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Sharon's Phase 3a > Obstetrics and Gynaecology > Flashcards

Obstetrics and Gynaecology Flashcards

1
Q

sDefine antepartum haemorrhage

A

Bleeding from or in to the genital tract from 24+0 weeks of pregnancy and prior to the birth of the baby.

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2
Q

What are causes of antepartum haemorrhage?

A
  1. Placenta praevia/LLP.
  2. Vasa praevia.
  3. Placental abruption.

Serious with high morbidity and mortality

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3
Q

Define postpartum haemorrhage (PPH)

A

Bleeding after vaginal birth >500ml or caesarean > 1000ml

Major PPH > 1000ml: moderate = 1000 to 2000ml, severe = > 2000ml

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4
Q

Define primary PPH

A

PPH within 24 hours of delivery.

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5
Q

Define secondary PPH

A

PPH from 24 hours to 12 weeks after delivery

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6
Q

What are the 4 causes of primary PPH?

A

4Ts

  • Tone: uterine atony (not well contracted)
  • Trauma: genital tract injury
  • Tissue: retained products of conception
  • Thrombin: underlying clotting disorder
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7
Q

What are risk factors of primary PPH?

A
  1. Previous PPH
  2. Overdistension of uterus (e.g. macrosomia)
  3. Multiparity
  4. Caesarean
  5. Induction
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8
Q

What are the clinical features (symptoms & signs) of primary PPH?

A

Symptom: heavy vaginal bleeding

Signs: shock e.g. tachycardia, hypotension, reduced GCS

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9
Q

If PPH was due to atony, what would you see/feel on examination?

A

Enlarged, soft, or boggy uterus.

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10
Q

If PPH was due to trauma, what would you see/feel on examination?

A

Visible lacerations/tears

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11
Q

If PPH was due to tissue, what would you see/feel on examination?

A

Incomplete placental tissue or membranes

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12
Q

What investigations are done for PPH?

A
  • Vital signs
  • Bloods - FBC, clotting, group & save/crossmatch, U+Es
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13
Q

What can minimise risk of PPH?

A
  • Treat antenatal anaemia
  • Active management of third stage of labour - uterotonic drugs (e.g. oxytocin), deferred cord clamping, controlled traction to deliver placenta.
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14
Q

What is the general management of PPH?

A
  • ABCDE
  • IV access
  • IV Fluids until blood products available
  • Blood products
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15
Q

What is the management of PPH due to atony

A
  • Mechanical simulation of uterus
  • Bi-manual compression, uterotonic drugs (e.g. oxytocin, carboprost, ergometrine)
  • Surgical - intra-uterine balloon tamponade, haemostatic sutures
  • Hysterectomy
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16
Q

What is the management of PPH due to trauma?

A

Surgical repair of tears

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17
Q

What is the management of PPH due to thrombin?

A

Tranexamic acid, discuss blood products with haematology

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18
Q

What is the management of PPH due to tissue?

A

Manual removal of retained product of conception (e.g. retained placenta) in theatre

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19
Q

Give some complications of primary PPH

A

Shock, DIC, Sheehan’s syndrome (pituitary gland necrosis),PTSD, death.

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20
Q

What are some causes of secondary PPH?

A
  • Infection - endometritis
  • Retained products of conception.
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21
Q

What are the clinical features of secondary PPH?

A
  • Tender or bulky uterus
  • Open cervical os with foul-smelling discharge
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22
Q

What are the investigation s for secondary PPH?

A
  • Sepsis - FBC, U&Es, CRP, lactate, blood cultures.
  • HVS (high vaginal swab)
  • Pelvic ultrasound scan to look for retained products.
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23
Q

What is the management for secondary PPH?

A

Infection = Abx

Retained products = surgical evacuation

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24
Q

What is placental abruption?

A

The complete (7%) or partial detachment (93%) of the placenta from the decidua basalis before delivery

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25
Q

What are the risk factors for placental abruption?

A
  • Previous abruption
  • Maternal age > 35
  • Multiparity
  • Smoking
  • Cocaine
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26
Q

What is a revealed placental abruption?

A

It is when blood is seen leaking from the vagina in placental abruption

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27
Q

What is a concealed placental abruption?

A

Blood accumulates behind placenta with no obvious external bleeding.

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28
Q

What signs indicate that a placental abruption is likely?

A
  • Firm, ‘woody’ tense uterus.
  • Fetal distress or absent heart beat
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29
Q

Investigations for placental abruption

A

Vital signs - BP, HR, oxygen sats, temp, RR.

Bloods - FBC, U&Es, LFTs (pre- eclampsia/HELLP), clotting, G&S.

Ultrasound scan - location of the bleed.

CTG - To monitor the foetus

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30
Q

General management for placental abruption

A
  • Resuscitation e.g. IV fluids, blood products
  • Anti-D if mother Rhesus Negative
  • Steroids if birth <34 weeks expected for fetal lung develop and reduce RDS
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31
Q

Placental abruption: management <36 weeks

A
  1. No fetal distress - close observation
  2. Fetal distress - immediate c-section
  3. Stillborn - C-Section if haemodynamically unstable, if not induce.
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32
Q

Placental abruption: management > 36 weeks

A
  1. No fetal distress -induce and deliver vaginally or c-section
  2. Fetal distress - immediate c-section
  3. Stillborn - C-Section if haemodynamically unstable, if not induce.
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33
Q

Complications of placental abruption

A
  • Major haemorrhage
  • Shock
  • DIC
  • Premature birth
  • Stillbirth
  • Placental insufficiency > intrauterine growth restriction
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34
Q

What is placenta accreta?

A

Placenta accreta is a spectrum of abnormal placenta adherence to the uterus.

  1. Placenta accreta
  2. Placenta Increta
  3. Placenta percreta
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35
Q

Placenta accreta is the mildest form of the placenta accreta spectrum, where does the placenta attach in this case?

A

The villi of the placenta attaches to the myometrium of the uterus without deep invasion.

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36
Q

Where does the placenta attach in placenta increta?

A

The placenta villi extend into the myometrium of the uterus but do not reach the uterine serosa.

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37
Q

Where does the placenta attach in placenta percreta?

A

The villi penetrate the myometrium, reaching the uterine serosa (perimetrium) and potentially adjacent organs.

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38
Q

What are risk factors for placenta accreta spectrum?

A
  • Previous placenta accreta
  • Previous c-section
  • Placenta praevia
  • Uterine abnormality e.g. fibroids
  • Maternal age: >35
  • Multiparity
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39
Q

What is often the only symptom for placenta accreta spectrum?

A

PAINLESS vaginal bleeding, usually in third trimester.

However, it may be asymptomatic.

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40
Q

What are the investigations for placenta accreta spectrum?

A
  • Seen at 20-week ultrasound scan.
  • FBC to assess Hb if acute bleed
  • Group + save - if patient considered for transfusion
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41
Q

What is the management for placenta accreta spectrum?

A
  • Delivery at 35 - 36+6 weeks so any haemorrhage can be managed
  • Hysterotomy after delivery to prevent severe haemorrhage
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42
Q

What are the complications of placenta accreta spectrum?

A
  • PPH due to retained placenta
  • Disseminated intravascular coagulopathy (DIC)
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43
Q

Antenatal care: When would a woman have her booking appointment and what is the purpose of it?

A
  • 8-10w.
  • Offer general lifestyle advice.
  • Comprehensive obstetric history and examination.
  • Check for bloods, HIV, Hep.B, Syphilis, Rubella.
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44
Q

Define placenta praevia

A

Implantation of the placenta in the lower uterine segment, potentially causing partial or complete covering of the internal os.

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45
Q

What is grade 1/2 placenta praevia?

A

Low lying placenta but does not cover os.

Grade 1 - encroaches lower uterus, but does not reach internal os

Grade 2 - reaches internal os but does not cover it

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46
Q

What is grade 3/4 placenta praevia?

A

Placenta covers internal os

Grade 3 - partially cover
Grade 4 - completely covers

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47
Q

What are risk factors for placenta praevia?

A
  • Previous C-section
  • Multiparity
  • Age >40,
  • Smoking
  • Assisted conception
  • Deficient endometrium.
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48
Q

What are symptoms of placenta praevia?

A

Painless vaginal bleeding.

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49
Q

What are signs of placenta praevia?

A
  • Non-tender uterus
  • Vaginal bleeding
  • Abnormal lie/presentation

Do not do a vaginal examination (can worsen bleeding)

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50
Q

When is placeta praevia usually detected?

A

20 week anomaly scan.

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51
Q

What investigations are carried out for placenta praevia?

A

If bleeding:

  • Vital signs - BP, HR, oxygen sats, temp, RR.
  • Bloods - FBC, U&Es, LFTs ( pre- eclampsia/HELLP), clotting, G&S.
  • 1st line: - uterine USS - site of the placenta and grade.
  • CTG - To monitor the fetus.
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52
Q

What is the management plan for placenta praevia?

A

If identifed at anomoly scan - repeat ultrasound at 32 weeks then 36 weeks if still there.

If still praevia at 36 weeks weeks - planned C-section.

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53
Q

What is a complication of placenta praevia?

A

Major haemorrhage at delivery - death :(

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54
Q

What is breech presentation?

A

When the presenting part of the fetus (the lowest part) is the legs and bottom.

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55
Q

What are the different types of breech presentations?

A
  • Complete breech - legs are fully flexed at the hips and knees
  • Incomplete breech, with one leg flexed at the hip and extended at the knee
  • Extended/frank breech - both legs flexed at the hip and extended at the knee
  • Footling breech - foot presenting through the cervix with the leg extended
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56
Q

What is the management for breech presentation?

A

≤ 36 weeks - watch and wait as most turn spontaneously

From 36 weeks for nulliparous women and 37 weeks for multiparous women:

  • external cephalic version (ECV)
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57
Q

Breech: management plan if ECV fails?

A

Vaginal or C-section delivery led by experienced obstetricians and midwives

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58
Q

Describe a ‘normal’ pregnancy. What are the parameters for 1st, 2nd and 3rd trimesters?

A

Normal pregnancy~ 40 weeks following LMP.

1st: LMP - 12 weeks gestation
2nd: 13 weeks - 27 weeks gestation
3rd: 28 weeks to giving birth

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59
Q

Define gravidity

A

Gravidity is the total number of pregnancies a woman has had, regardless of outcome.

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60
Q

Define parity

A

Parity is the total number of pregnancies that a woman carried over the threshold of viability (24+0 in the UK), including stillborns.

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61
Q

Describe the physiological changes during pregnancy.

A
  • Blood volume increases: RBC, WBC & platelets increase;
  • Albumin, Urea & Creatinine decrease
  • Increased Cardiac Output
  • Increased tidal volume (lung capacity)
  • Increased skin pigmentation
  • Breast & nipple enlargement
  • Increased GFR
  • Water retention
  • Increased temperature
  • Decreased gut motility
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62
Q

At many weeks does labour usually occur?

A
  • From 37 weeks-42 weeks
  • Below 37 weeks - preterm labour
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63
Q

How does labour begin?

A
  • Fetal presenting part engages in pelvis
  • Prostaglandins stimulate cervix effacement (thin, shorten and soften)
  • Pressure on cervix stimulates oxytocin release from pituitary (+ve feedback loop)
  • Oxytocin stimulates uterine contractions from fundus, increasing in strength and frequency
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64
Q

What are the signs of onset of labour?

A
  • Show (mucus plug from the cervix)
  • Rupture of membranes
  • Regular, painful contractions
  • Dilating cervix on examination
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65
Q

What is the first stage of labour?

A

From onset of true contractions to 10cm dilated.

Most likely will rupture membranes during this stage.

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66
Q

Describe the phases of first stage of labour

A
  • Latent phase: cervix dilates up to the first 3-4cm, typically slow
  • Active phase: 4 - 10cm , regular contractions, 1cm/hr
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67
Q

What is the second stage of labour?

A

10cm cervical dilation to delivery of baby

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68
Q

What does second stage of labour depend on?

A

3Ps

  • Power - uterine contractions
  • Passage - size & shape of mother’s pelvis
  • Passenger - attitude (posture), lie, presentation, size
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69
Q

What is the third stage of labour?

A

The completed birth of the baby to the delivery of the placenta.

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70
Q

What is active management of third stage of labour?

A
  • Dose of IM oxytocin given to mother to help uterus contract and expel placenta.
  • Controlled cord traction - pulling umbilical cord while carefully guiding the placenta out
  • Initiated if haemorrhage or > 60 min delay in placenta delivery
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71
Q

Define induction of labour (IOL)

A

The use of medications to stimulate the onset of labour.

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72
Q

What medications are used for IOL?

A
  • Vaginal prostaglandin E2 (dinoprostone): tablet (Prostin) or vaginal pessary (Propess)
  • Propess releases local prostaglandins over 24 hours > stimulates cervix and uterus to cause the onset of labour.
  • Cervical ripening balloon (CRB) - inserted into the cervix and gently inflated to dilate the cervix.
  • Artificial rupture of membranes with an oxytocin infusion - used to progress labour after vaginal prostaglandins
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73
Q

How is monitoring carried out during IOL?

A
  • Cardiotocography (CTG) assesses the fetal heart rate and uterine contractions
  • Bishop score
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74
Q

What is Bishop score?

A

Bishop’s score is used to determine whether to induce labour.

> 8 predicts successful induction

< 8 cervical ripening might needed to prep cervix

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75
Q

What is the management if labour induction is not progressing?

A

Most women will give birth within 24 hours of IOL:

  • Further vaginal prostaglandins
  • Artificial rupture of membranes and oxytocin infusion
  • Cervical ripening balloon (CRB)
  • Elective caesarean section
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76
Q

What is the main complication of IOL?

A

Uterine hyperstimulation - prolonged and frequent contractions, causing fetal distress and compromise.

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77
Q

What is the management for uterine hyperstimulation?

A
  • Removing the vaginal prostaglandins, or stopping the oxytocin infusion
  • Tocolysis with terbutaline (nice recommend nifedipine (myometrium relaxation)
  • Emergency C-section
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78
Q

What is a miscarriage?

A

Spontaneous termination of a pregnancy.

Early miscarriage is before 12 weeks gestation.

Late miscarriage is between 12 and 24 weeks gestation.

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79
Q

Risk factors for miscarriage?

A
  • Advancing maternal age: > 35
  • Previous miscarriage
  • Lifestyle: smoking, alcohol during pregnancy
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80
Q

What are the different types of miscarriages?

A
  • Missed miscarriage
  • Threatened miscarriage
  • Inevitable miscarriage
  • Incomplete miscarriage
  • Complete miscarriage
  • Recurrent
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81
Q

What is a missed (silent) miscarriage?

A

The fetus is no longer alive, but no symptoms have occured.

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82
Q

What is a threatened miscarriage?

A

Mild vaginal bleeding +/- abdo pain, closed cervical os and a fetus that is alive.

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83
Q

What is an inevitable miscarriage?

A

Heavy vaginal bleeding with pain + clots with open cervical os, leads to complete or incomplete miscarriage.

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84
Q

What is an incomplete miscarriage?

A
  • Pain and vaginal bleeding, cervical os open.
  • Products of conception are retained after miscarriage
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85
Q

What is a complete miscarriage?

A

A full miscarriage has occurred, and there are no products of conception left in the uterus.

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86
Q

What is a recurrent miscarriage?

A

≥ 3 consecutive miscarriages before 24 weeks of gestation.

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87
Q

What is the investigation of choice for miscarriage?

A

Transvaginal ultrasound scan to confirm viability of pregnancy.

