasa préavis Unknown
What is placenta praevia?
When all or part of the placenta implants in the lower segment of the uterine segment
How is placenta praevia classified?
Grade I - IV depending on how close to the cervical os
How does placenta praevia present?
Painless PV bleeding
Malpresentation of the foetus
Incidental finding also possible
What is placental abruption?
Haemorrhage resulting from the premature separation of the placenta before the birth of the baby
How is placenta praevia classified?
External abruption
Relatively-concealed abruption
Concealed abruption
What are the complications may occur with placental abruption?
Maternal shock (disproportionate to bleeding) Maternal DIC Renal failure Postpartum haemorrhage Foetal death
What is vasa praevia?
A condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture
What is preterm labour?
Onset of labour before 37 weeks completed gestation
How is preterm labour classified?
Mildly preterm at 32-36 weeks
Very preterm at 28-32 weeks
Extremely preterm at 24-28 weeks
What is the incidence of preterm labour?
Around 5-7% of singletons
Around 30-40% of multiple pregnancies
What factors predispose one to preterm labour?
Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection e.g. UTI
How is preterm labour diagnosed?
Contractions with evidence of cervical change on vaginal exam
How is preterm labour managed?
When viable consider tocolysis to slow contraction, steroids for foetal lung development and transfer and aim for vaginal delivery
What neonatal morbidity can be a result of preterm labour?
List five at least
Respiratory distress syndrome Intraventricular haemorrhage Cerebral palsy Nutritional deficiency Infection Visual impairment Hearing loss
What is gestational hypertension?
Blood pressure consistency above normal(either mild moderate or severe) developing during pregnancy after 20 weeks gestation
What is pre-eclampsia?
New hypertension after 20 weeks gestation in association with significant proteinuria
What clinical criteria is required for the diagnosis of pre-eclampsia?
New-onset hypertension with significant proteinuria measured by:
Automated reagent strip >+1
Spot urinary protein: creatinine ratio >30,g/mmol
24-hour urinary protein collection >300mg/day
What is the pathophysiology of pre-eclampsia?
Secondary invasion of maternal spiral arterioles by trophoblasts leading to reduced placental perfusion and an imbalance between vasoconstriction and vasodilators in pregnancy
What are the risk factors for developing pre-eclampsia?
First pregnancy Extremes of maternal age History of pre-eclampsia BMI >35 Multiple pregnancy
List some maternal complications of pre-eclampsia
Eclampsia (seizures) Severe hypertension HELLP syndrome DIC Renal failure Pulmonary oedema and cardiac failure
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
What is DIC?
Disseminated intravascular coagulation
List some foetal complications of pre-eclampsia
Intrauterine growth restriction
Foetal distress
Prematurity
Increased postnatal mortality
What are the symptoms of pre-eclampsia?
9
Headache Blurred vision Epigastric pain Vomiting Sudden swelling of the face and hands Convulsions Clonus/brisk reflexes Reduced urine output
What investigations are indicated for pre-eclampsia?
Full blood count (for haemolysis and platelets)
LFTs
Renal function (urea, creatinine, rate)
Coagulation tests if indicated clinically
Foetal (scan for IUGR and cardiotocography
What is the only curative option for pre-eclampsia?
Delivery of the baby and the placenta
How is pre-eclampsia managed conservatively?
Close observation
Antihypertensives
Steroids for foetal lung development (if gestation <36 weeks)
Seizure management (IV Magnesium sulphate and avoid fluid overload)
Why is pregnancy a hypercoagulable state?
To protect the mother against bleeding post-delivery
Due to increased fibrinogen, factor VIII, platelets and an increase in fibrinolysis
How is the risk of VTE managed in pregnancy?
TED stockings
Advice about mobility and hydration
Prophylactic anticoagulants if high risk
What are the signs and symptoms of VTE/PE?
Pain in calf Unilateral increase in calf girth Calf tenderness Breathlessness Pain on breathing Cough Tachycardia Hypoxia Pleural rub
How is VTE/PE investigated in pregnancy?
ECG Blood gases Doppler V/Q scans of the lungs CTPA (CT pulmonary angiogram)
What types of diabetes may affect a pregnancy?
Pre-existing (T1/2DM)
Gestational diabetes
What stresses of pregnancy may make pre-existing diabetes more dangerous?
Insulin requirements of the mother increase (HPL, HCG, cortisol all have anti-insulin effects)
Foetal hyper-insulinaemia (macrosomia and increased risk of neonatal hypoglycaemia and respiratory distress syndrome)
What is gestational diabetes?
Carbohydrate intolerance with onset in pregnancy
Reverts to normal after delivery (increased risk of developing T2DM later in life)
How is diabetes managed in pregnancy?
Preconception - good glycaemic control, folic acid supplementation, dietary advice, retinal and renal assessment
During pregnancy - optimise glucose control, watch foetal growth
Around labour - early feeding to prevent neonatal hypoglycaemia
How is gestational diabetes screened for?
If high risk then offer HbA1c at booking and OGTT if >6%
What is a commensal micro-organism?