Checks for fetal heartbeat, size and pole

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88
Q

Types of management of miscarriages

A
  • Expectant (do nothing and awaiting spontaneous miscarriage)
  • Medical
  • Surgical
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89
Q

Management of miscarriage if less than 6 weeks gestation with bleeding

A

Expectant provided no other risk factors (e.g. previous ectopic)

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90
Q

Management of miscarriage if more than 6 weeks gestation with bleeding

A

NICE recommends referral to early pregnancy assessment service (EPAU)

They will carry out a USS to determine location and viability of the pregnancy

Consider and exclude ectopic always

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91
Q

What is the management for threatened miscarriage?

A

Monitoring and analgesia (paracetamol - NSAIDs best avoided)

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92
Q

What is the management for incomplete miscarriages?

A
  • Medical management (misoprostol)
  • Surgical management (evacuation of retained products of conception)

Analgesia (paracetamol) and counselling

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93
Q

What is the management for complete miscarriage?

A

Analgesia (paracetamol) and counselling

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94
Q

What is the management for recurrent miscarriages?

A

Find and treat underlying cause (e.g. antiphospholipid syndrome)

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95
Q

When do are women who miscarried offered anti-D immunoglobulin?

A

In the UK, anti-D immunoglobulin are offered to rhesus-negative women following surgery to manage miscarriage.

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96
Q

When is expectant management offered to women who miscarried?

A

First-line for women without risk factors for heavy bleeding or infection.

1 – 2 weeks are given to allow the miscarriage to occur spontaneously.

A repeat urine pregnancy test 3 weeks after to confirm that miscarriage is complete.

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97
Q

What is the medical management for miscarriage?

A

Dose of Misoprostol - oral or vaginal suppository.

Misoprostol - prostaglandin analogue and binds to prostaglandin receptors and activates them.

Prostaglandins soften the cervix and stimulate uterine contractions.

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98
Q

What are the surgical management options for miscarriage?

A
  • Manual vacuum aspiration under local anaesthetic as an outpatient
  • Electric vacuum aspiration under general anaesthetic

This is done to remove retained products of conception.

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99
Q

What is pre-eclampsia?

A

New hypertension that occur in pregnant women, with proteinuria (>300mg/24 hrs) and end-organ dysfunction, that occur after 20 weeks gestation.

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100
Q

Risk factors for pre-eclampsia?

A

High risk:

  • Pre-exisiting HTN, diabetes, SLE, CKD etc.
  • Pre-eclampsia in a previous pregnancy

Moderate risk:

  • Nulliparity
  • FHx of pre-eclampsia
  • BMI >30

High risk for pre-eclampsia if one high, or two moderate RFs

Refer high risk women to urgent secondary care review

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101
Q

What are the investigations to diagnose pre-eclampsia?

A
  • BP ≥ 140/90mmHg
  • Urinalysis ≥ 300 mg of protein in 24 hours; or protein:creatinine ratio ≥ 30mg/mmol; or albumin:creatinine ratio ≥ 8mg/mmol
  • Fetal ultrasound
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102
Q

What is the management for moderate pre-eclaspmia (140/90 - 159/109 mmHg)?

A
  • Outpatient
  • Aim for < 135/85mmHg
  • Bloods 2x week (FBC, LFTs and renal function)
  • Offer medication if BP persistently ≥ 140/90mmHg
  • Admission if clinical concern for mother or baby
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103
Q

Management for severe pre-eclampsia (≥ 160/110 mmHg)

A

Hospital admission for monitoring

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104
Q

Management of pre-eclampsia (similar to HTN in pregnancy)

A
  • Admission if BP > 160/110 mmHg
  • If BP < 160/110mmHg depending on clinical concern for mother and baby’s wellbeing
  • Monitor BP at least 48 hours
  • Urine dipstick testing is not routinely necessary (the diagnosis is already made)
  • Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed every two weeks
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105
Q

Management of gestational hypertension without proteinuria

A
  • Aim for > 135/85 mmHg
  • Admission if > 160/110 mmHg
  • Urine dipstick testing at least weekly
  • Monitoring of blood tests weekly (FBC, U+E, LFTs)
  • Monitoring fetal growth by serial growth scans
  • PlGF (placental-growth factor) testing on one occasion
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106
Q

When are women offered prophylaxis for pre-eclampsia?

A

Aspirin from 12-week gestation for women with

  • A single high-risk factor
  • Two or more moderate-risk factors
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107
Q

How are decisions for delivery made for a pregnant woman with pre-eclasmpia?

A

< 34 weeks - monitor and only plan delivery if evidence of maternal/fetal compromise. Give magnesium sulfate (prevent seizures) and corticosteroid if delivery likely.

34 - 37 weeks - same as above, give corticosteroid if delivery likely.

> 37 weeks - plan delivery

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108
Q

What are the signs and symptoms of preeclampsia?

A

Symptoms:

  • Headaches
  • Visual disturbance
  • Epigastric or RUQ pain (liver swelling/HELLP)
  • Vomiting

Signs:

  • BP ≥ 140/90mmHg, severe is 160/110mmHg
  • Proteinuria
  • Oedema of face, hands or feet
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109
Q

What are the complications of pre-eclampsia?

A

Maternal: Eclampsia (seizure resulting from pre-eclampsia), HELLP syndrome, stroke

Fetal: intrauterine growth restriction, preterm delivery, placental abruption

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110
Q

How do you treat eclampsia?

A

Eclampsia is pre-eclampsia with seizures.

Treated with magnesium sulphate

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111
Q

What is HELLP syndrome?

A

Haemolysis, Elevated Liver enzymes, and Low Platelets.

Pre-eclampsia with thrombotic microangiopathy

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112
Q

What is termination of pregnancy?

A

A termination of pregnancy (TOP), or abortion, involves an elective procedure to end a pregnancy.

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113
Q

What law governs termination of pregnancy (TOP)?

A

1967 Abortion Act.

Altered by the 1990 Human Fertilisation and Embryology Act - latest gestational age where an abortion is legal changed from 28 weeks to 24 weeks.

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114
Q

In the UK, what are the current legal requirement for TOP < 24 weeks gestation?

A

Continuing the pregnancy poses greater risk to the physical or mental health of the woman or existing children than a TOP.

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115
Q

In the UK, what are the current legal requirements for TOP at any gestation?

A
  • Risk to life of the woman
  • Risk of “grave permanent injury” to the physical or mental health of the woman
  • Substantial risk of serious handicap to the child due to physical or mental abnormalities
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116
Q

Who must agree to a TOP and where must it take place?

A

Two registered medical practitioners, and undertaken in an NHS hospital or approved premise by a registered medical practitioner.

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117
Q

How can a woman access TOP?

A

Self-referral , GP , or GUM clinic .

Marie Stopes UK is a charity providing TOP, remotely for women less than 10 weeks gestation

Doctors who conscientiously object to TOP should ensure a woman has access to services through another doctor or self-referral.

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118
Q

What are the investigations for a TOP?

A

First-line: pregnancy test: urinary or serum beta-human chorionic gonadotropin (beta-hCG)

Ultrasound: to confirm the location of and to date the pregnancy

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119
Q

What is used for medical management for TOP (usually used for < 10 weeks gestation)?

A

Mifepristone (anti-progestogen) - halts the pregnancy and relaxes the cervix.

Misoprostol (prostaglandin analogue) 1 – 2 day later = prostaglandin analogue, which soften the cervix and stimulate uterine contractions to expel products of conception.

> 10 weeks onwards additional misoprostol doses are given until complete expulsion.

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120
Q

What is cervical priming?

A

Where the cervix is softened and dilated prior to surgical TOP.

Examples include misoprostol, mifepristone or osmotic dilators .

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121
Q

What procedure is usually used for TOP at 12 - 14 weeks gestation?

A

Vacuum aspiration, where pregnancy is terminated via suction.

Local or general anesthesia.

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122
Q

What procedure is usually used for TOP 14 - 24 weeks gestation?

A

Cervical dilatation and evacuation using forceps or D + C (dilation + curettage)

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123
Q

TOP: when are women given anti-D prophylaxis?

A

Rhesus negative women having a surgical TOP from 10 weeks gestation onwards.

The NICE guidelines (2019): consider in women less than 10 weeks gestation.

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124
Q

Define diabetes in pregnancy

A

Pre-existing diabetes mellitus(type 1 or type 2) orgestational diabetes mellitus(GDM), which develops during pregnancy.

GDM is due to insulin resistance due to hormonal changes and increased demand for insulin production.

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125
Q

What are the risk factors for diabetes in pregnancy?

A
  • BMI >=30
  • Previous GDM
  • Advanced maternal age: >40
  • Ethnicity: South Asian, Black Afro-Caribbean, Middle Eastern
  • Previous child born large: >4.5kg
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126
Q

What are the clinical features of diabetes in pregnancy?

A

Symptoms:

  • Increased thirst (polydipsia)
  • Increased urination (polyuria)
  • Fatigue
  • Dry mouth
  • Blurred vision

Sign:
- Large for dates uterus

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127
Q

What are the investigations for diabetes in pregnancy?

A

At risk: OGTT at 24-28 weeks gestation.

Previous GDM: OGTT after the booking appointment and again at 24-28 weeks

OGTT is oral glucose tolerance test - 75g glucose after overnight fast and blood glucose measured after 2 hours.

2 hours glucose > 7.8mmol/L or fasting glucose > 5.6mmol/L is diagnostic.

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128
Q

What is the management for diabetes in pregnancy?

A
  • Blood glucose>7mmol= insulin
  • Blood glucose <7mmol:
  • Lifestyle modifications: diet, regular exercise, self monitoring of blood glucose
  • Medication: metformin or g lienclamide (sulfonylurea)if lifestyle changes insufficient
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129
Q

Guidance for pregnant women with pre-existing diabetes

A

Before pregnancy - aim for good glucose control, 5 mg folic acid from preconception to 12 weeks gestation

Retinopathy screening shortly after booking and 28 weeks. Referral to an ophthalmologist to check for diabetic retinopathy. EXAM FAV!

NICE advise planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).

A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. Also considered if poorly controlled GDM/T2DM

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130
Q

Antenatal care: when does the booking appointment (first antenatal appointment) take place?

A

8 to 12 weeks

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131
Q

Antenatal care: what happens at the booking appointment?

A
  • General history and assess for risks e.g. gestational diabetes and pre-eclampsia
  • BMI, BP, urine dip (protein in urine)
  • Bloods: FBC, blood group and rhesus status
  • Screening: foetal anomalies, sickle cell anaemia, thalassaemia, HIV, hep B, syphilis, chlamydia, gonorrhea, group B strep.
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132
Q

Antenatal care: what happens at the first scan (11 - 14 weeks gestation)?

A

Ultrasound:
- Gestational age
- Detect multiple pregnancy

Combined screening test: Down’s, Edward’s and Patau’s syndrome

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133
Q

What is measured in the combined test carried out between 11 to 14 weeks?

A
  • First line and most accurate for Down syndrome
  • Fetal nuchal translucency (thickness of an area of fetal neck tissue - > 6mm indicates Downs) on USS
  • Blood β-hCG level (higher = more risk)
  • Pregnancy associated plasma protein-A (PAPP-A) (lower = more risk)
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134
Q

Triple test to screen for Down syndrome (done between 14 - 20 weeks if combined test cannot be done)

A

Only involves maternal blood tests:

  • Beta-HCG – a higher result indicates greater risk
  • Alpha-fetoprotein (AFP) – a lower result indicates a greater risk
  • Serum oestriol (female sex hormone) – a lower result indicates a greater risk
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135
Q

Antenatal care: what appointment occurs at 14 - 18 weeks gestation?

A

Appointment with the midwife.

Reassess risk of pre-eclampsia and foetal growth restriction, BP and urine dipstick

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136
Q

Antenatal care: what appointment occurs at 18 - 20+6 weeks gestation (20-week scan)?

A

Second scan (anomaly scan)

Ultrasound to locate placenta and screening for further foetal anomalies

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137
Q

What fetal abnormality is screened for in the quadruple test, done between 14 - 20 weeks

A

Downs syndrome if nuchal translucency can’t be measured or > 14 weeks gestation

Measures:
- Maternal serum alpha-fetoprotein (lower = more risk)
- total hCG (higher = more risk)
- unconjugated oestriol (uE3) (lower = more risk)
- inhibin-A (higher = more risk)

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138
Q

Antenatal care: what appointment occurs at 25 weeks gestation?

A

Midwife appointment only if nulliparous.

  • History and examination
  • Measure symphysis-fundal height (SFH)
  • BP and urine dipstick
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139
Q

Antenatal care: what appointment occurs at 28 weeks gestation?

A
  • History and examination
  • Measure SFH
  • Enquire about foetal movements
  • BP & urine dipstick
  • Bloods: FBC, blood group and antibodies
  • Anti-D if rhesus negative
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140
Q

Antenatal care: what appointment occurs at 31 weeks?

A

Only if nulliparous, appointment with midwife

  • History and examination
  • Measure SFH
  • Enquire about foetal movements
  • BP
  • Urine dipstick
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141
Q

Antenatal care: what appointment occurs at 34 weeks?

A
  • History and examination
  • Measure SFH
  • Enquire about foetal movements
  • BP, urine dipstick
  • Anti-D if rhesus negative
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142
Q

Antenatal care: what appointment occurs at 36 weeks?

A
  • History and examination
  • Abdominal examination to determine presentation
  • Measure SFH
  • Enquire about foetal movements
  • BP & urine dipstick
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143
Q

Antenatal care: what appointment occurs at 38 weeks?

A
  • History and examination
  • Abdominal examination to determine presentation
  • Measure SFH
  • Enquire about foetal movements
  • BP, urine dipstick
  • Discuss prolonged pregnancy
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144
Q

Antenatal care: what appointment occurs at 40 weeks?

A
  • History and examination
  • Abdominal examination to determine presentation
  • Measure SFH
  • Enquire about foetal movements
  • BP & urine dipstick
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145
Q

Antenatal care: what appointment occurs at 41 weeks?

A
  • Midwife appointment: History and examination
  • Abdominal examination to determine presentation
  • Measure SFH
  • Enquire about foetal movements
  • BP & urine dipstick
  • Offer membrane sweep (artifical rupture of memebrane)
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146
Q

Give some examples of foetal abnormalities are that are tested for at the at 18 - 20+6 weeks scan (20-week scan).

A
  • Edwards’ syndrome
  • Patau’s syndrome
  • Anencephaly
  • Spina bifida
  • Gastroschisis/exomphalos
  • Congenital heart disease
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147
Q

What is a multiple pregnancy?

A

A pregnancy with more than one fetus.

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148
Q

What are the different types of twin pregnancies?

A
  • Monozygotic: identical twins (from a single zygote)
  • Dizygotic: non-identical (from two different zygotes)
  • Monoamniotic: single amniotic sac
  • Diamniotic: two separate amniotic sacs
  • Monochorionic: share a single placenta
  • Dichorionic: two separate placentas
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149
Q

Which type of twin pregnancy have the best outcome?

A

Diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

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150
Q

How is a twin pregnancy diagnosed?

A

Diagnosed at the dating ultrasound scan (between 10 and 13 + 6). USS also used to determine:

  • Gestational age
  • Number of placentas (chorionicity) and amniotic sacs (amnionicity)
  • Risk of Down’s syndrome (as part of the combined test)
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151
Q

What are some risks to the mother in a twin pregnancy?

A
  • Anaemia
  • Polyhydramnios (increased amniotic fluids)
  • Hypertension
  • Preterm birth
  • C-section
  • PPH
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152
Q

What are some risks to the babies in a twin pregnancy?

A
  • Miscarriage
  • Stillbirth
  • Twin-twin transfusion syndrome
  • Congenital abnormalities
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153
Q

What is twin-twin transfusion syndrome?

A

Occurs when the fetuses share a placenta.

One fetus (recipient) receives most of the blood supply, while the other fetus (donor) is starved of blood.

Recipient becomes fluid overloaded > heart failure & polyhydramnios.

Donor has growth restriction, anaemia and oligohydramnios.

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154
Q

What is the management for twin-twin transfusion syndrome?

A

Mother referred to tertiary specialist fetal medicine centre.

In severe cases, laser treatment to destroy the connection between the two blood supplies.

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155
Q

What antenatal care does a woman with a twin pregnancy recieve?

A

Managed by a specialist obstetrics team.

Additional monitoring for anaemia, with FBC at booking clinic, 20 weeks and 28 weeks

Additional USS to look out for growth restriction, growth disparities and TTTS

  • 2 weekly scans from 16 weeks for monochorionic twins
  • 4 weekly scans from 20 weeks for dichorionic twins
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156
Q

How are twins usually delivered?

A

Monoamniotic twins = elective c-section between 32 and 33 + 6 weeks.

Diamniotic twins - aim to deliver between 37 and 37 + 6 weeks:

  • Try VD if presenting twin cephalic
  • C-section might be required for second baby after
  • Elective C-section offered if presenting twin not cephalic
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157
Q

What is cord prolapse?

A

When the umbilical cord descents through the cervix alongside or past the presenting foetal part in the presence of ruptured membranes.

Obstetric emergency > cord compression = loss of blood supply to foetus

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158
Q

What are the risk factors for cord prolapse?

A

General:

  • Multiparity
  • Low birth weight (<2.5kg)
  • Preterm labour (<37weeks)
  • Malpresentation

Procedure-related:

  • ECV
  • Artificial rupture of membrane (ARM)
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159
Q

What are the clinical features of cord prolapse?

A

Symptoms: cord felt in vagina

Signs: cord seen in the vagina, abnormal foetal HR pattern

Although sometimes, no clinical signs or symptoms and fetal HR pattern normal

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160
Q

What are the invetigations for cord prolapse?

A
  • Vaginal/speculum examination: check for cord prolapse 4-hourly in labour, and after SROM.
  • Fetal heart auscultation: after VE in labour and SROM.
  • Cardiotocography (CTG): abnormal foetal heart rate is non-specific sign
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161
Q

What is the management for cord prolapse?

A

Obstetric emergency that require IMMEDIATE delivery of fetus.

  1. Elevate fetal presenting part - prevent cord compression
  2. C-section if VD not imminent:
  • Category 1 (within 30 minutes) if abnormal fetal HR pattern
  • Category 2 (within 75 minutes): if foetal HR pattern remains normal with continuous CTG monitoring
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162
Q

What are the complications that can arise from cord prolapse?

A

Fetal complications depends on time interval between cord prolapse and delivery

  • Birth asphyxia
  • Hypoxic brain injury
  • Cerebral palsy
  • Perinatal death
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163
Q

How is obesity in pregnancy classified?

A

Class I: BMI 30-34.9
Class II: BMI 35-39.9
Class III: BMI ≥40

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164
Q

What is venous thromboembolism (VTE) in pregnancy?

A

VTE can occur as a DVT or PE during pregnancy.

Pregnancy is a hypercoagulable state due an increase in clotting factors and decreased fibrinolysis.

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165
Q

What problems can obesity in pregnancy cause?

A

Obesity in pregnancy can lead to insulin resistance, increased pro-inflammatory markers, and increased risk of hypertension.

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166
Q

What are the risk factors for VTE during pregnancy?

A

Highest risk period is postpartum.

  • History of VTE
  • Immobility
  • Age: >35
  • Obesity: BMI>30
  • Smoking
  • C-section
  • Pre-eclampsia
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167
Q

What are the risk factors for obesity in pregnancy?

A

Affects about 1 in 5 women in pregnancy.

Risk factors include sedentary lifestyle, high calorie diet, socio-economic status, and genetic disposition.

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168
Q

What are the clinical features of DVT

A
  • Leg pain: typically unilateral
  • Leg swelling
  • Calf tenderness
  • Erythema + warmer in affected area
  • Oedema: >3cm difference between symptomatic calf and contralateral limb
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169
Q

Wat are the investigations for obesity in pregnancy?

A

1st line: BMI: height and weight

Consider:

  • Oral glucose tolerance test: >= 7.8mmol/l is diagnostic of GDM.
  • All women with obesity should have a GTT at 24-28 weeks as they are at increased risk of gestational diabetes.
  • Lipid profile
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170
Q

What are the signs and symptoms of a PE during pregnancy?

A

Symptoms

  • Pleuritic chest pain - sharp chest pain on inhale and exhale
  • Shortness of breath

Signs:

  • Tachypnoea
  • Tachycardia
  • Hypotension
  • Haemoptysis
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171
Q

Management of obesity in pregnancy?

A

First-line:

  • Lifestyle modifications: diet and exercise counselling
    Folic acid: 5mg, from 1 month pre-conception - end of first trimester

Second-line:

  • Metformin: if GDM present and not managed by lifestyle modifications
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172
Q

What are the investigations for VTE in pregnancy?

A

DVT: Doppler ultrasound. If negative, repeat on day 3 and 7 in high-risk patients.

PE:

1st line:
- Chest xray
- ECG

Gold standard:
- CT pulmonary angiogram (CTPA)

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173
Q

What is anaemia during pregnancy?

A

Anaemiais defined as a low concentration of haemoglobin in the blood.

Pregnant women are screened for anaemia at the booking appointment and 28-weeks gestation.

During pregnancy, plasma volume increases, and so haemoglobin concentration reduces. This alongside increased demand for B12 also can cause B12 deficiency.

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174
Q

What is the management for DVT in pregnancy?

A

Low molecular weight heparin (LMWH), such as dalteparin. dose based on woman’s weight at booking clinic.

Start immediately at diagnosis until six-weeks postnatally.

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175
Q

What are the clinical features of anaemia in pregnancy?

A

Often asymptomatic, women might have:

Shortness of breath

Fatigue

Dizziness

Pallor

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176
Q

What is the management if a pregnant woman has massive PE with haemodynamic instability?

A

Life-threatening scenario.

  • Unfractionated heparin
  • Thrombolysis
  • Surgical embolectomy
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177
Q

What are the normal ranges of hb throughout pregnancy?

A

Booking bloods > 110 g/l

28 weeks gestation > 105 g/l

Post partum > 100 g/l

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178
Q

What is the prophylaxis given to pregnant women at risk of VTE?

A

1st line:

LMWH (e.g. dalteparin) from 28 weeks gestation if 3 risk factors, in the first trimester if ≥4 risk factors. Continue until 6-week postnatal with pause during labour.

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179
Q

Anaemia in pregnancy: What can MCV show?

A

The mean cell volume (MCV) can indicate the cause of the anaemia:

  • Low MCV: iron deficiency
  • Normal MCV: physiological anaemia due to the increased plasma volume of pregnancy
  • Raised MCV: B12 or folate deficiency
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180
Q

What is shoulder dystocia?

A

When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

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181
Q

What is the management of anaemia in pregnancy?

A
  1. Iron: iron replacement (e.g. ferrous sulphate 200mg 3x daily).
  2. B12: seek specialist haemologist advice:
  • Intramuscular hydroxocobalamin injections
  • Oral cyanocobalamin tablets
  1. Folate:
  • All women: folic acid 400mcg per day. If folate deficiency present then folic acid 5mg daily.

Thalassaemia and Sickle Cell Anaemia: managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

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182
Q

How would shoulder dystocia present?

A
  • Difficulty with delivering head and face
  • Failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head.
  • Turtle-neck sign: where tje head is delivered but then retracts back into the vagina.
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183
Q

What is the management for shoulder dystocia?

A

Obstetrics emergency - led by experienced midwives and obstetricians.

  • Sound the alarm and call for help
  • Episiotomy - surgical incision of the perineum and the posterior vaginal wall.
  • McRoberts manoeuvre - mother in knee to chest position to lift pubic symphysis out of the way.
  • Rubins manoeuvre - reaching into vagina to put pressure on baby’s shoulders to help it move under the pubic symphysis.

Wood’s screw manoeuvre during Rubins manoeuvre. The other hand puts pressure on the baby’s shoulders to rotate baby to help delivery.

  • Zavanelli manoeuver - pushes baby back in to prepare for emergency c-section.
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184
Q

What are some of the complications that can arise from shoulder dystocia?

A
  • Fetal hypoxia (and subsequent cerebral palsy)
  • Perineal tears
  • Postpartum haemorrhage
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185
Q

What is a caesarean section?

A

A c-section is a surgical operation to deliver the baby via an incision in the abdomen and uterus.

Emergency or elective.

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186
Q

What are the different categories of caesarean section?

A

Category 1 - Immediate threat to the life of the woman or fetus. Delivery in 30 mins.

Category 2 - Maternal or fetal compromise that is not immediately life-threatening. Delivery within 75 mins

Category 3 - no maternal or fetal compromise but needs early delivery

Category 4 - elective

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187
Q

What are some indications for elective (planned) c-section?

A

Performed with spinal anesthesia and usually after 39 weeks gestation.

  • Previous caesarean
  • Placenta praevia
  • Breech presentation
  • Other malpresentations: e.g. unstable lie (fluctuates from oblique, cephalic, transverse etc.)
  • Cervical cancer
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188
Q

What kind of anesthetics is usually used for a c-section?

A

Regional anaesthetic – ‘topped-up’ epidural or a spinal anaesthetic.

Sometimes GA is needed if concerns about fetal wellbeing (cat 1 sections). GA faster than spinal anaesthetics.

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189
Q

Describe what cut is used in a c-section?

A

Usually a transverse lower uterine segment incision using scalpel - Joel-cohen incision.

Blunt dissection is then used after to separate the remaining layers of the abdominal wall and uterus.

The baby is delivered by hand/forceps with pressure on the fundus.

The uterus is sutured closed inside the abdomen.

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190
Q

What layers of the abdomen is dissected in a c-section?

A
  1. Skin
  2. Subcutaneous tissue
  3. Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
  4. Rectus abdominis muscles
  5. Peritoneum
  6. Vesicouterine peritoneum – a flap separating uterus and bladder
  7. Uterus (perimetrium, myometrium and endometrium)
  8. Amniotic sac
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191
Q

What measures are used to reduce risk in a c-section?

A
  • H2 receptor antagonists (e.g. ranitidine) or PPI (e.g. omeprazole) before the procedure to prevent aspiration pneumonitis
  • Prophylactic antibiotics
  • Oxytocin during the procedure to < risk of PPH
  • VTE prophylaxis with LMWH
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192
Q

What prophylaxis is provided for VTE after a c-section?

A
  • Early mobilisation
  • Anti-embolism stockings
  • LMWH (e.g. dalteparin)
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193
Q

What is abnormal uterine bleeding (note this is different from abnormal vaginal bleeding)?

A

AUB is any variance of the normal menstrual cycle, which is defined by four parameters (frequency, regularity, duration, and volume).

Acute or chronic

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194
Q

List some causes of AUB

A
  • Polyps
  • Fibroids
  • Malignancy + hyperplasia: all gynae cancer (e.g. endometrial)
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195
Q

What are some other causes of AUB?

A
  • Use of medication - particularly hormonal contraception or drugs interfering with the hypothalamic-pituitary-ovarian axis (such as SSRIs).
  • Pregnancy-related bleeding - mandatory to rule out pregnancy in AUB!
  • Traumatic injury during intercourse and sexual abuse
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196
Q

What are the risk factors for AUB?

A
  • Women at the extremes of reproductive age (just after puberty and before menopause)
  • Polycystic ovary syndrome
  • Obesity
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197
Q

What are the investigations for AUB?

A

Pregnancy test (urine or blood beta-hCG level) - mandatory to rule out pregnancy in women of reproductive age even if on contraception.

FBC - diagnosis of anaemia important in determining severity of AUB.

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198
Q

What is the management plan for AUB?

A

Emergency management of excessive AUB:

  • IV conjugated oestrogen, or combined oral contraceptive, or a progestogen-only treatment.
  • Tranexamic acid - prevents excessive bleeding

Medical ongoing
management:

  • Intrauterine device - mirena coil releases progesterone to stop AUB

Surgical management if above insufficient:

  • Dilation and curettage (D&C) - cervix dilated and endometrium scraped with spoon-like instrument
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199
Q

What is the pelvic floor?

A

The pelvic floor is made up of layers of muscles which support the bladder, bowel and uterus.

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200
Q

What are the different types of pelvic organ prolapse?

A
  • Uterine prolapse - the uterus descends into the vagina.
  • Vault prolapse - occurs in women who have had a hysterectomy, the top of the vagina (vault) descends in the vaginal canal.
  • Rectoceles - a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Associated with constipation.
  • Cystoceles - a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.

-

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201
Q

What are the causes/risk factors for pelvic organ prolapse?

A
  • Multiple vaginal deliveries
  • Advanced age and postmenopause status
  • Obesity
  • Chronic respiratory disease causing coughing
  • Chronic constipation causing straining
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202
Q

What are the clinical features of pelvic organ prolapse?

A
  • A feeling of “something coming down” in the vagina
  • A dragging or heavy sensation in the pelvis
  • Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
  • Bowel symptoms, such as constipation, incontinence and urgency
  • Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
  • A lump/mass in vagina, worse on straining or bearing down.
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203
Q

What examination is conducted for pelvic organ prolapse?

A
  1. Patient empty bladder
  2. Patient in dorsal or left lateral position
  3. Sim’s speculum is held on the anterior vaginal wall to examine for a rectocele, and the posterior wall for a cystocele.
  4. Patient asked to cough or “bear down” to assess the full descent of the prolapse.
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204
Q

What is the conservative management of pelvic organ prolapse?

A

For women with mild symptoms, or if vaginal pessaries and surgery are contraindicated.

  • Physiotherapy (pelvic floor exercises)
  • Weight loss
  • Management of stress/urge incontinence - reduce caffeine intake, anticholinergic agents
  • Vaginal oestrogen cream
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205
Q

What is the medical management for pelvic organ prolapese?

A
  • Vaginal pessaries: inserted into vagina to provide extra support to the pelvic organs.
  • Significant improvement in symptoms
  • Types include ring and donut pessaries
  • Change every 3 months
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206
Q

What are the surgical management options for pelvic organ prolapse? Don’t need to know types in detail

A

Surgery is the gold-standard treatment for pelvic organ prolapse, including:

  • Pelvic floor repair
  • Hysterectomy
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207
Q

What are the complications that can arise from surgery for pelvic floor prolapse?

A
  • Pain, bleeding, infection, DVT
  • Damage to the bladder or bowel
  • Recurrence of the prolapse
  • Altered experience of sex
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208
Q

What is obstetric cholestasis (intrahepatic cholestasis of pregnancy)?

A

Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby.

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209
Q

What are the signs and symptoms of obstetric cholestasis?

A

Presents usually in third trimester.

  • Itching (pruritis) = main symptom
  • Fatigue
  • Dark urine
  • Pale, greasy stools
  • Jaundice
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210
Q

What are the investigations for obstetric cholestasis?

A
  • Bile acid levels:
  • ≥ 10 micromol and < 40 micromol (mild)
  • ≥ 40 micromol/L and <100 micromol/L (moderate)
  • ≥100 micromol/L (severe)
  • LFTs: deranged ALT, AST and GGT.
  • Placenta produces ALP, so raised ALP with otherwise normal LFTs is likely due to this
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211
Q

What is the management for obstetric cholestasis?

A
  • 1st line: emollient
  • Consider: sedating antihistamine (chlorphenamine), does not help itching but improves sleep
  • In women with severe obstetric cholestasis - induction or elective c-section from 35 weeks, as they are at higher risk of stillbirth.
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212
Q

What are neural tube defects (NTDs)?

A

Congenital malformations that result from incomplete closure of the neural tube during embryonic development.

The neural tube starts to form in early pregnancy and closes about 4 weeks after conception.