A microbe that derives food or other benefits from another microorganisms without hurting or helping it
What is a sexually transmitted microbe?
A virus, bacteria or protozoa which can be spread by sexual contact (may be a commensal or pathogen)
What is a sexually transmitted infection?
An infection by a pathogen which is sexually transmissible and which is unlikely to be transmitted by non-sexual means
What is a sexually transmitted disease?
A disorder of structure of function caused by a sexually transmitted pathogen
What is the causative agent of gonorrhoea?
Neisseria gonorrhoeae
What proportion of men don’t have symptoms in gonorrhoea infection?
10% of men
What proportion of women don’t have symptoms in gonorrhoea infection?
> 50% of women
What symptoms do some men get with a gonorrhoea infection?
Thick, profuse, yellow discharge, dysuria
Rectal and pharyngeal infections are often asymptomatic
What symptoms do some women get with a gonorrhoea infection?
Vaginal discharge or intermenstrual/post-coital bleeding
List some complication of gonorrhoea infection
Males - Epididymitis
Females - PID or Bartholin’s abscess
How long does gonorrhoea take to incubate before symptoms appear?
Usually 5-6 days
Can range from 2 days to 2 weeks
How is gonorrhoea diagnosed?
Nucleic acid amplification test (NAAT)
How is gonorrhoea treated? Describe the follow up required?
Ceftriaxone 1g IM
Test of cure after 2 weeks and test reinfection in 3 months
What is the infective organism in chlamydia infection?
Chlamydia trachomatis serovars D to K
What specific serovar of chlamydia causes lymphogranuloma venereum, causing symptoms of severe proctitis?
Serovar L2b
What proportion of men have symptomatic chlamydia?
<30%
How does symptomatic chlamydia present in men?
Slight watery discharge and dysuria
Potential conjunctivitis
What proportion of women have symptomatic chlamydia?
<20%
How does symptomatic chlamydia present in women?
Vaginal discharge, dysuria, Intermenstrual/post-coital bleeding
Potential conjunctivitis
Outline some potential complications of chlamydia
Male- epididymitis,
Female - PID, ectopic pregnancy, pelvic pain, infertility
How is chlamydia diagnosed?
Men - first void urine sample
Women - cervical/urethral/rectal swab
All specimens tested with NAAT
How is chlamydia treated?
Doxycycline 100mg bp for 1 week
Azithromycin 1g po once if pregnant
What herpes virus types cause simplex infection?
Types 1 and 2
What proportion of HSV infections are symptomatic?
20%
What is the clinical presentation of symptomatic HSV infection?
Recurring symptoms of burning/itching leading to blisters/ulcers
Inguinal lymphadenopathy, flu-like symptoms, dysuria
What complications may occur in HSV infection?
Autonomic neuropathy (urinary retention), neonatal infection
How is HSV infection diagnosed?
Diagnosis is clinical and confirmed by swabs from relevant sites for PCR
How is HSV treated?
Primary infection - aciclovir 400mg tis for 5 days
Recurrence: consider long term aciclovir, lidocaine ointment for pain
What is the infective organism of trichomoniasis?
Trichomonas vaginalis
Usually asymptomatic in men, describe the clinical presentation of symptomatic trichomoniasis?
Profuse thin vaginal discharge - greenish, frothy and foul-smelling.
How is trichomoniasis treated?
Metronidazole 400mg po bd for 5 days or 2g single dose
What complications are associated with trichomoniasis?
Miscarriage and preterm labour
Anogenital warts are caused by what virus types?
Human papilloma virus (HPV) types 6 and 11 (occasionally type 1)
What symptoms may occur in anogenital warts?
Lumps with a surface texture of a small cauliflower
Occasionally itching or bleeding especially if perianal or intraurethral
How are anogenital warts diagnosed?
Usually able to make clinical diagnosis.
Biopsy to exclude intraepithelial neoplasia (rare)
How are anogenital warts treated?
Topical treatments - podophyllotoxin, imiquimod
Other - cryotherapy, diathermy
What is the causative agent of syphilis?
Treponema pallidum
Syphilis can often be entirely asymptomatic to mild symptoms. Outline the progression of symptomatic syphilis
Primary - local ulcer (chancre)
Secondary - rash, mucosal ulceration, patchy alopecia
Early latent - no symptoms but less than 2 years since caught
Late latent - no symptoms but greater than 2 years since caught
Tertiary - neurological, cardiovascular or gummatous (rare)
How is syphilis diagnosed?
Clinical signs
Serology to microorganism, IgGEIA
PCR sample from ulcer
How is syphilis treated?
Benazathine penicillin or doxycycline
Vulvovaginal candiosis is a common non-STI genital infection. What factors predispose a woman to developing this condition?
Diabetes or oral steroid use
Immunosuppressed (e.g. HIV infection)
Pregnancy
Of reproductive age
What is the most common microbe responsible for vulvovaginal candidosis?
Candida glabrata et al (usually acquired from bowel)
What are the symptoms of vulvovaginal candidosis?