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213
Q

What are the most common types of NTDs?

A
  • Anencephaly - most of the brain and skull is missing and incompatible with life
  • Spina bifida = “split spine”:
  • Spina bifida occulta: mild form of spina bifida with no visible protrusion.
  • Meningocele: protrusion of meninges through a spinal defect, but the spinal cord remains in place
  • Myelomeningocele : protrusion of the spinal cord and meninges through a defect in the vertebral column.
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214
Q

What are the risk factors for NTDs?

A
  • Folic acid deficiency during pregnancy
  • Maternal diabetes
  • Maternal obesity
  • Previous child with NTD
  • Use of valproate or carbamazepine
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215
Q

What are the symptoms of spina bifida?

A

Myelomeningocele (spina bifida aperta) is the most severe form and so it has the most clinical feature:

Symptoms

  • Weakness of the lower limbs
  • Bowel and bladder incontinence
  • Reduced sensation of the lower limbs
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216
Q

What are the signs of spina bifida?

A
  • Sac-like protrusion over lower part of spine: in meningocele/myelomeningocele
  • Benign skin features over lower part of spine: skin tags, dimples, hairy patches
  • Enlarged head: caused by hydrocephalus
  • Hyperreflexia and hypertonia of the lower limbs: predominantly myelomeningocele
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217
Q

What are the investigations for spina bifida?

A
  • Antenatal triple/quadruple test between 15 - 20 weeks
  • Antenatal ultrasound - locate NTD
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218
Q

What is the management plan for spina bifida?

A
  • Folic acid supplement - at least one month before conception to 12 weeks (400 mcg or 5mg if risk factors)
  • MDT approach with paeds, neurosurgery, ortho and genetic counselling
  • Surgical repair for myelomeningoceles
  • Regular monitoring with specialist neurosurgeon through adulthood.
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219
Q

What is gastroschisis?

A

Defect of the abdominal wall that occur in utero, and result in herniation of abdominal contents without a sac.

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220
Q

What is exomphalos/omphalocele?

A

Defect of the abdo wall of neonates that result in the protrusion of abdominal content into a peritoneal sac.

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221
Q

What are the causes/risk facotrs for gastroschisis?

A
  • Maternal smoking
  • Maternal age < 20
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222
Q

What are the causes/risk factors for omphalocele?

A
  • Maternal smoking
  • Maternal age > 35
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223
Q

What are the clinical features of gastroschisis?

A

The lack of a protective membrane covering the abdominal contents ,meams that a inflammatory film/peel forms around the contents > intestinal atresia (bowel obstruction due to congenital causes) due to ischaemia and significant fluid imbalance and heat loss!!

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224
Q

What are the clinical feature of an omphalocele?

A

They are abdominal wall defect ranging from 4 to 12 cm in size, usually located centrally.

The abdominal contents have a protective membranous covering in utero, the intestines are usually healthy at birth.

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225
Q

What investigations are used to detect gastroschisis?

A
  • Elevated maternal alpha fetoprotein
  • Positive antenatal USS - fluid-filled bowel loops floating freely in amniotic fluid, or even intestinal atresia.
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226
Q

What investigations are used to detect omphalocele?

A
  • Antenatal USS - abdominal masses outside abdominal wall
  • Fetal chromosomal abnormalities - if omphalocele confirmed on USS then amniocentesis to detect trisomy 13, 18 and 21 etc. as they are associated
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227
Q

What is the management for gastroschisis?

A
  • Acute: fluid resus, temperature stabilisation and bowel protection
  • Surgical repair
  • Postsurgical NG tube and parenteral nutrition
228
Q

What is the management for omphalocele?

A
  • Acute: fluid resus, temperature stabilisation
  • Intact membrane: NG tube to decompress bowel
  • Ruptured membrane: bowel protection + surgical repair
  • Parenteral nutrition
229
Q

What is a ventricular septal defect?

A

A hole in the septum between the two ventricles. Classified as a cyanotic heart disease as it creates a right-left shunt whereby blood bypasses the lungs iand into the systemic circulation.

230
Q

What are the causes/risk factors of VSD?

A
  • Associated with genetic conditions such as Downs syndrome
  • Can occur after MI as ischaemia can damage the ventricular septum.
231
Q

What are the clinical features of VSD?

A
  • Often asymptomatic and presents in adulthood.
  • Might be detected at antenatal scan as a murmur.
  • Pan-systolic murmur more at left lower sternal border in 3rd/4th ICS +/- systolic thrill on palpation.

Note: ddx for pan-systolic murmur include VSD, mitral regurgitation and tricuspid regurgitation.

232
Q

What are the investigations for VSD?

A
  • Diagnostic test of choice : Echocardiogram
  • CXR - cardiomegly
  • ECG - not diagnostic but provides evidence of chamber enlargement if present
233
Q

What is the management plan for VSD?

A

Small = observation

Medium/large = transvenous catheter closure via the femoral vein or open-heart surgery.

Prophylactic abx if undergoing surgery as increased risk of infective endocarditis.

234
Q

What is rhesus incompatibility?

A

Rhesus antigen is a type of antigen present on some fetal RBCs.

Rhesus (Rh) incompatibility is a condition where an Rh-negative mother carrying an Rh-positive fetus can produce antibodies against paternally derived Rh antigens on fetal red blood cells. These antibodies can cross the placental membrane and destroy fetal RBCs.

235
Q

Rhesus incompatibility: what are sensitisation events?

A

Times when maternal blood is mixed with fetal blood, thus providing opportunity for the maternal anti-rhesus antibodies to develop against paternally derived Rh antigens on fetal RBCs.

This does not usually cause problems in the first pregnancy, but will do so in subsequent pregnancies.

236
Q

Rhesus incompatibility: give examples of sensitisation events.

A
  • Miscarriage > 12 weeks
  • Abdominal trauma e.g. placental abruption
  • At birth
237
Q

How do we determine the rhesus status of an expectant mother?

A

This is done at the booking appointment between 8 - 10 weeks by determining mother’s blood type. If mother is rhesus negative then prophylaxis is given regardless of the fetal rhesus status.

238
Q

What is the management for a rhesus-D negative mother?

A

IM anti-D injections, this prevents sensitisation by attaching to rhesus-D antigens on fetal RBCs in maternal circulation, causing them to be destroyed. S0 the maternal immune system does not create antibodies against the rhesus-D antigen.

  • Anti-D injections are given routinely on two occasions and sensitisation events:
  • 28 weeks gestation
  • Birth (if the baby’s blood group is found to be rhesus-positive)
239
Q

What disease can Rh incompatibility lead to?

A

Haemolytic disease of the fetus and newborn, also known as erythroblastosis fetalis.

240
Q

What is intrauterine growth restriction (IUGR)?

A

When there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.

241
Q

What are some causes of IUGR?

A
  • Pre-eclampsia
  • Maternal smoking
  • Maternal alcohol
  • Mternal anaemia
  • Malnutrition
  • Maternal/fetal infection
242
Q

What are the clinical features of IUGR?

A
  • Small for gestational age - < 10th percentile
  • Reduced amniotic fluid volume
  • Reduced fetal movements
  • Abnormal CTGs
243
Q

What are the short-term complications of IUGR?

A
  • Fetal death or stillbirth
  • Birth asphyxia (lack of O2)
244
Q

What are the long-term effects of IUGR?

A
  • Cardiovascular disease, particularly hypertension
  • Type 2 diabetes
  • Obesity
  • Mood and behavioural problems
245
Q

WHat are the risk factors for SGA?

A
  • Previous SGA baby
  • Antepartum haemorrhage
  • Antiphospholipid syndrome
  • Pre-eclampsia
  • > 35
  • Obesity
  • Smoking
  • Diabetes + GD
  • Existing hypertension
  • Multiple pregnancy
246
Q

What monitoring is provided for SGA (can be caused by IUGR)?

A

Low-risk - symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards.

SFH < 10th centile = serial growth scans with umbilical artery doppler (pre-eclampsia monitoring)

Women with one major or multiple minor risk factors are booked for serial growth scans with umbilical artery doppler.

247
Q

What is the management for SGA?

A
  • Pre-eclampsia risk = aspirin
  • Stop smoking
  • Identify cause for SGA e.g. bloods and urine dipstick for pre-eclampsia
  • Early delivery where growth is static, or there are other concerns (e.g. abnormal doppler)
248
Q

What is defined as premature (preterm) labour?

A

Labour that occurs between 24 to 37 weeks gestation.

249
Q

How is prematurity classified?

A

The World Health Organisation classify prematurity as:

  • Under 28 weeks: extreme preterm
  • 28 – 32 weeks: very preterm
  • 32 – 37 weeks: moderate to late preterm

Babies are considered non-viable < 23 weeks.

250
Q

What causes premature labour?

A
  • Preterm prelabour rupture of membrane (P-PROM)
  • Advanced cervical dilation
  • Uterine contractions
  • Cervical length < 2cm
251
Q

Prophylaxis of premature labour

A

Vaginal progesterone as gel or pessary, maintains pregnancy and prevents labour

Offered to women with cervical length < 25mm on vaginal USS between 16 - 24 weeks gestation

Cervical Cerclage - a stitch is put in the cervix to add support and keep it closed, removed when woman goes into labour or reaches term

Offered to women as above or previous premature birth or cervical trauma e.g. colposcopy

“Rescue” cervical cerclage offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

252
Q

Talk through the definition, diagnosis and management of preterm prelabour rupture of membrane (P-PROM).

A

P-PROM is where the amniotic sac ruptures, before the onset of labour and in a preterm pregnancy.

Ix: speculum exam > pooling of amniotic fluid in vagina

Mx: prophylactic abx (e.g. erythromycin) to prevent chorioamnionitis
and induction of labour offered from 34 weeks

253
Q

What is preterm labour with intact membrane.

A

Regular painful contraction (>1 in 10) and cervical dilatation, without rupture of the amniotic sac.

254
Q

How is preterm labour with intact membrane diagnosed?

A
  • Clinical assessment includes a speculum examination to assess for cervical dilatation.
  • < 30 weeks - clinical assessment enough to offre management of preterm labour
  • > 30 weeks gestation, a transvaginal ultrasound to determine cervical length.
  • <15mm = preterm labour management
  • > 15mm = preterm labour is unlikely
255
Q

What is the management for preterm labour with intact membrane?

A
  • CTG (cardiotocogram)
  • Tocolysis with nifedipine to suppress labour
  • Maternal corticosteroids < 35 weeks to help fetal lung development
  • IV magnesium sulphate: < 34 weeks to reduce risk of cerebral palsy
  • Delayed cord clamping to increase blood supply to baby
256
Q

What is a perineal tear?

A

A tear that occurs in the perineum when external vaginal opening is too narrow to accommodate the baby.

257
Q

What are the different types of perineal tear?

A
  • First-degree – limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
  • Second-degree – including the perineal muscles, but not affecting the anal sphincter
  • Third-degree – including the anal sphincter, but not affecting the rectal mucosa
  • 3A – less than 50% of the external anal sphincter affected
  • 3B – more than 50% of the external anal sphincter affected
  • 3C – external and internal anal sphincter affected
  • Fourth-degree – including the rectal mucosa
258
Q

What are the risk factors for perineal tears?

A
  • Nulliparity
  • Large babies ≥ 4kg
  • Shoulder dystocia
  • Asian ethnicity
  • Occipito-posterior position
259
Q

What is a episiotomy?

A

A cut in the perineum made by an obstetrician or midwife in anticipation of needing additional room for delivery.

  • Local anaesthetics
  • Cut at 45 degrees to avoid damaging the anal sphincter- mediolateral episiotomy.
  • The cut is sutured after delivery.
260
Q

What is the management of perineal tears?

A
  • First-degree tears usually does not require surgery.
  • Second-degree = suture
  • A third or fourth-degree tear = repair in theater

Additional measures:

  • Broad-spectrum antibiotics
  • Laxatives
  • Physiotherapy to reduce the risk and severity of incontinence
  • Followup to monitor complications
261
Q

What are the complications of perineal tears?

A

Short term: pain, infection, bleeding

Long-term:

  • Urinary/anal incontinence
  • Altered bowel habit (3rd and 4th)
  • Sexual dysfunction and dyspareunia (painful sex)
  • Mental health impact
262
Q

How is HIV transmitted from mother to baby?

A
  • In utero
  • intrapartum (during childbirth)
  • Breastfeeding postnatal if maternal viral load uncontrolled
263
Q

What is Group B streptococcus (GSB) infection?

A

This bacteria usually harmlessly colonises the GI and GU tract, but can cause severe infection for mother and baby due to transmission during delivery.

Cause of neonatal sepsis

264
Q

What are some risk factors for HIV in pregnancy?

A
  • Needle sharing with IVDUs
  • Unprotected receptive penile-vaginal/anal intercourse
  • High maternal viral load (perinatal transmission)
  • Absence of antenatal maternal antiretroviral therapy
265
Q

How is GBS infection passed from mother to baby?

A

Vertical transmission during childbirth.

266
Q

What are the investigations for HIV in pregnancy?

A
  • Maternal HIV-1/HIV-2 antigen/antibody enzyme-linked immunosorbent assay (ELISA)
  • Neonatal HIV DNA or RNA PCR
267
Q

What are the risk factors for GBS?

A
  • Positive GBS culture in current or previous pregnancy
  • Previous birth resulting in neonatal GBS infection
  • Pre-term labour
  • Prolonged rupture of membranes
268
Q

What is the management of HIV in pregnancy?

A
  • Pregnant women should continue their anti-retrovirals (ART)
  • For women with viral load >1000 copies/mL at 38 weeks or more = c-section and ART
  • Infants born to HIV-infected mothers: postnatal ART
269
Q

What investigations are carried out for GBS?

A

In the UK, women are not routinely screened for GBS as colonisation status can change throughout pregnancy.

If a pregnant woman is suspected of having GBS, then bloods such as FBC, U+E, serum creatinine to check for sepsis as they are deranged in sepsis.

270
Q

What is the management of HIV in pregnancy?

A
  • Pregnant women should continue their anti-retrovirals (ART)
  • For women with viral load >1000 copies/mL at 38 weeks or more = c-section and ART
  • Infants born to HIV-infected mothers: postnatal ART
271
Q

What are the clinical features of GBS infection?

A

Maternal: UTI, chorioamnionitis, postnatal endometritis
Newborn: sepsis, pneumonia, meningitis

272
Q

What is congenital cytomegalovirus (CMV) infection?

A

A condition that occurs due to a cytomegalovirus (CMV) infection in the mother during pregnancy.

273
Q

What is the management for GBS?

A
  • Intrapartum prophylactic abx (NICE recommends Benzylpenicillin and getamacin) during labour and delivery if risk factors.
  • Abx choice depends on allergy history, antimicrobial susceptibility testing, and the potential effects on the fetus or breast milk.
  • Always follow local guidelines
274
Q

How is congenital CMV usually spread?

A

The virus is mostly spread via the infected saliva or urine of asymptomatic children. Most cases of CMV in pregnancy do not cause congenital CMV.

275
Q

What are the clinical features of congenital CMV infection?

A
  • Fetal growth restriction
  • Microcephaly
  • Hearing loss
  • Vision loss
  • Learning disability
  • Seizures
276
Q

What is congenital rubella syndrome?

A

Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation.

277
Q

What can prevent congenital rubella syndrome?

A

Women who are planning to get pregnant getting the MMR (mumps, measles and rubella) vaccine.

Pregnant women should not receive this as live vaccine - instead, given after childbirth.

278
Q

What are the clinical features of congenital rubella syndrome to look out for?

A
  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning disability
279
Q

What are the investigations for congenital rubella syndrome?

A
  • Serology tests to confirm rubella infection.
  • Audiology tests for hearing impairment
  • Ophthalmology review
  • Echocardiography for congenital heart defects
280
Q

What is the management for congenital rubella syndrome?

A
  • Supportive
  • Regular monitoring and followup
281
Q

What is congenital toxoplasmosis?

A

Toxoplasmosis infection is usually an asymptomatic, and it is caused by the toxoplasma gondii parasite.

Infected cat faeces are a common way of transmitting the infection.

Congenital toxoplasmosis is when it is passed from mother to fetus.

282
Q

What is the classic triad of congenital toxoplasmosis?

A
  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis (inflammation of the choroid and retina in the eye
283
Q

What are the investigations for congenital toxoplasmosis?

A
  • Antenatal ultrasound - foetal abnormalities
  • Amniocentesis with PCR
  • Maternal IgM testing to check for previous exposure
  • Foetal blood test
284
Q

What is the management for toxoplasmosis infection in pregnancy?

A

The antibiotic spiramycin

285
Q

What is neonatal herpes simplex virus (HSV) infection?

A

Neonatal herpes simplex virus (HSV) infection is a potentially severe condition in newborns that can occur during delivery.

It is transmitted from the mother to baby when the baby comes in contact with primary vesicles in the maternal genital tract during delivery.

286
Q

What are the clinical features of neonatal HSV infection?

A
  • Vesicular lesions on the skin, eye, or oral mucosa
  • Severe cases: seizures, encephalitis or sepsis
287
Q

What is the investigations for neonatal HSV infection?

A
  • PCR
  • MRI in case of encephalitis
288
Q

What is the management of neonatal HSV infection?

A

Maternal: elective caesarean section or intrapartum IV acyclovir if primary lesions present at term or primary outbreak within 6 weeks of labour

Neonatal: parenteral acyclovir

289
Q

What is parvovirus B19 infection?

A

Parvovirus B19 infection typically affects children.

Self-limiting, and the rash (characteristric macular erythrometheous facial rash) and symptoms usually fade over 1 – 2 weeks.

290
Q

What complications can parvovirus B19 infection cause in pregnancy?

A

Particularly in first and second trimester:

  • Miscarriage or fetal death
  • Severe fetal anaemia
  • Hydrops fetalis (fetal heart failure)
  • Maternal pre-eclampsia-like syndrome
291
Q

What are the clinical features of congenital parvovirus B19 infection?

A

Starts with non-specific viral symptoms.

2 - 5 days: macular, erythromathous rash on one or both cheeks - “slapped cheeks” appearance.

Then reticular (net-like) mildly erythematous rash affecting the trunk and limbs, can be raised and itchy.

292
Q

Why does parvovirus cause fetal anaemia?

A

Parvovirus infects the erythroid progenitor cells in the fetal bone marrow and liver. These cells produce red blood cells, and the infection causes them to produce faulty red blood cells that have a shorter life span > anaemia > heart failure, referred to as hydrops fetalis.

293
Q

What is haemolytic disease of the newborn (HDN)?

A

An immunological disorder that occurs when a rhesus negative mother becomes sensitised to her baby’s rhesus positive blood cells in utero, and her body mounts an immune response to the fetal RBCs.

294
Q

How does HDN occur?

A

It occurs due to immune response because of rhesus or ABO blood group incompatibility between the mother and foetus. Sensitisation events are responsible for fetal blood entering maternal circulation.

295
Q

Clinical features of HDN?

A
  • Hydrops foetalis (HF) appearing as foetal oedema seen on antenatal ultrasound
  • Neonatal jaundice
  • Foetal anaemia causing skin pallor
  • Hepatosplenomegaly
  • Severe oedema if HF in utero
296
Q

Investigations for HDN?

A
  • Direct Antiglobulin Test (DAT)/ DIrect Coombs Test on fetal blood sample, to see if antibodies mounted against RBCs
  • Liver function tests (LFTs) to check for complications
297
Q

Management for HDN?

A
  • Intrauterine blood transfusions
  • Early delivery if severe

Postnatal:

  • Phototherapy or exchange transfusion to manage high bilirubin
  • Immunoglobulin administration to prevent further haemolysis
  • Regular follow-up to assess developmental issues
298
Q

DIfferential diagnosis for HDN?

A

Thalassemia: also presents with anaemia, hepatosplenomegaly, and jaundice

299
Q

What is an instrumental delivery?

A

It is an assisted vaginal delivery using a ventouse suction cup or forceps.

300
Q

What are some indications for instrumental delivery?

A

Based on the clinical judgement of the midwife or obstetrician during 2nd stage of labour.

Key indications:

  • Failure to progress - more likely if epidural
  • Fetal distress - abnormal CTG
  • Maternal exhaustion
301
Q

What are the main risks to the baby of instrumental delivery?

A
  • Cephalohaematoma (blood between skull and periosteum (membrane around the bones)) with ventouse
  • Facial nerve palsy with forceps
302
Q

What are the main maternal risks of instrumental delievery?

A
  • Postpartum haemorrhage
  • Perineal tears
  • Bladder or bowel incontinence
  • Nerve injury (obturator or femoral nerve)
303
Q

What are some contraindications for instrumental delivery

A
  • Unengaged fetal head in singleton pregnancies.
  • Breech and face and most brow presentations.
  • Preterm gestation (<34 weeks) for ventouse.
  • Cord prolapse with fetal compromise
304
Q

What are baby blues?

A

Baby blues affect > 50% of women in the first week after birth, particularly first-time mothers.

  • Mood swings
  • Low mood
  • Anxiety
  • Irritability
  • Tearfulness
305
Q

What can cause baby blues?

A
  • Significant hormonal changes
  • Recovery from birth
  • Sleep deprivation
  • The responsibility of caring for the neonate
  • Establishing feeding
306
Q

What is the management for baby blues?

A

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

307
Q

What is postnatal depression?

A

It is depression that women experiencing after giving birth, it usually starts to affect mothers 3 months after birth.

Symptoms should last at least two weeks before a diagnosis is made.

308
Q

What are the symptoms of postnatal depression?

A

Similar to depression that occur outside of pregnancy.

  • Low mood
  • Anhedonia (lack of pleasure in activities)
  • Low energy
309
Q

What are the investigation for postnatal depression?

A

Screening questions:

  • During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and
  • “During the past month, have you often been bothered by having little interest or pleasure in doing things?
  • Edinburgh Postnatal Depression Scale (EPDS) score > 11 suggestive of depression
310
Q

What are the risk factors for postnatal depression?

A
  • History of depression, or anxiety
  • Recent stressful life events
  • Poor social support
  • Stopping psychopharmacological treatments
311
Q

What is the management plan for postnatal depression?

A
  • Mild cases - additional support, self-help and GP followup
  • Moderate cases - antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy

Severe cases - specialist psychiatry services

NICE recommends speaking to specialist perinatal mental health team before starting mum on antidepressants.

312
Q

What is endometriosis?

A

A condition where endometrium-like tissue grows outside of the uterine cavity.

313
Q

What are the clinical features of endometriosis?

A
  • Dysmenorrhoea (painful period)
  • Dyspareunia (deep)
  • Subfertility
  • Cyclical rectal bleeding (if growth on bowel) or blood in urine
  • Pelvic exam: palpable tender nodules on ovaries or surrounding ligaments
314
Q

Risk factors for endometriosis

A
  • Reproductive age
  • FHx of endometriosis
  • Nulliparous
315
Q

What are the investigations for endometriosis?

A
  • 1st line: Transvaginal ultrasound
  • Gold standard: laparoscopy - allows visualisation and immediate treatment such as ablation
316
Q

What is the management for endometriosis?

A

Medical Management

  • Analgesia: paracetamol or NSAIDs
  • COCP

Surgical Management

  • Diathermy (heat) of lesions
  • Ovarian cystectomy
  • Laparoscopic excision/ablation if patient wants to maintain fertility
317
Q

Differential diagnoses for endometriosis

A
  • Primary dysmenorrhea
  • Uterine conditions r.g. fibroids
  • PID
318
Q

What is endometrial cancer?

A

A malignancy that originates from the endometrium, the inner lining of the uterus.

319
Q

What are the risk factors for endometrial cancer?

A

Exposure to unopposed estrogen:

  • Nulliparity
  • Obesity
  • Early menarche
  • Late menopause
  • Polycystic ovary syndrome
320
Q

What are the clinical features of endometrial cancer?

A
  • Postmenopausal bleeding (endometrial cancer until proven otherwise)
  • Intermenstrual bleeding
  • Pelvic pain
  • Abdominal discomfort or bloating
  • Weight loss
  • Anaemia

Bimanual exam - enlarged uterus or no change

321
Q

What are the investigations for endometrial cancer?

A

1st line: tranvaginal USS - detects endometrial thickness, >5mm = further Ix

Gold standard: hysteroscopy and endometrial biopsy

322
Q

Stages of endometrial cancer

A

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

323
Q

What is the management for endometrial cancer?

A

Stage 1- 2: Hysterectomy with bilateral salpingo-oophorectomy - removes uterus, cervix, ovaries and fallopian tube)

Stage 3 - 4:

  • Radical hysterectomy - removal of pelvic lymph nodes, surrounding tissues and top of the vagina
  • Radiotherapy + Chemotherapy
  • Progesterone - slow cancer progression
324
Q

What is the criteria for a 2WW urgent cancer referral for endometrial cancer?

A

Pot-menopausal bleeding (more than 12 months since LMP)

325
Q

What is dysmenorrhea?

A

Dysmenorrhoea is pain that occurs in conjunction with menstruation, where this pain becomes severe or debilitating.

326
Q

Types of dysmenorrhea

A

Primary: idiopathic and in absence of pelvic pathology

Secondary: due to underlying pathology e.g. endometriosis, uterine fibroids, PID

327
Q

Symptoms of dysmenorrhea

A
  • Pelvic pain
  • Nausea
  • Vomiting
  • General malaise
  • Diarrhoea
  • Fatigue
328
Q

Investigations for dysmenorrhea

A
  • Exclude STIs
  • Abdo exam: tenderness/mass,
  • Bimanual examination: cervical tenderness
  • Pelvic ultrasound if suspect underlying pathology (e.g. fibroids, endometriosis)
329
Q

What is the management for dysmenorrhea?

A

Medical management

  • NSAIDs
  • COCP
  • Progestogen-only pill
  • Levonorgestrel (progesterone)-releasing IUD (e.g. Mirena©)

Surgical management

  • Endometrial ablation or hysterectomy
330
Q

What is an ectopic pregnancy?

A

When a fertilised egg implants outside the uterus.

The most common site is a fallopian tube. other sites include entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.

331
Q

What are the risk factors for ectopic pregnancy?

A
  • Previous ectopic pregnancy
  • Previous pelvic inflammatory disease
  • Previous surgery to the fallopian tubes
  • Intrauterine devices (coils)
  • Older age
  • Smoking
332
Q

What are the signs and symptoms of ectopic pregnancy?

A

Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain!

Classic features:

  • Missed period
  • Constant lower abdominal pain in the right or left iliac fossa
  • Vaginal bleeding
  • Lower abdominal or pelvic tenderness
  • Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Also ask about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (bleeding irritated diaphragm)

333
Q

What are the investigations for ectopic pregnancy?

A
  • Pregnancy test to confirm pregnancy
  • Transvaginal ultrasound to locate the pregnancy
334
Q

Ectopic pregnancy: describe expectant management and its criteria

A

Awaiting natural termination

Criteria:

  • Close follow up and monitoring of hCG levels to ensure successful termination
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level < 1500 IU / l
335
Q

Ectopic pregnancy: describe medical management and its criteria

A
  • IM Methotrexate (teratogenic)
  • Criteria same as expectant except:
  • HCG level must be < 5000 IU / l
  • Confirmed absence of intrauterine pregnancy on ultrasound
336
Q

Ectopic pregnancy: describe surgical management and its criteria

A

Criteria:

  • Pain
  • Adnexal mass > 35mm
  • Visible heartbeat
  • HCG levels > 5000 IU / l
  • Laparoscopic salpingectomy - removal of affected fallopian tube
  • Laparoscopic salpingotomy - excision of the ectopic pregnancy while preserving the fallopian tube
337
Q

What is infertility?

A

Infertility is the diminished ability of a couple to conceive a child over a two year period.

Start investigations if the couple has been trying for 12 months without success, after 6months if the woman is over 35 as the ovarian reserves might be reduced and time is more precious

338
Q

What are some causes of infertility?

A

Factors affecting natural fertility include:

  • Increasing age
  • Obesity
  • Smoking
  • Excessive alcohol
  • Genetic causes: Turner’s syndrome (XO)
  • Ovulation/endocrine disorders: e.g. PCOS
  • Tubal abnormalities: adhesions secondary to PID

Uterine abnormalities: e.g. fibroids , endometriosis

Testicular disorders: testicular cancer, oligospermia, premature or retrograde ejaculation

339
Q

What are the intial investigations for infertility?

A
  • Semen analysis
  • Serum progesterone 7 days prior to expected period, usually D21, as progesterone is released by the corpus luteum so increase on D21 = ovulation has occured
  • FSH levels: high = low ovarian reserve as the pituitary release more FSH in an attempt to stimulate the ovaries
  • High LH indicate PCOS
  • Anti-Mullerian hormone, high = good ovarian reserve
  • TFT
  • BMI
340
Q

Investigations in secondary care for infertility

A

-Transvaginal ultrasound scan: To identify uterine abnormalities

  • Hysterosalpingography: Assess tubal patency.

Laparoscopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis).

341
Q

What is the management for infertility?

A

Lifestyle: weight loss, smoking cessation

Medical:

  • Clomifene to stimulate ovulation
  • Gonadotropins if resistant to clomifene

Tubal:

  • Laparoscopic surgery to remove endometriosis/adhesions
  • IVF

Uterine:

  • Surgery to correct polyps, fibroids etc.

Sperm:

  • Surgical sperm retrieval
  • Surgical correction e.g. vas deferens blockage
  • Intrauetrine insemination
342
Q

What is cervical cancer?

A

A type of cancer that occurs in the cells of the cervix.

Most are squamous cell carcinoma, followed by adenocarcinoma

343
Q

What virus is cervical cancer most linked to?

A

Human papilloma virus (HPV) - particularly type 16 and 18 = ~70% cervical cancers.

HPV vaccine offered to girls and boys aged 12 - 13 target these strains.

344
Q

Stages of cervical cancer

A

Stage 1: Confined to the cervix

Stage 2: Invades the uterus or upper 2/3 of the vagina

Stage 3: Invades the pelvic wall or lower 1/3 of the vagina

Stage 4: Invades the bladder, rectum or beyond the pelvis

345
Q

What are the risk factors for cervical cancer?

A

Increased risk of catching HPV:
- Increased number of sexual partners
- Early sexual activity

Non-engagement with cervical screening

Other:
- Smoking
- Family history
- Immunosuppression

346
Q

What are the signs and symptoms of cervical cancer?

A

Non-specific, examine cervix with speculum

  • Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
  • Abnormal vaginal discharge
  • Pelvic pain
  • Dyspareunia (pain or discomfort with sex)
347
Q

When examining the cervix, what signs warrant a 2WW urgent colposcopy referral?

A
  • Ulceration
  • Inflammation
  • Bleeding
  • Visible tumour
348
Q

Describe the cervical screening programme.

A

Purpose: detects dyskaryotic cells which are pre-cancerous allowing early treatment

Target group: women (and trans men with a cervix) between 25 - 64

25 - 49: every 3 years
49 - 64: every 5 years

349
Q

What are the possible outcomes from cervical screening?

A
  • Inadequate
  • Normal
  • Borderline
  • Mild dyskaryosis
  • Moderate dyskaryosis
  • Severe dyskaryosis
  • Possible invasive squamous cell carcinoma
  • Possible glandular neoplasia

Tested for HPV status

HPV-negative: return to routine screening

HPV-positive with normal cytology = repeat after 12 months

Abnormal cytology = colposcopy

Inadequate = repeat in 3 months

350
Q

What are the investigations for cervical cancer?