Often asymptomatic
Thrush symptoms (itch and thick, white discharge)
How is vulvovaginal candidosis diagnosed/
Characteristic history
Examination findings (fissuring, erythema stellate lesions, discharge)
Investigtions (Gram stained, culture in Sabouraud’s medium)
How is vulvovaginal candidosis?
Azole antifungals (clotrimazole 500mg)
Resistant case (establish sensitivities)
Other management (maintain skin, avoid irritants etc.)
What is the commonest cause of abnormal vaginal discharge?
Bacterial vaginosis
What are the symptoms of bacterial vaginosis?
Asymptomatic in 50% of cases
Watery grey/yellowish “fishy” discharge
May be worse after period/sex
Sometimes sore/itch from dampness
How is bacterial vaginosis diagnosed?
Characteristic history Examination findings (thin homogenous discharge) Gram stained smear of discharge
How is bacterial vaginosis treated?
Metronidazole (oral or vaginal gel)
Clindamycin (vaginal)
What is balanoposthitis?
Inflammation (usually infective) of the glans of the penis/foreskin
What is erythrasma?
Infection of the skin around the groin by corynebacterium minutissimum
For what reasons may a pregnant woman be referred to genetics?
Family history of genetic disease
Suspicion of genetic condition
Genetic counselling (increase understanding and aid decision making)
Give examples of targetted genetic tests possible in pregnancy
CF mutation
Haemoglobinopathies
Tay-Sachs Disease
At what stage of gestation is chorionic villous sampling possible?
8-10 weeks
At what stage of gestation is amniocentesis possible?
14-16 weeks
What is the major risk associated with invasive foetal testing?
Miscarriage risk of approx. 1-2% (CVS>amnio)
What conditions are screened for within the general population at birth?
(8)
Phenylketonuria Congenital hypothyroidism Sickle cell disease Medium-chain acetyl Co-A dehydrogenase deficiency Maple syrup urine disease Glutaric aciduria type 1 Homocystinuria Cystic Fibrosis
What is the inheritance pattern of phenylketonuria?
Recessive condition
What is the pathology of phenylketonuria?
Inability to breakdown phenylalanine
If untreated, causes serious mental disability
How is phenylketonuria managed?
Strictly controlled diet
What is the pathology of congenital hypothyroidism?
Not enough thyroxine. Untreated, babies will fall seriously ill and develop both mental and physical disabilities
How is Medium-chain Co-A dehydrogenase deficiency inherited?
Recessive inheritance
What is the pathology of Medium-chain Co-A dehydrogenase deficiency?
Cannot break down fat to make energy. Serious life-threatening symptoms can occur quickly if not feeding well
How is Medium-chain Co-A dehydrogenase deficiency managed?
Prevent metabolic crisis - avoid fasting
Emergency regimen - glucose polymer and IV dextrose
What is the inheritance pattern of Duchenne’s Muscular Dystrophy?
X-linked
What is the main risk factor which increases the risk of Downs Syndrome?
Maternal age
How is cystic fibrosis diagnosed in babies?
Immunoreactive trypsin (first six weeks)
Guthrie Sweat Test
Genotyping
What is Tay-Sachs disease?
Progressive lysosomal storage disease caused by hexosaminidase A deficiency leading to a build up of lipid ganglioside in nerve cells o the brain
What is Gillick competence?
A part of medical law which allows a doctor to determine whether a minor patient is able to consent to medical treatment without parental permission
What are the Fraser guidelines?
Criteria for determining whether a minor is able to consent to getting contraception
Outline the Fraser guidelines
Five questions to ask yourself:
- Is the girl mature enough to understand the advice and implications of treatment?
- Is the girl likely to being to have sex regardless of getting the treatment?
- Did you try to persuade the girl to allow yourself to inform their parents
- Would the girls health suffer without treatment?
- Is treatment in the girl’s best interests?
How is a patient’s stage of puberty assessed?
Self-staging with the Tanner Scale
What is amenorrhoea?
Absence of a menstrual cycle
What is primary amenorrhea? At what ages is this investigated?
Failure to start a menstrual cycle.
Investigate at age 16 if secondary sexual characteristics develop
Investigate at age 14 if no secondary sexual characteristics develop
What is secondary amenorrhoea?
Secondary amenorrhea is the absence of menstruation in a woman who had been menstruating but later stops for 4+ months in the absence of pregnancy, lactation (production of breast milk), cycle suppression with the contraceptive pills, or menopause.
List some causes of amenorrhoea
7
Hypothalamus-Pituitary-Ovarian Axis Dysfunction
Obesity
Low BMI
Polycystic ovarian syndrome (PCOS)
Overactive thyroid gland
Extreme emotional stress
Excessive exercise
What is PCOS?
Polycystic Ovarian Syndrome
A syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism underlying insulin resistance and polycystic ovary morphology.
What criteria are used to diagnose PCOS?
Rotterdam criteria
Two out of three of the following:
- Oligo- or anovulation
- Clinical/biochemical signs of hyperandrogenism
- Radiographic evidence of polycystic ovaries
How is PCOS treated?
Weight reduction
Lifestyle changes
Oral contraceptive pill (antiandrogen effect)
Eflornithine cream for facial hair
Endometrial protection (achieved with COCP or Minera IUS)
Fertility treatment
Menorrhagia is a common complaint. How would you address this concern in a young woman?
Reassure and speak directly to the patient
Medical options: Tranexamic acid, oral contraceptives etc.
Advise use of ibuprofen (helps with pain and can reduce bleeding by up to 40%)
What is a labial agglutination? What medical conditions can it lead to?
Fusion of labia in the midline (usually) which encourage the retention of urine and vaginal secretion leading to an increased likelihood of vulvovaginitis and UTI
How are labial adhesions treated? When is medical treatment indicated?
Improve hygiene
Medical treatment (oestrogen creams/surgical separation) indicated when there is difficulty urinating or chronic vulvovaginitis
When is a vaginal discharge normal in infants and prepuberty respectively?
A mucoid discharge in the first two weeks of life is common due to exposure to maternal oestrogen
Increased oestrogen production by maturing ovaries in prepuberty can cause a vaginal discharge
Pathological vaginal discharge can be caused by a few different mechanisms; list four
Infection (E. coli, proteus, pseudomonas)
Haemolytic streptococcal vaginitis
Fungal vaginitis
A foreign body
How is vaginal discharge investigated?
4
Culture to identify organism
Urinalysis to rule out cystitis
Review hygiene
Indication under anaesthesia to rule out foreign body
How is puberty induced medically?
Gradual build-up of oestrogen dose and once maximum height potential is achieved progesterone is added.
What is the definition of a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines
What is the definition of a female pelvic organ prolapse?
Refers to the descent of the pelvic organs towards or through the vagina
What is the incidence of pelvic organ prolapse?
Affect 12-30% of multiparous and 2% of nulliparous women
What is the pelvic floor?
Muscular sling that forms the floor to the inferior pelvic aperture and allows transmission of vagina and rectum through hiatuses.
The pelvic floor is one functional unit consisting of three layers; what are they?
Endo-pelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the endo-pelvic fascia?
Network of fibre-muscluar connective type tissue that surrounds various visceral structures (uterofascial ligaments/pubocervical fascia/ rectovaginal fascia)
What is the pelvic diaphragm?
Layer of striated muscles with its fascial coverings (lavatory ani and coccyges muscles)
What is the urogenital diaphragm?
The superficial and deep transverse perineal muscles with their fascial coverings
LIst risk factors for pelvic organ prolapse
5
Pregnancy and vaginal brith Advancing age Obesity Previous pelvic surgery Others (hormonal, constipation, exercise, occupation)
List types of pelvic organ prolapse
Urethrocele Cystocele Uterovaginal prlapse Enterocele Rectocele Apical prolapse
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethral only
What is a cystocele?
Prolapse of the upper anterior wall of the vagina involving the bladder
What is a uterovaginal prolapse?
Term used to describe prolapse of the uterus, cervix and upper vagina
What is an enterocele?
Prolapse of the upper posterior wall of the vagina containing loops of small bowel
What is a rectocele?
Prolapse of the lower posterior wall fo the vagina involving the rectum bulging into the vagina
What is an apical prolapse?
Descent of uterus, cervix, or vaginal vault
List the signs and symptoms of pelvic organ prolapse including vaginal, urinary and bowel
Vaginal - sensation of bulge, seeing bulge, pressure, heaviness, difficulty inserting tampons
Urinary - incontinence, frequency/urgency, hesitation, incomplete voiding, need to splint
Bowel - incontinence, incomplete voiding, digital evacuation to complete defaecation
How is pelvic organ prolapse investigated and classified?
Investigations: USS/MRI, urodynamics, IVU
Classified: POPQ Score
How can pelvic organ prolapse be prevented?
Avoid constipation
Pelvic floor muscle training
Smaller family size
How is pelvic organ prolapse treated?
Pelvic floor muscle training
Pessaries
Surgery
Outline the potential symptoms of ovarian cancer
Vague Indigestion/early satiety/poor appetite Altered bowel habit/pain Bloating/discomfort/weight gain Pelvic mass (asymptomatic or pressure symptoms)
How is ovarian cancer diagnosed?
Radiology - US scan/CT (abdomen and pelvis)
CA125 raised (>35)
How specific is a raised CA125 in the detection of ovarian cancer?
Not very specific:
Raised in malignancy of ovary, breast and colon/pancreas
Benign conditions include menstruation, endometriosis, PID, liver disease and recent surgery
How is ovarian cancer staged?
Stage 1 - limited to ovarian capsule
Stage 2 - pelvic extension
Stage 3 - peritoneal implants + nodes
Stage 4 - distant metastasis
How is ovarian cancer treated?
Surgery (laparotomy)
Chemotherapy (advent or neo-aduvant)
Post-menopausal bleeding is a common complaint. How is it investigated?
Trans-vaginal US (measures endometrial thickness and contour) - pipelle biopsy is >4mm or irregular
Hysteroscopy (local or general anaesthetic)
What demographic of women is endometrial cancer most common in?
Post-menopausal women with a typical history of high circulating oestrogen (obesity, hormone therapy, PCOS, early menarche/late menopause)
How does endometrial cancer present?