A

1st line: urgent colposcopy
Cancer staging: CT chest, abdo, pelvis

351
Q

Findings from colposcopy

A

A grading system known as cervical intraepithelial neoplasia (CIN) is used to grade the level of dysplasia (premalignant changes) found at colposcopy (different from dyskaryotic changes at screening)

  • CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
  • CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
  • CIN III or cervical carcinoma in situ.: severe dysplasia, very likely to progress to cancer if untreated
352
Q

What is the management for cervical cancer?

A
  • Early-stage 1A: large loop excision of the transformation zone (LLETZ) or cone biopsy
  • Stage 1B – 2A: radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
  • Stage 2B – 4A: Chemotherapy and radiotherapy
  • Stage 4B: surgery, radiotherapy, chemotherapy and palliative care
353
Q

Differential diagnosis for cervical cancer

A
  • Endometrial cancer
  • Cervical polyps
354
Q

What is premenstrual syndrome (PMS)?

A

Psychological, physical, and behavioural symptoms that occur in the luteal phase of the menstrual cycle and cause distress or disruption to the patient’s life.

355
Q

What are the symptoms of PMS?

A
  • Mood swings and irritability
  • Depression and anxiety
  • Fatigue and sleep problems
  • Bloating, breast tenderness, headaches, joint/muscle pain
  • Changes in appetite and food cravings
356
Q

What are the investigations for PMS?

A
  • Comprehensive patient history
  • Clinical diagnosis
  • Ask patient to keep symptom diary for at least 2 menstrual cycles to help confirm diagnosis
357
Q

What is the management for PMS?

A

Non-pharmacological:

  • Improve diet, exercise, smoking cessation, reduce alcohol
  • Stress reduction: relaxation techniques
  • Cognitive behavioural therapy

Pharmacological:

  • COCP
  • GnRH analogues: effectively induce a menopausal state
  • SSRIs and SNRIs
358
Q

What is an ovarian cyst?

A

An ovarian cyst is a fluid-filled sac that develop in the ovaries.

Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women - mostly benign.

Postmenopausal women - concern for malignancy and needs Ix.

359
Q

What are the signs and symptoms of ovarian cysts?

A
  • Asymptomatic
  • Acute unilateral pelvic pain - suggestive of haemorrhage rupture, ovarian torsion

Signs if rupture:

  • Intra-peritoneal haemorrhage with haemodynamic compromise
360
Q

DDx for ovarian cysts

A
  • Ovarian cancer
  • Ovarian torsion
  • Ectopic pregnancy
  • Appendicitis
361
Q

What are the investigations for ovarian cysts?

A

Red flag symptoms for malignancy:

Abdominal bloating, reduced appetite, weight loss, ascites, lymphadenopathy

1st line
- Pregnancy test to exclude ectopic
-Transvaginal USS
- Serum CA-125 in suspected malignancy and all PM women

362
Q

What is the management for ovarian cysts?

A

Pre-menopausal:

  • <5cm resolve without treatment
  • 5 - 7 cm: routine referral to gynae and yearly ultrasound
  • > 7cm: consider MRI scan or surgical evaluation

Postmenopausal:

  • Raised CA125 = 2WW
  • Normal CA 125 and cyst < 5cm = ultrasound every 4 - 6 months

Surgical management:

  • Persistent/enlarging cysts = laparoscopic ovarian cystectomy
363
Q

Define menopause

A

Menopause is the permanent cessation of menstruation, defined by ≥ 12 months of amenorrhea in otherwise healthy women ≥ 45.

Perimenopause is the time around menopause, where women experience vasomotor symptoms and irregular periods.

364
Q

What causes menopause?

A

Ovarian follicular failure leading to oestrogen
deficiency.

  • Oestrogen and progesterone level: low
  • LH and FSH levels are high, in response to an absence of negative feedback from oesterogen
365
Q

Physiology of menopause

A

In the ovaries, the maturation of primordial follicles to primary and secondary follicles is always occurring independently of the menstrual cycle.

FSH stimulates the further development of secondary follicles, and as the follicles mature, the granulosa cells around them release oestrogen.

Oestrogen = negative feedback to pituitary and reduces LH and FSH release

Menopause starts with a decline in ovarian follicle development = reduced production of oestrogen.

During perimenopause, the lowered levels of oestrogen = no negative feedback = increased LH and FSH

Failing follicle development = anovulation = irregular menstrual cycles

No oestrogen = no endometrium development = amenorrhoea

Lower levels of oestrogen also cause the perimenopausal symptoms.

366
Q

When does menopause typically occur?

A

45 - 55

≤40 = premature menopause due to premature ovarian insufficiency

367
Q

What are the signs and symptoms of perimenopause/menopause?

A

Vasomotor symptoms: hot flushes, night sweats

Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia

Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration

368
Q

DDx for menopause

A
  • Thyroid disease
  • Depression
  • Premature ovarian insufficiency
369
Q

Investigations for peri-/menopause

A

≥ 45 = clinical diagnosis

FSH blood test to help with the diagnosis in:

  • Women under 40 years with suspected premature menopause
  • Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
370
Q

Management for peri/menopause

A
  • HRT - oestrogen oral, transdermal or topical - cyclical if still having periods, continuous if stopped.
  • Progesterone to counteract unopposed oestrogen
  • SSRIs
  • CBT
  • Vaginal moisturers

Women need to use effective contraception for:

  • Two years after the last menstrual period
    if < 50
    One year after the last menstrual period > 50
371
Q

What are fibroids?

A

Fibroids are benign smooth muscle tumours originating from the myometrium of the uterus.

Common in women older than 30, with peak incidence in their 40s

372
Q

What are the different types of fibroids?

A
  • Intramural - within the myometrium - can distort uterine shape
  • Subserosal - just below the outer layer of the uterus - can grow large and fill abdo cavity
  • Submucosal - below the endometrium
373
Q

Signs and symptoms of fibroids

A
  • Often asymptomatic
  • Heavy menstrual bleeding (menorrhagia) is most common
  • Dysmenorrhea
  • Urinary/bowel symptoms due to pelvic pressure/fullness
374
Q

Differential diagnosis for fibroids

A

Endometriosis

375
Q

Investigations for fibroids

A
  • Hysteroscopy initial Ix for submucosal fibroids with menorrhagia
  • Transvaginal & transabdo ultrasound for larger fibroids
  • Endometrial biopsy
  • MRI before surgery to determine size, shape and blood supply of the fibroids
376
Q

Management for fibroids

A

Less than 3 cm + no uterine distortion + heavy menstrual bleeding:

  • Mirena coil (1st line)
  • NSAIDs and tranexamic acid

Symptomatic fibroids = medical management above or surgery

Surgery =

  • Myomectomy
  • Ablation
  • Uterine artery embolisation
  • Hysterectomy

-

377
Q

What is pelvic inflammatory disease (PID)?

A

Inflammation and infection of the organs of the pelvis, it spreads from the cervix.

378
Q

What microorganisms cause PID?

A
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
379
Q

What are the risk factors for PID?

A
  • Not using barrier contraception
  • Multiple sexual partners
  • Younger age
  • Existing STI
  • Previous PID
380
Q

What are the symptoms of PID?

A
  • Pelvic or lower abdominal pain
  • Abnormal vaginal discharge
  • Intermenstrual or postcoital bleeding
  • Dyspareunia
  • Fever
  • Dysuria
381
Q

What might you find on examination in PID?

A
  • Pelvic tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
382
Q

What are differentials for PID?

A
  • Appendicitis
  • Endometriosis
  • Ectopic pregnancy
383
Q

What are the investigations for PID?

A
  • Nucleic acid amplification test (NAAT) swabs for gonorrhoea and chlamydia
  • Pregnancy test to exclude ectopic
  • WWC, CPR for infection
384
Q

What is the management for PID?

A
  • Referred to a genitourinary medicine (GUM) specialist service
  • Empirical antibiotics
  • Abx depends on local guidelines but generally:
  • IM ceftriaxone 1g once + Doxycycline + Metronidazole

Severe cases -sepsis or pregnant

  • Hospital for IV abx
385
Q

What is Hyperemesis gravidarum?

A

Severe form of nausea and vomiting in pregnancy (NVP). The RCOG guideline (2016) criteria are “protracted (prolonged)” NVP plus:

  • More than 5 % weight
    loss compared with before pregnancy
  • Dehydration
  • Electrolyte imbalance
386
Q

What is the management for hyperemesis gravidarum?

A

1st line: conservative - smaller portions, avoid triggers, sour liquids better than water, ginger

Medical - Pyridoxine and/or doxylamine

Acute management - IV fluids, antiemetics, U+E monitoring, thiamine, anti-thrombotic stockings

387
Q

What is vulvar cancer?

A

a malignant growth that primarily affects the skin of the vulva - most commonly squamous cell carcinoma.

388
Q

What are the clinical features of vulvar cancer?

A
  • A lump with/wo lymphadenopathy
  • Vulval itching or discomfort
  • A non-healing ulcer
  • Vulval pain
  • thickening or changes in color of vulvar skin
  • Abnormal bleeding or discharge
389
Q

Ddx for vulvar cancer?

A
  • Lichen sclerosus
  • Bartholin’s cyst
390
Q

Investigations for vulvar cancer

A
  • Vulvar examination - then biopsy if suspected malignancy?
391
Q

Management for vulvar cancer

A

Simple: radical or local wide excision

Advanced: surgery + radiotherapy +/- chemo

392
Q

Define menorrhagia

A

Menorrhagia is excessive menstrual bleeding that significantly impacts a woman’s life.

393
Q

What are some causes of menorrhagia?

A

Local: endometriosis, adenomyosis, fibroids
Systemic: Bleeding disorders (e.g. VWB), hypothyroidism, obesity

394
Q

What are the key things to ask in a gynae history?

A

Age at menarche

Cycle length, days menstruating and variation

Intermenstrual bleeding and post coital bleeding

Contraceptive history

Sexual history

Possibility of pregnancy

Plans for future pregnancies

Cervical screening history

Migraines with or without aura (for the pill)

Past medical history and past drug history

Smoking and alcohol history

Family history

395
Q

What are differentials for menorrhagia?

A

Fibroids
Adenomyosis
Endometrial polyps
Endometrial can er

396
Q

What are the investigations for menorrhagia?

A
  • Pelvic exam - speculum and bimanual
  • Bloods - FBC for anaemia, coagulation screen, TFT
  • Swabs - infection
  • Hysteroscopy - if suspect submuscosal fibroids, endometrial cancer
  • Pelvic + transvaginal USS - large fibroids, adenomyosis
397
Q

What is the management for menorrhagia?

A

Non-hormonal:

  • Tranexamic acid (antifibrinolytic – reduces bleeding)
    -Mefenamic acid (NSAID – reduces bleeding and pain)

Hormonal:

  • Mirena coil (first line)
  • Combined oral contraceptive pill

Refer to secondary care if ineffective or fibroids > 3cm.

Surgery: Endometrial ablation or hysterectomy

398
Q

What microorganism causes chlamydia infection?

A

Chlamydia Trachomatis

399
Q

How is chlamydia infection transmitted?

A
  • Sexual contact
  • Vertical (mother to baby)
400
Q

What are the risk factors for chlamydia infection?

A
  • Under 25
  • New sexual partner
  • > 1 sexual partner/year
  • Not using condoms
401
Q

What are the clinical features of chlamydia in women?

A
  • 70% asymptomatic
  • dysuria,
  • pelvic pain
  • post coital/intermenstrual bleeding
402
Q

What are the clinical features of chlamydia in men?

A
  • 50% symptomatic
  • Urethral discharge
  • Dysuria
  • Testicular pain
403
Q

What are the complications that can arise from chlamydia?

A

Epididymo-orchitis
pelvic inflammatory disease (1-30%), infertility, ectopic pregnancies

404
Q

Investigation for chlamydia?

A
  • Nucleic acid amplification technique (NAAT) sensitivity 96-98%, specificity >95%
405
Q

Management for chlamydia?

A
  • Doxycycline 100mg BD for 7 days
  • Doxycycline contraindicated in pregnancy

Alternative regimens:
Azithromycin 1G OD day 1, 500mg OD day 2+3

Advice:

  • No sexual contact for 1 week
  • Contact tracing

Test of cure:

  • Retest in 3 months if under 25.
  • Test of cure (TOC) in 6 weeks if pregnant or rectal infection
406
Q

What causes gonorrhea infection?

A

Neisseria Gonorrhoea (gram-negative diplococcus)

Transmission: sexual contact, vertical

407
Q

What are the clinical features of gonorrhea infection in women?

A
  • 50% asymptomatic,
  • 50% mucopurulent discharge
  • pelvic pain (25%)
  • dysuria (12%)
408
Q

What are the clinical features of gonorrhea in men?

A

Asymptomatic (<10%)

Mucopurulent discharge (80%)

Dysuria (50%)

409
Q

What are the complications that can arise from gonorrhea infection?

A

Epididymo-orchitis in men, pelvic inflammatory disease in women

410
Q

What are the investigations for gonorrhea?

A
  • microscopy (sensitivity 90-95% if discharge present, 50% if not)
  • nucleic acid amplification technique (NAAT) sensitivity >96%
  • culture (important due to increasing antibiotic resistance with GC)
411
Q

What is the management for gonorrhea?

A
  • Ceftriaxone 1g IM (mixed with 3.5msl 1% lidocaine)
    ·
  • Ciprofloxacin 500mg PO stat FIRST-LINE where sensitivities available prior to treatment
412
Q

In addition to treatment, what advice would you give a patient who was diagnosed with gonorrhea?

A
  • No sexual contact for 1 week after patient and their partner are treated
  • PIL leaflet on condition
  • Health advisor for contact tracing.

Test of cure: 2 weeks after treatment

413
Q

What are the causes of non-sepcific urethritis (NSU)/non-gonorrheal urethritis?

A

Urethritis is inflammation of the urethra.

50% no cause found

45% chlamydia trachomatis

10-25% Mycoplasma genitalium

414
Q

What are the risk factors for NSU?

A
  • Sexually active, -
  • Unprotected sex
  • Homo/bisexual
  • Aged <35
  • Multiple partners
415
Q

Clinical features of NSU

A
  • Asymptomatic
  • Urethral discharge
  • Dysuria
416
Q

Investigations for NSU

A
  • Microscopy: gram stained urethral smear (diagnose if >5 pus cells per film)
  • Culture
  • First pass urine (FPU) to test for GC/CT and Mycoplasma
  • Urinalysis
    ·
  • MSU
417
Q

Management for NSU

A
  • Doxycycline 100mg BD 7 days

Advice:
- No sexual contact for 1 week after treatment for themselves and their partner

  • PIL leaflet on condition
  • Contact slip for partner notification
418
Q

What causes trichomoniasis infection (TV)?

A

Trichomonas vaginalis (TV) -flagellated protozoon

Transmission: sexual contact

Treatment:
· metronidazole 400mg PO BID x 7 days

Advice:
· no sexual contact for 1 week after patient and partner treated
· PIL on condition
· See health advisor for contact tracing
Test of cure:
· Only if pregnant as these is some evidence TV can cause pre-term birth

419
Q

What are the clinical features of TV in women?

A
  • Asymptomatic (10-50%)
  • Yellow frothy discharge
  • itching
  • Dysuria
  • Pelvic pain
  • Strawberry cervix on examination
420
Q

What are the clinical features of TV in men?