Abnormal vaginal bleeding (post-menopausal most commonly)
LIst some benign causes of postmenopausal bleeding
3
Peri-menopausal bleeding
Atrophic vaginitis
Polyps (cervical or endometrial)
How is endometrial cancer staged?
1A - inner half of myometrium 1B - outer half 2 - invades cervix 3A - serosa/adnexa 3B - vagina/parametrium 3C - pelvic or para-aortic nodes 4 - bladder/bowel/intra-abdominal
What are the two histological types of endometrial cancer?
Type 1 - Endometrioid adenocarcinoma (commonest)
Type 2 - Uterine serous/clear cell carcinoma (high grade, more aggressive, worse prognosis)
How is endometrial cancer treated?
Main treatment is total abdominal hysterectomy with removal or tubes, ovaries and peritoneal washings
What is menopause?
Last period
What is the average age of the menopause?
Average age of 51
How long does the perimenopausal period last before the menopause?
Approx. 5 years
What is the definition of premature menopause?
Occurring before the age of forty
What is the mechanism behind the menopause?
Ovarian insufficiency (oestradiol falls and FSH rises)
List some common symptoms of the menopause
Vasomotor symptoms Vaginal dryness Low libido Muscle and joint aches Mood changes and poor memory Fatigue
What extra-gynaecological condition can arise as a result of the menopause?
Osteoporosis
How is osteoporosis investigated/diagnosed?
Reduced bone mass seen on DEXA scan (t-scores)
How is osteoporosis prevented and treated?
Exercise Adequate calcium/vit D HRT Bisphosphonates Denosumab
What is the mode of action of denosumab?
Monoclonal antibodies to osteoclasts
Outline treatment for menopause
Local - vaginal oestrogen
Systemic - HRT (plus progesterone if patient still has uterus)
Specific treatment - SERMs, SSRI/SNRI
What are the advantages and disadvantages of taking HRT?
Benefits - alleviates symptoms, no increase in CVS risk if aged <60
Risks - breast cancer, ovarian cancer, VTE
What are some contraindications to taking HRT?
4
Active hormone-dependent cancer
Active liver disease
Investigate abnormal bleeding
High risk for breast/ovarian cancer or VTE
What is the difference between polycystic ovaries and polycystic ovarian syndrome?
PCO is the presence of small peripheral ovarian cysts (up to 10 per ovary is acceptable) with no clinical symptomology
PCOS also includes irregular ovulation, high androgens and underlying insulin resistance
What are the approx. normal ages of menarche and menopause respectively?
Age 13 for menarche
Age 51 for menopause
What hormone triggers menses?
Fall in progesterone as corpus leuteum degenerates into the non-functional corpus albicans two weeks after ovulation with failure of implantation
What is the mean blood loss volume of menstruation?
30-40ml
What s the definition of menorrhagia?
Heavy periods (>80ml/cycle)
What is dysmenorrhoea?
Painful periods
What is oligomenorrhoea?
Infrequent periods
Age is an important predictor of menstrual problems; certain demographics are more likely to present with certain conditions.
List some common conditions seen in early teens, teens to mid-forties and after menopause respectively.
Early teens - anovulatory or coagulation issues
Teens-40’s - STIs, contraception issues, endometriosis/adenomyosis/fibroids etc.
Menopause - malignancies, thyroid dysfunction
Outline the FIGO Classification of Abnormal Uterine Bleeding
Polyps Adenomyosis Leiomyoma Malignancy Coagulation (e.g. vWF) Ovarian (e.g. PCOS) Endocrine (e.g. thyroid) Iatrogenic (e.g. warfarin) Not yet classified
What is dysfunctional uterine bleeding?
Abnormal bleeding but no structural/endocrine/neoplastic or infectious causes found
How is dysfunctional uterine bleeding treated?
Medical: tranexamic/mefenamic acid, hormonal contraception
Surgical: endometrial ablation or hysterectomy
What is endometriosis?
Chronic, oestrogen-dependent condition characterised by growth of endometrial tissue outside of the uterine cavity (usually ovary, pouch of Douglas or pelvic peritoneum)
What symptoms are associated with endometriosis?
Premenstrual pelvic pain
Dysmenorrhoea
Deep dysparenuria
Subfertility
What signs may be apparent in endometriosis?
Tender nodules in rectovaginal septum
Limited uterine mobility
Adnexal mass
How is endometriosis diagnosed?
Gold standard - laparoscopy
MRI for deep endometriosis or USS for chocolate cysts
How is endometriosis diagnosed?
Hormonal contraception (LNG-IUS, progesterones, COCP)
Often medical treatment fails and then surgical endometrial ablation or hysterectomy are options
What is adenomyosis?
Endometrial tissue growing in the myometrium
What are the signs/symptoms of adenomyosis?
Heavy, painful periods
Bulky and tender uterus
How is adenomyosis diagnosed?
Difficult to diagnose, MRI may be suggestive however majority of diagnoses are made post-hysterectomy
What are fibroids?
Smooth muscle growths also known as leiomyoma
How are fibroids diagnosed?
Combination of clinical exam/suggestive history and imaging (USS or hysteroscopy)
What are the different anatomical locations a fibroid can be in?
Intra-mural
Submucous
Subserous
What symptoms may fibroids cause?
Pressure symptoms
Menorrhagia
Intermenstrual bleeding
Pain, malpresentation or obstruction in labour
How are fibroids treated?
Often asymptomatic and require no treatment
Standard menorrhagia treatment if the cavity is not distorted
GnRH analogues can be helpful
Submucous fibroids can be removed transcervical resection, myomectomy, uterine artery embolisation or hysterectomy
Outline the screening programme for cervical cancer in the UK
Women aged 25-64 are offered 5 yearly smears tested for high-risk HPV (hrHPV).
Positive samples are then triaged ith cytology. Overall very sensitive and specific
What happens if hrHPV is identified in the screening process?
If cytology is normal - repeat test in one year
If dyskaryosis is identified - refer for colposcopy
What is colposcopy?
Examination of the cervix to see limits of lesion and define treatment area
Punch biopsy if cervical intraepithelial neoplasia stage 2/3
What are the high-risk variants of HPV virus?
Types 16 and 18 - cause high-grade CIN and rarely cancer
What are the two components to the anatomy of the cervix?
Endocervix - columnar epithelium
Ectocervix - squamous epithelium
What is the word for abnormal cytology in cervical smears?
Dyskaryosis
What features may constitute a diagnosis of cervical dyskaryosis?
INcreased size and nucleus: cytoplasm ratio
Variation in size, shape and outline
Coarse irregular chromatin
How is dyskaryosis classified?
Low or high grade
How does HPV infection cause dyskaryosis?
Viral DNA integrates host cell genome
Overexpression of viral E6 and E7 proteins
Deregulation of host cell cycle
What is the precancerous condition of the cervix caused by HPV called?
Cervical intraepithelial neoplasia
What is the definition of cervical intraepithelial neoplasia?
Disorganised proliferation of abnormal cells in the squamous epithelium of the cervix
How is CIN graded?
CIN1: Low grade - will regress
CIN2: May regress
CIN3: unlikely to regret (precursor to invasive cancer)
What are the features of CIN seen under a microscope?
6
Lack of maturation Variation in cell size Nuclear enlargement Irregularity of cells Hyperchromasia Cellular disarray
How is CIN treated and followed up?
Treatment options: LLETZ (large loop excision of the transition zone), thermal coagulation or laser ablation
Follow-up: ensures treatment was effective, reassures women and observes for invasive cancer
What risk factors are associated with cervical cancer?
5
Aged 45-55 High-risk HPV infection Early age of first intercourse Older age of partner Cigarette smoking
What are the common symptoms of cervical cancer?
Abnormal vaginal bleeding Post-coital bleeding Intermenstrual bleeding Discharge Pain
How is cervical cancer detected?
Clinical (symptomatic)
Identified through screening
Diagnosed through biopsy
What are the two histological forms of cervical cancer?
Majority are squamous carcinoma (80%) Adenocarcinoma also (rising in relevancee)
How is cervical cancer staged?
Stage 1A - microscopic invasive Stage 1B - Tumours confined to cervix Stage 2 - Upper vagina Stage 3 - Lower vagina/pelvis Stage 4 - bladder or rectum invasion
How is cervical cancer staged?
PET-CT
MRI
EUA (examination under anaesthesia)
Localised cervical cancer can be treated with local excision but above stage 1, radical hysterectomy is preferred. Outline the procedure.
Exploration of pelvic and para-aortic space.
Removal of uterus, cervix, upper vagina, parametria and pelvic nodes
What other adjuvant/palliative treatment options are available for cervical cancer?
Radiotherapy
Chemotherapy
Caesium insertion (brachytherapy)
The urinary tract consists of what two mutually dependent components?
- Upper tract (kidneys and ureters)
2. Lower tract (bladder and ureter)
What is the function of the upper urinary tract?
A low-pressure distendable conduit with intrinsic peristalsis
Transports urine from nephrons to the bladder
What is the function of the lower urinary tract?
A low-pressure storage system for urine which efficiently expels at an appropriate time and place
What mechanism prevents back-flow of urine in normal physiology/anatomy?
The vesico-ureteric mechanism - protects nephrons from pressure damage and infection
What is the nerve supply of the bladder?
Storage - hypogastric nerve (sympathetic T10-L2)
Voiding - pelvic nerve (parasympathetic S2-S4)
Voluntary control - pudendal nerve (somatic S2-4)
What muscle in the bladder is responsible for emptying?
Detrusor contraction
What is the definition of urinary incontinence?
Any involuntary leakage of urine
What is the definition of stress urinary incontinence?
Involuntary leakage on effort or exertion (e.g. coughing, laughing etc.)
What is the definition of urge incontinence?
Involuntary leakage of urine by or immediately preceded by urgency
What is mixed urinary incontinence?
Involuntary leakage of urine by or immediately preceded by urgency and on effort or exertion
List the risk factors for developing urinary incompetence?