A
  • asymptomatic (15-50%), urethral discharge, dysuria, frequency
421
Q

Investigations for trichomonas

A
  • Charcoal swab from posterior fornix in females and examined under microscope
  • Urethral/first catch urine culture in males
422
Q

Management for trichomonoas

A
  • Metronidazole 400mg PO BID x 7 days

Advice:

  • No sexual contact for 1 week after patient and partner treated
  • PIL on condition
  • See health advisor for contact tracing

Test of cure:

  • Only if pregnant as these is some evidence TV can cause pre-term birth
423
Q

What is ovarian cancer?

A

Ovarian cancer is a malignancy originating from various cell types found within the ovary.

Most common is epithelial ovarian tumours.

424
Q

Risk factors for ovarian cancer

A

Exposure to unopposed oestrogen - HRT, obesity, numerous ovulations (early menarche/late menopause)

  • Older age
  • Smoking
  • BRCA genes.

Protective factors include:

Childbearing (parity)
Breastfeeding
Early menopause
Use of combined oral contraceptive pill (COCP)

425
Q

Types of ovarian cancer

A

Epithelial ovarian tumours

Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries

Germ cell tumours

Originate from the germ cells in the embryonic gonad

Sex cord cell tumours

Originate from connective tissue, less aggressive than epithelial cell tumours

426
Q

Ix for ovarian cancer

A

Initial

  • CA125 blood test (>35 IU/mL is significant)
  • Pelvic ultrasound

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:

  • Menopausal status
  • Ultrasound findings
  • CA125 level

Further investigations in secondary care include:

  • CT scan to establish the diagnosis and stage the cancer
  • Histology (tissue sample) using a CT guided biopsy
427
Q

Clinical features of ovarian cancer

A

Presents late in dosease:

  • Abdominal discomfort
  • Bloating
  • Early satiety
  • Urinary frequency or change in bowel habits

In later stages, the disease may cause:

  • Ascites (due to vascular growth factors increasing vessel permeability)
  • Pelvic, back and abdominal pain
  • Palpable abdominal or pelvic mass

If above, then 2WW

428
Q

Differential diagnosis for ovarian cancer

A
  • Fibroids
  • Ovarian cysts
  • Endometrial cancer
429
Q

Stages of ovarian cancer

A
  • Stage 1: Confined to the ovary
  • Stage 2: Spread past the ovary but inside the pelvis
  • Stage 3: Spread past the pelvis but inside the abdomen
  • Stage 4: Spread outside the abdomen (distant metastasis)
430
Q

What is the treatment of ovarian cancer?

A
  • Managed by gynaecology oncology MDT
  • Early disease: removal of the uterus, ovaries, Fallopian tubes
  • Adjuvant chemotherapy
431
Q

What causes bacterial vaginosis?

A

If vaginal pH >4.5, normal vaginal flora (lactobacilli) dominated by anaerobes, e.g., gardnerella vaginalis causing symptoms of bacterial vaginosis.

Not sexually transmitted

432
Q

What are the clinical features of bacterial vaginosis?

A
  • Asymptomatic (50%)
  • Thin white offensive smelling vaginal discharge (not associated with soreness, itching or irritation).
433
Q

Investigations for BV

A

Gram stained vaginal smear

  • Grade I (normal – only lactobacilli seen)
  • Grade II (intermediate – mixed flora, some lactobacilli present)
  • Grade III (bacterial vaginosis- few/no lactobacilli seen on slide)

Or charcoal HVS or self taken low-vaginal swab for microscopy

“Clue cells” on microscopy = BV, common MCQ

434
Q

Management for BV

A
  • If asymptomatic, no treatment needed. Might resolve spontaneously.
  • Abx of choice for anaerobic bacteria: Metronidazole orally or vaginal gel

Advice:

  • Written and verbal information on prevention e.g. washing only with water,avoiding soaps/shower gels/bubble bath, avoiding washing hair in bath
435
Q

What organism causes thrush?

A

Candida albicans (80-92%), not sexually transmitted

436
Q

What are the risk factors for thrush?

A
  • Uncontrolled diabetes mellitus
  • Immunosuppression
  • Hyperoestrogenaemia (including HRT and the COCP)
  • Broad-spectrum antibiotics
437
Q

What are the clinical features of thrush in women?

A
  • Vulval itch and soreness
  • Vaginal discharge (typically curdy, non-offensive)
  • Superficial dyspareunia
  • External dysuria
438
Q

Clinical features of thrush in men

A
  • Red skin, Swelling, irritation
  • Soreness and Itchiness
  • Phimosis (tight foreskin)
  • Dysuria
  • Dyspareunia

Chronic/ recurrent infection in men can lead to phimosis

439
Q

What are the investigations for thrush?

A
  • Routine microscopy
  • Microscopy, culture, and sensitivity (black charcoal swab)
440
Q

Management for genital thrush

A

Canesten duo OTC, contains

  • Clotrimazole pessary 500mg
  • Clotrimazole 2% vaginal cream

For men
- Clotrimazole 1% cream

Advice: wash only with water, avoid bubble baths/shower gels, wear cotton underwear.

441
Q

What causes both genital and oral herpes?

A

Herpes simplex virus (HSV)

  • HSV type 1- the usual cause of oral herpes (cold sores)
  • HSV type 2- historically associated with sexual transmission

(note either type can cause both oral and genital herpes)

442
Q

What is the pathophysiology of HSV infection?

A

HSV is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions.

Viral shedding and transmission can occur even if an individual is asymptomatic.

Following primary infection, virus becomes latent in sensory ganglia, periodically reactivating to cause symptomatic lesions or asymptomatic viral shedding

443
Q

What are the clinical features of genital herpes?

A
  • Asymptomatic (80%)
  • Painful blisters and ulcers,
  • Dysuria
  • Tender inguinal lymphadenitis
  • Discharge, fever, myalgia
444
Q

Complications of HSV infection?

A

Urinary retention, aseptic meningitis, adhesions

445
Q

Investigations for HSV infection

A

Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms.

Clinical diagnosis through history and examination

  • HSV DNA detection by PCR
  • Sites to be sampled by swab: base of ulcer
446
Q

Management of genital herpes

A
  • Primary herpes - Aciclovir 400mg TDS for 5 days, topical anaesthetic agents e.g. Instillagel prn.
  • Recurrences of herpes – Aciclovir 800mg TDS for 2 days
  • If >6 outbreaks a year consider suppressive therapy with Aciclovir 400mg BD for 12 month
  • Hospitalisation if urinary retention for catheterisation.
447
Q

What causes genital warts?

A

Human papillomavirus (HPV)

Transmission: skin to skin contact

448
Q

What are the clinical features of genital warts?

A
  • Most asymptomatic
  • Can appear from 3 weeks to years after exposure to the virus
  • More common in pregnancy due to immune suppression
  • Fleshy lumps, itching, distorted flow of urine if present in urethra
449
Q

What is the management for genital warts?

A
  • Podophyllotoxin (Warticon) - antiviral cream
  • Imiquimod (Aldara): stimulate local immune response
  • Cryotherapy : three freeze thaw cycles weekly
450
Q

What causes syphilis infection?

A
  • Treponema pallidum: Gram -ve spirochete
  • Transmission: sexual, vertical
451
Q

What are the different stages of syphilis infection?

A
  • Primary
  • Secondary
  • Early latent
  • Late latent
  • Tertiary
  • Neurosyphilis - infection of the CNS with neuro symptoms. Ary
452
Q

What are the clinical features of primary syphilis infection?

A

Chancre - painless ulcer develops at site of invasion, 10-90 days post-exposure

453
Q

What are the clinical features of secondary syphilis infection?

A
  • Maculopapular rash on trunk, palms and soles
  • Generalised adenopathy
  • Condylomata lata (lesions - secondary manifestation of syphilis)
  • Snail track ulcers
  • Moth-eaten alopecia
454
Q

What are the clinical features of early/late latent syphilis infection?

A

Asymptomatic

Early = within 2 years of infection

Late = after 2 years

455
Q

What are the clinical features of tertiary syphilis infection?

A

Cardiovascular

  • Aortic incompetence, LVH, aneurysms

Gummatous lesions:

  • Chronic painless nodules that break down into ulcers which heal slowly, osteitis
456
Q

What is neurosyphilis?

A

Complication of syphilis: can occur at any time and include meningitis, optic neuritis, sensorineural hearing loss.

Specific pupil sign - Argyll-Robertson pupil - a constricted pupil that accommodates when focusing on a near object but does not react to light.

(Prostitute pupil because “it accommodates but does not react”)

457
Q

Investigations for syphilis

A

Screening: antibody testing - treponemal EIA, TPPA

Samples from sites of infection tested via:

  • Darkfield microscopy
  • Polymerase chain reaction (PCR)

The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) = non-specific but sensitive.

Detects number of antibodies againist syphilis infection, higher numbers = greater chance of active infection

458
Q

Management for syphilis

A

Early: Benzathine penicillin G stat IM single dose

Late: IM Pen G for 2 to 3 weeks

Neurosyphilis = IV pen G 10 - 14 days

Penicillin allergy = doxycycline or tetracycline

459
Q

Follow-up for syphilis

A
  • At 3, 6, 12 months
  • Discharge if adequate response
  • if indicated, six monthly until VDRL negative
  • 4x or higher increase in VDRL titre = reinfection or treatment failure = retreatment
460
Q

What causes HIV infection?

A

Retrovirus human immunodeficiency virus (type 1 and type 2) - type 1 most common

Transmission: any sexual contact, needle sharing, needle stick injury, vertical, blood transfusion

461
Q

What are the stages of HIV infection?

A
  1. acute infection: often asymptomatic
  2. seroconversion (2-6 weeks post exposure): myalgia, fever, rash, severe sore throat
  3. Asymptomatic phase: loss of CD4 cells, persistent generalised lymphadenopathy (30%)
  4. AIDS: CD4 count <200 x 106/L, fatal if untreated
462
Q

Investigations for HIV

A
  • Point of care test for HIV antibody, window period of 90 days, so retest after 90 days post unprotected sex
  • Blood sample for type 1 and type 2 HIV antigen/antibody - window period of 45 days, retest 7 weeks after unprotected sex
  • If +ve HIV test, need repeat test to confirm the diagnosis
463
Q

Monitoring for HIV

A

CD4 count and viral load (aim is undetectable viral load)

464
Q

Management for HIV

A
  • HAART (highly active anti-retroviral therapy)
  • Recommendations to begin HAART at point of diagnosis
  • NRTIs (nucleoside analogue reverse transcriptase inhibitors)
  • PI (protease inhibitor)
  • NNRTIs (non- nucleoside analogue reverse transcriptase inhibitors)
  • Integrase inhibitors
465
Q

Give some examples of AIDS-defining illness

A

These illnesses are associated with end-stage HIV, when the CD4 count is so low that it allows for unusual opportunistic infections and malignancies to appear:

  • Kaposi’s sarcoma
  • Pneumocystis jirovecii pneumonia (PCP - fungal)
  • Cytomegalovirus infection
  • Candidiasis (oesophageal or bronchial)
  • Lymphomas
  • Tuberculosis
466
Q

Describe the pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV

A

PEP (post exposure prophylaxis):

  • 28-day course of anti-retroviral drugs to prevent HIV, must be given within 72 hours of exposure otherwise not effective

PrEP (Pre-Exposure Prophylaxis):

  • Anti-retroviral therapy for MSM at high risk of HIV transmission, aims to reduce transmission
  • Given as event-based or daily treatment with single tablet co-formulation Tenofovir/Emtricitabine
467
Q

How is hepatitis B transmitted?

A

Transmission: Sexual transmission, parenteral (blood, blood products, IVDUs), vertical

Incubation period: 40-160 days

468
Q

What are the clinical features of hepatitis B?

A
  • Asymptomatic in 10-50% of adults in the acute phase – especially if HIV +ve
  • Most people fully recover from the infection within 1-3 months.
  • 5-15% become chronic hepatitis B carriers, usually asymptomatic – may have fatigue, loss of appetite
469
Q

Investigations for hepatitis B

A

Serology

  • HBV surface antigen (HBsAg)- active infection
  • Surface anti-body (HBsAb) – implies vaccination or past or current infection as HBsAg given in vaccination
  • Core antibodies (HBcAb) – implies past or current infection
470
Q

Management for hep B

A
  • Acute phase: rest, hydration, admission to hospital if severely unwell
  • Chronic infection may require anti-viral treatment via specialist clinic

Advice:
- Avoid unprotected sexual contact until patient is non-infectious/partners successfully vaccinated)

  • Hep B is a notifiable disease
  • Contact tracing to include any sexual contact or needle sharing during infectious period
471
Q

Vaccinations for hep B

A

Engerix B 1ml

  • Routine (0,1,6 months)
  • Super accelerated course (0,7,21 days + 1 yr booster) for sexual assault/recent high-risk exposure

Check Hep B sAb 8 weeks after last vaccine, if >10 then immune, if <10, need repeat course/booster and recheck

472
Q
A
  • Fulminant hepatitis (< 1%) - liver failure
  • Chronic infection i.e. >6 months (5-10%)
  • If pregnant: risk of miscarriage/premature labour in acute infection
473
Q

Describe the transmission routes and incubation period for hepatitis C

A

Transmission: Parenteral, vertical, rarely sexually transmitted (<1%)

Incubation: 4-20 weeks, serology is usually positive 3 months after exposure but can take up to 9 months

474
Q

Clinical features of hep C

A

Similar to hep B, about 60% are asymptomatic

475
Q

Complications of hep C

A
  • 50-85% become chronic carriers
  • Severe liver disease (30%), hepatocellular carcinoma, - Pregnancy – miscarriage and pre-term birth risks
476
Q

Who should be screened for hep C?

A
  • Sex workers,
  • IVDU
  • Victims of sexual assault
  • HIV +ve MSM (and their partners),
  • Born outside of W Europe/Australia/ North America
  • Blood transfusions, tattoos, piercings, acupuncture, dental procedures done abroad
477
Q

Investigations for hep C

A
  • Hepatitis C antibody is the screening test
  • Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate the viral load and identify the genotype
478
Q

Management for hep C

A

Refer to gastro/hepatology for treatment and for counselling on transmission (not to donate blood/tissues/semen), and alcohol abstinence.

No vaccine for hep C.

479
Q
A
480
Q

What is vasa praevia?

A

Vasa praevia is an obstetric emergency where foetal vessels run near or across the internal cervical os, placing them at risk of rupture during membrane rupture.

481
Q

3 cardinal features of vasa praevia?

A
  • Painless vaginal bleeding
  • Rupture of membranes
  • Foetal bradycardia or death
482
Q

How is vasa praevia diagnosed?

A

Antenatal diagnosis with transabdominal or transvaginal ultrasonography

483
Q

Management for vasa praevia

A

Elective caesarean section before ROM, around 35-36 weeks of gestation.

Emergency caesarean section if mother goes into labour or ROM

484
Q

Drugs to avoid during breastfeeding

A

LAMBAST

  • Lithium
  • Amiodarone
  • Methotrexate
  • Benzodiapizines
  • Aspirin
  • Sulfonamides
  • Tetracyclines
485
Q

What treatment is given to a newborn baby if mum has hepatitis B

A

HBV IgG and HBV vaccination within 24 hours of delivery

486
Q

Describe breast anatomy

A
  • Breasts sits in front of the chest wall
  • Made up of mostly adipose tissue
  • The areola surrounds the nipple
  • Behind the nipples are the ducts, which leads into the lobules where breast milk is produced
487
Q

Differentials of breast lump

A
  • Most significant: breast cancer
  • Fibroadenoma
  • Fibrocystic breast changes
  • Breast cysts
  • Fat necrosis
  • Lipoma
  • Galactocele
488
Q

What is triple assessment for breast cancer?