6
Age Parity Menopause Smoking Pelvic floor trauma Surgery
What aspects of the patient history are important for urinary incontinence?
Assessment of risk factors
Medical conditions (DM. cognitive, anti-depressants etc.)
Presentation (irritation, incontinence, voiding, fluid intake etc.)
What aspects of the patient examination are important for urinary incontinence?
Abdominal
Neurological
Gynaecological
Pelvic floor assessment (prolapse, stress, Pelvic mass
What investigations are relevant for urinary incontinence?
4
Urinalysis
Pot-voiding residual assessment
Urodynamics
Multi-channel cystometry (for stress incontinence)
How is urinary continence managed?
Lifestyle changes - stop smoking, lose weight, reduce alcohol/caffeine
Medical treatment - duloxetine
Physiotherapy - pelvic floor muscle training
Surgery
What surgical options are available for urinary incontinence?
(4)
Tension free-vaginal tape
Transobturator tape
Colposuspension
What complications are associated with surgery for the correction of urinary incontinence?
Bladder perforation
Vaginal and urethral erosions
Several vascular injuries
What is overactive bladder syndrome?
A symptom complex usually but not always related to urodynamically demonstrable detrusor overactivity
What are the symptoms of overactive bladder syndrome?
Urgency, frequency and nocturia
How is overactive bladder syndrome treated?
Lifestyle changes (normalise fluid intake, reduce caffeine, stop smoking and lose weight)
Bladder retraining (timed voiding)
Medication (antimuscarinic, TCAs, botox)
Recent advances (neuromodulation with needle stimulation)
What is female genital mutilation?
FGM comprises all procedures that involve partial or total removal of the external female genitalia
Outline the four types of FGM?
Type 1 - clitoridectomy
Type 2 - Excision
Type 3 - Infibulation
Type 4 - Other (e.g. pricking, piercing, burning)
What is vulval intraepithelial neoplasia?
An HPV-assocaited skin condition of the vulva
What is the average age of presentation?
36 years old (decreasing age)
What are the aims of treatment for vulval intraepithelial neoplasia?
Prevent invasive disease/cancer
Preserve sexual function
Preserve body image
How is VIN managed?
Surveillance
Topical (imiquimod, cidofivir etc.)
CO2 laser ablation
What is the clinical appearance of VIN?
Raised papular or plaque erosions with sharp border and keratitis edges
How is VIN diagnosed?
Punch biopsy under local anaesthetic
What are the common origins of vulval cancer?
VIN or lichen planus
What is the differential diagnosis when considering vulval cancer?
BCC
Melanoma
Bartholin’s gland abscess
Tinea cruris
What are the symptoms of vulval cancer?
Painful/itching/bleeding lump or ulcer on the vulva
What is the average age of a patient presenting with vulval cancer?
75% over the age of 75
How is vulval cancer staged?
Depends on size and lymph node involvement (stages 1-4)
How is vulval cancer managed?
Surgery - radical local excision and node dissection
Radiotherapy
Chemotherapy
What is the commonest malpresentation in pregnancy?
Breech Position - where the lower limbs of the foetus are the presenting part
How is Breech position treated? What is the success rate?
External cephalic version (ECV) success rate is 40-60%; if unsuccessful then requires C-section
List other types of malpresentation/malpositions?
Occipitoposterior
Face presentation
Brow presentation
Transverse lie
What is cord prolapse?
Descent of the umbilical cord through the cervix and below the presenting part after rupture of the membranes
What is the foetal complication due to cord prolapse?
Asphyxia due to cord compression and vasospasm due to exposure
How is cord prolapse recognised on CTG?
Foetal bradycardia and variable decelerations
How is cord prolapse diagnosed with certainty?
Bimanual examination
How does ectopic pregnancy typically present?
Always think of an ectopic pregnancy in a women of reproductive age who presents with abdominal pain, bleeding, fainting, diarrhoea and vomiting
What hormone profile may indicate ectopic pregnancy?
Failure of b-HCG to double every 48-72 hours until it reaches 10,000-20,000 mgU/ml
How should presumed ectopic pregnancy be investigated?
If suspected, patient should have two large bore cannulas inserted (FBC, group and save taken)
TVUS (transvaginal ultrasound) to locate ectopic
How is ectopic pregnancy managed?
Expectant (asymptomatic and haemodynamically stable) - take b-HCG levels every 48hrs to confirm
Medical - methotrexate single dose for TOP and contraception for 3 months following
Surgical - laparoscopy or salpingectomy
What is pelvic inflammatory disease?
Infection of the upper genital tract caused by ascending infections from the endocervix (STIs 25%, anaerobes, endogenous bacteria)
What is the usual presentation of PID?
History of lower abdominal pain (constant or intermittent, uni/bilateral) Deep dysparenuria Discharge Intermenstrual or post-coital bleeding Fever
What investigations are indicated in the case of PID?
Cervical swabs for STIs (culture and sensitivities)
Blood tests for WCC and CRP
How is PID managed?
Depending on severity can manage as outpatient or inpatient with prompt antibiotic treatment and contact-tracing:
Outpatient: Ceftriaxone/azithromycin + doxycyline + metronidazole
Inpatient: IV antibiotics similar to above
What are the complications of PID?
Tube-ovarian abscess
Recurrent/chronic PID
Ectopic pregnancy
Sub-fertility
Outline the options for emergency contraception
Emergency IUCD - take within 120hrs of UPSI
Ulipristal acetate (EllaOne) - as above
Levonorgestrel - within 72hrs of UPSI
List some contraindications to the use of the combined oral contraceptive pill
Venous disease (VTE)
Arterial disease (congenital heart disease etc.)
Liver disease
History of breast cancer
Caution in: smokers, obesity, hypertensive patients
What are the absolute contraindications of induction of labour?
(4)
Abnormal lie
Known pelvic obstruction
Placenta praevia
Foetal distress
What are the relative contraindications of induction of labour?
Previous caesarian section (risk of rupture/ dehiscence)
Asthma (prostaglandins can cause an attack)
What is augmentation of labour?
Required when contractions reduce in frequency or strength in active labour even when there is spontaneous onset of labour
Before augmentation of labour can be commenced, what examination must take place?
Contraindications such as obstruction due to malposition
What medication is used to augment labour? How is it given?
Oxytocin is given as slow IV infusion
What drugs are used in the active management of the third stage of labour?
Syntometrine (oxytocin and ergometrine) given as IM injection
Oxytocin given as IV infusion or IM injection
What are the contraindications for the use of syntometrine?
Pre-eclampsia
Hypertension
Cardiac conditions
What physical interventions are indicated in primary post-partum haemorrhage?
Rubbing up a compression
Bimanual compression
What medications are indicated for the treatment of postpartum haemorrhage?
Oxytocin Syntometrine (given IM) Carboprost/ hemabate given IM Misoprostol Tranexamic acid
What medications are indicated in the treatment of threatened preterm labour?
Steroids (betamethasone or dexamethasone) IM injection (2 x 12mg doses given 24 hours apart) to women at 24-35 weeks
Given even if delivery is imminent (improves foetal lung development)
What is the action of tocolytic actions?
Tocolytic drugs (known as tocolysis) inhibits uterine contractions
When is tocolysis initiated?
Usually used in women in threatened preterm labour from 24 to 35 weeks
What drugs can be used for tocolysis?
Calcium channel blockers (nifedipine given orally)
Oxytocin receptor antagonists e.g. atosiban
Beta-2-agonists e.g. terbutaline
Indomethacin
What medications are indicated during pregnancy for hypertension?
Combined alpha and beta-blockers e.g. labetalol (first line in labour)
Others include: nifedipine, methyldopa and hydralazine
In women symptomatic of pre-eclampsia, what medications may be started to prevent seizures?
IV MgSO4
What antihypertensives are contraindicated in pregnancy?
ACEIs, ARBs and spironolactone
How is morning sickness treated?
Buccastem and encourage patient to keep up food and fluids if they can tolerate them
What is hyperemesis gravidarum?
Prolonged and severe nausea and vomiting during early pregnancy
What hormone is hyperemesis gravidarum most commonly associated with?
beta-HCG
In what pregnancy-related conditions is hyperemesis gravidarum most common and why?
Molar pregnancy (gestational trophoblastic disease) Multiple pregnancy
Both associated with higher levels of beta-HCG
When is hyperemesis gravidarum most common to begin (i.e. weeks gestation) in pregnancy?
6-12 weeks as this correlates with the peak in beta-HCG levels
What is the differential diagnosis of a pregnant woman presenting (early on) with nausea, vomiting and clinical signs of dehydration?
Hyperemesis gravidarum
Morning sickness
UTI
Pancreatitis
What investigations are most useful in the diagnosis of hyperemesis gravidarum?
Urinalysis
Urea and electrolytes
What biochemical imbalances and urinalysis results are most commonly seen in hyperemesis gravidarum?
Low sodium and potassium
Low urea
Ketonuria
FBC may show raised haematocrit
What is the fluid replacement of choice for hyperemesis gravidarum?
Normal saline (or Hartmann's solution) Potassium solution can be added if hypokalaemic
What fluid type is contraindicated and why?
Dextrose solution (precipitates Wernicke’s encephalopathy and can also worsen hyponatraemia)
What drugs can be offered in extreme cases of hyperemesis gravidarum?
Cyclizine
Thiamine
Corticosteroids (last resort)
If a patient is struggling with nutritional intake, what options are available? What speciality should be consulted?
Nutritional supplements
NG tube
TPN
Dietetics should be involved early
What are the common side effects of TPN?
Phlebitis and thrombosis
How is TPN delivered?
Through a central line (to reduce risk of phlebitis)
What is Wernicke’s encephalopathy? How does it present and how is it treated?
Neurological disorder caused by severe vitamin B1 deficiency
Triad of confusion, ophthalmoplegia and ataxia
Treated with IV thiamine (B1)
What are the complications of developing Wernicke’s encephalopathy during pregnancy?
Associated with 40% risk of foetal death
Korsakoff psychosis (retrograde amnesia, reduced ability to learn and confabulation) - 50% recovery rate