A

Triple assessment is standard practice to exclude or diagnose breast cancer:

  • Clinical assessment (history and examination
  • Imaging (USS or mammogram)
  • Histology (fine needle aspiration or core biopsy
489
Q

Clinical features that suggest breast cancer

A
  • Hard, irregular, painless lumps that are fixed in place
  • Lumps tethered to the skin or chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
  • Lymphadenopathy especially in the axilla
490
Q

When should a patient be referred for a two week wait referral for suspected breast cancer?

A
  • An unexplained breast/axillary lump aged ≥ 30
  • Unilateral nipple changes in patients aged ≥ 50 (discharge, retraction or other changes)
  • Skin changes suggestive of breast cancer
491
Q

Risk factors for breast cancer

A
  • Female (99% of breast cancers)
  • Increased oestrogen exposure (earlier onset of periods and later menopause)
  • More dense breast tissue (more glandular tissue)
  • Obesity
  • Smoking
  • Family history (first-degree relatives)
  • HRT
492
Q

Genes associated with increased risk of breast cancer

A

BRCA = BReast CAncer gene

BRCA1 and 2 = tumour suppressor genes

Mutations = increased breast and ovarian cancer risk

493
Q

Risks associated with mutations in the BRCA1 gene

A
  • 70% breast cancer by 80
  • 50% ovarian cancer
  • Increased bowel and prostate cancer risk
494
Q

Risks associated with BRCA2 mutation

A
  • 60% breast cancer by age 80
  • 20% ovarian cancer
495
Q

Types of breast cancer

A
  • Ductal carcinoma in situ (DCIS)
  • Lobular Carcinoma in situ (LCIS)
  • Invasive Ductal Carcinoma
  • Invasive lobular carcinoma (ILC)
  • Inflammatory breast cancer
  • Paget’s Disease of the Nipple
496
Q

Define Ductal Carcinoma In Situ (DCIS)

A
  • Pre-cancerous or cancerous epithelial cells of the breast ducts
  • Localised to a single area
  • Often picked up by mammogram screening
  • Potential to spread locally over years
  • Potential to become an invasive breast cancer (around 30%)
  • Good prognosis if full excised and adjuvant treatment
497
Q

Define lobular carcinoma in situ (LCIS)

A
  • Pre-cancerous condition in typically pre-menopausal women
  • Asymptomatic and undetectable on mammogram
  • Incidental detected on breast biopsy
  • Increased risk of breast cancer (30%)
  • Managed with close-monitoring (6 monthly exams and yearly mammograms)
498
Q

Define invasive ductal carcinoma - NST

A
  • NST = no special/specific type
  • Originates in cells from the breast ducts
  • Most invasive breast cancers are this type
  • Seen on mammograms
499
Q

Define inflammatory breast cancer

A
  • 1-3% of breast cancers
  • Presents similarly to a breast abscess or mastitis
  • Swollen, warm, tender breast with pitting skin (peau d’orange)
  • Does not respond to antibiotics
  • Worse prognosis than other breast cancers
500
Q

Define Paget’s Disease of the Nipple

A
  • Looks like eczema of the nipple/areolar
  • Erythematous, scaly rash
    Indicates breast cancer involving the nipple
  • May represent DCIS or invasive breast cancer
  • Requires biopsy, staging and treatment, as with any other invasive breast cancer
501
Q

Screening programme for breast cancer

A

Mammogram every 3 years for women aged 50 to 70 years in the UK

502
Q

Which patients are considered high-risk for breast cancer?

A
  • A first-degree relative with breast cancer, diagnosed under 40, or bilateral breast cancer under 50
  • Two first-degree relatives with breast cancer
  • Referral to secondary care breast clinic or specialist genetic clinic
  • Genetic counselling
503
Q

Types of imaging for breast cancer

A
  • Young women generally have more dense breasts with more glandular tissue
  • USS in young women, good at differentiating solid vs cystic lumps (e.g. under 30 years old)
  • Mammograms more effective in older women, calcification missed by USS
504
Q

Management of high-risk patients for breast cancer

A
  • Annual mammogram
  • Chemoprevention (Tamoxifen if premenopausal or Anastrozole if postmenopausal)
  • Risk reducing bilateral mastectomy or bilateral oophorectomy (removing ovaries)
505
Q

Define fibroadenoma

A

Common benign tumours of stromal/epithelial breast duct tissue

Small and mobile (breast mouse)

Common in younger women (20 - 40) as responds to oestrogen and progesterone

506
Q

How would fibroadenoma present on examination?

A
  • Painless
  • Smooth
  • Round
  • Well-circumscribed
  • Firm
  • Mobile
  • ≤3cm
507
Q

What are fibrocystic breast changes?

A

Variation of normal and not considered a disease.

The connective tissues (stroma), ducts and lobules of the breast responds to oestrogen and progesterone and becomes fibrous and cystic - fluctuates with the menstrual cycle

508
Q

Symptoms of fibrocystic changes of the breast

A
  • Lumpiness
  • Breast pain or tenderness (mastalgia)
  • Fluctuation of breast size
  • Symptoms occur before menstruating (within 10 days) and resolve after menstruation
509
Q

Management of fibrocystic breast changes

A
  • Exclude cancer
  • Wear supportive bra
  • NSAIDs e.g. ibuprofen
  • Avoid caffeine
  • Apply heat
510
Q

Define breast cysts

A
  • Benign, individual and fluid-filled lumps
  • Most common cause of breast lumps, 30 - 50
  • Can be painful
  • Might fluctuate in size over the menstrual cycle
511
Q

How would breast cysts present on examination?

A
  • Smooth
  • Well-circumscribed
  • Mobile
  • Possibly fluctuant
512
Q

Investigations for breast cysts

A
  • Might increase the risk of breast cancer
  • Need assessment to exclude cancer - imaging, aspiration or excision
513
Q

What is fat necrosis of the breast?

A

They are localised degeneration and scarring of the fat tissue in the breast that cause a benign lump.

514
Q

What causes fat necrosis?

A
  • Oil cysts (contains liquid fat)
  • Localised trauma
  • Radiotherapy
  • Surgery

This triggers an inflammatory reaction with fibrosis and necrosis of fat tissue.

515
Q

How does fat necrosis present on examination?

A
  • Painless
  • Firm
  • Irregular
  • Fixed in local structures
  • Might be skin dimpling or nipple inversion
516
Q

Investigations for fat necrosis

A
  • Exclude breast cancer
  • Ultrasound or mammogram shows similar appearance to breast cancer

Histology (fine needle aspiration or core biopsy) to confirm diagnosis

517
Q

Management for fat necrosis

A
  • After excluding breast cancer, treat conservatively, might resolve spontaneously over time
  • Surgical excision if needed
518
Q

What are lipoma of the breast?

A
  • Benign tumours of adipose tissue
  • They can occur anywhere on the body with adipose tissue
519
Q

On examination: lipoma

A
  • Soft
  • Painless
  • Mobile
  • Do not cause skin changes
520
Q

Management of lipoma

A
  • Conservative treatment with reassurance
  • Surgical removal if needed
521
Q

What is a galactocele?

A

Galactoceles occur in women that are lactating, often after stopping breastfeeding

Breast milk-filled cysts that occur with a lactiferous duct is blocked

522
Q

Presentation of galactocele

A
  • Firm, mobile, painless lump usually under the areola
523
Q

Management of galactocele

A
  • Benign and usually resolves without any treatment
  • Drain with needle
  • They can become infected and require antibiotics
524
Q

Most common sites that breast cancers metastasise to

A

2Ls , 2Bs

  • L – Lungs
  • L – Liver
  • B – Bones
  • B – Brain
525
Q

Different types of breast cancer receptors

A
  • Breast cancer cells can have receptors that can be targeted with breast cancer treatment
  • Oestrogen receptors (ER)
  • Progesterone receptors (PR)
  • Human epidermal growth factor (HER2)

Triple-negative = do not have any of the receptors

526
Q

Management for breast cancer

A
  • MDT involvement
  • Surgery
  • Chemo/Radiotherapy
  • Hormone therapy
527
Q

Surgery options for breast cancer

A
  • Breast-conserving (wide local excision) usually with radiotherapy
  • Mastectomy
  • Axillary clearance of lymph nodes (causes chronic lymphoedema)
528
Q

Hormone treatment options in breast cancer

A

Oestrogen-receptor positive:

  • Tamoxifen for premenopausal women - blocks oestrogen receptors in breast tissue and stimulates oestrogen receptors in the uterus and bones (prevents osteoporosis but increases risk of endometrial cancer)
  • Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole) - aromatase converts androgen to oestrogen, main source of oestrogen in fat tissue after menopause

REMEBER THEM

529
Q

Targeted treatments for HER2 positive breast cancer

A

Trastuzumab (Herceptin)

Pertuzumab (Perjeta) combined with Trastuzumab

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers.

530
Q

Follow-up for patients treated for breast cancer

A
  • Surveillance mammograms yearly for 5 years
  • Individual care plans
531
Q

Types of reconstructive surgery for patients receiving a mastectomy

A
  • Immediate reconstruction
  • Delayed reconstruction
  • Breast implants or flap reconstruction (using tissue from another part of the body)
532
Q

Define mastitis

A

Inflammation of the breast tissue and is a common complication of breastfeeding, it can occur with or without associated infection

533
Q

Cause of mastitis

A

Obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent blockage

534
Q

Presentation suggestive of mastitis

A
  • Painful breast
  • Fever and/or general malaise
  • A tender, red, swollen, and hard area of the breast, usually in a wedge-shaped distribution

Features indicating infection (hard to tell):

  • Nipple fissure that looks infected
  • Purulent discharge
  • Symptoms not improving after 12 - 24 hours
535
Q

Investigations for mastitis

A

If infection suspected, then a sample of milk sent for culture and sensitivities.

536
Q

Management of mastitis

A

If caused by duct blockage, then conservative:

  • Continued breastfeeding
  • Expressing milk
  • Breast massage
  • Heat pack
  • Simple analgesia
  • Warm showers

If ineffective or suspected infection then:

  • Flucloxacillin
  • Erythromycin if penicillin allergy
537
Q

What is a possible complication of mastitis?

A

Breast abscess, which might require surgical incision and drainage

538
Q

What is candida of the nipple?

A

Yeast infection that can occur often after a course of antibiotics for mastitis.

It can cause recurrent mastitis.

539
Q

Presentation of candida of the nipple

A
  • Sore nipples bilaterally, particularly after feeding
  • Nipple tenderness and itching
  • Cracked, flaky or shiny areola
  • Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
540
Q

Treatment for candida of the nipple

A

Both the mother and baby need treatment

  • Topical miconazole 2% after each breastfeed
  • Treatment for the baby (e.g. miconazole gel or nystatin)
541
Q

Define breast abscess

A

A collection of pus within an area of the breast, usually caused by a bacterial infection:

  • Lactational abscess
  • Non-lactational abscesses
542
Q

Risk factors for infective mastitis and breast abscesses

A
  • Key risk factor: smoking
  • Damage to the nipple provides bacterial entry
  • Breast disease e.g. cancer can affect drainage of the breast
543
Q

Infective organisms that cause infection of the breast

A
  • Most common is staphylococcus aureus
  • Streptococcal species
  • Enterococcal species
  • Anaerobic bacteria
544
Q

Presentation of breast abscesses

A
  • Acute onset (within a few days)
  • History of recent mastitis or prior breast abscess
  • Fever and/or malaise that might have subsided if abx for infective mastitis
  • Painful, swollen lump in the breast with redness, heat and swelling of overlying skin
  • Key feature on examination = swollen, fluctuant, tender lump within the breast
545
Q

Management of breast abscess

A
  • Referral to hospital on-call surgical team for
  • USS confirmation
    Drainage with needle aspiration or surgical incision and drainage
  • Microscopy, culture and sensitivities
  • Antibiotics (need to learn)
  • Continue breastfeeding or express milk
546
Q

Antibiotics for breast abscess

A
  • Gram-positive (staph aureus, streptococcal and enterococcal) = penicillin
  • Flucloxacillin for staph aureus skin condition (remember this!)
  • Anaerobic bacteria = co-amoxiclav +/- metronidazole
547
Q

Define intraductal papilloma

A

A warty lesion that grows within one of the ducts in the breast

Results from proliferation of epithelial cells

Non-cancerous but associated with atypical hyperplasia or breast cancer

548
Q

Presentation of intraductal papillomas

A
  • Peak between 35 - 55 of age
  • Often asymptomatic, incidental finding on mammogram or USS
  • Nipple discharge (clear or blood-stained)
  • Tenderness or pain
  • A palpable lump
549
Q

Diagnosis of intraductal papilloma

A

Triple assessment to exclude cancer:

  • Clinical assessment (history and examination)
  • Imaging (ultrasound, mammography and MRI)
  • Histology (core biopsy or vacuum-assisted biopsy)
550
Q

Management of intraductal papillomas

A

Complete surgical excision, and then the removed tissue is examined for atypical hyperplasia or cancer that the biopsy might have missed

551
Q
A
552
Q

Mnemonic to remember blood results in Downs Syndrome

A

HIT APE

H - HCG
I - Inhibin A
T - Thickened nuchal translucency

Down:
A - AFP
P - PAPP-A
E - Estriol

553
Q

Define Polycystic Ovarian Syndrome (PCOS)

A

PCOS is a common condition in women, causing metabolic and reproductive problems.

Characteristic features include:

  • Multiple ovarian cysts
  • Infertility
  • Oligomenorrhoea
  • Hyperandrogenism
  • Insulin resistance
554
Q

Rotterdam Criteria for PCOS

A

Common exam question!

Rotterdam criteria used for making dx of PCOS, diagnosis if two out of three criteria met:

  • Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
  • Hyperandrogenism - characterised by hirsutism (thick black hair growth in a male pattern) and acne
  • Polycystic ovaries on USS or ovarian volume of > 10cm3
555
Q

Key presenting features in PCOS

A
  • Oligomenorrhoea or amenorrhoea
  • Infertility
  • Obesity (in about 70% of patients with PCOS)
  • Hirsutism
  • Acne
  • Hair loss in a male pattern

Other features:

  • Insulin resistance and diabetes
  • Acanthosis nigricans (thickened, rough skin typically in body folds, associated with insulin resistance)
556
Q

Differentials of hirsutism

A
  • Medications e.g. corticosteroids
  • Ovarian or adrenal tumours that secrete androgens
  • Cushing’s syndrome
557
Q

Describe the pathophysiology of insulin resistance in PCOS

A

Insulin resistance is major part of PCOS

When the body is insulin-resistant, the pancreas has to produce more insulin to stimulate response from cells.

Insulin promotes release of androgens from ovaries and adrenal glands, so insulin resistance = higher androgen (e.g. testosterone) levels.

Therefore, high levels of insulin contributes to halting follicle development in the ovaries = anovulation and multiple partially developed follicles (polycystic ovaries on scan)

558
Q

Investigations for PCOS

A

NICE guidelines recommend the following bloods:

  • Testosterone
  • Sex hormone-binding globulin (suppresses androgen function)
  • Luteinizing hormone
  • Follicle-stimulating hormone
  • TSH
559
Q

Blood test results in PCOS

A

TOM TIP: key to remember for exams is raised LH and raised LH:FSH ratio

  • Raised luteinising hormone
  • Raised LH to FSH ratio (high LH compared with FSH)
  • Raised testosterone
  • Raised insulin
  • Normal or raised oestrogen levels
560
Q

Gold standard investigation for PCOS

A

Transvaginal ultrasound, the follicles might be arranged around the ovary - “string of pearls” appearance

Dx criteria either:

  • 12 or more developing follicles in one ovary
    OR
  • Ovarian volume of more 10cm3

Also, test for diabetes using oral glucose tolerance test

560
Q

When to initiate investigations for infertility?

A

If the couple has been trying for 12 months without success. 6 months if woman is over 35 as ovarian reserves will be reduced.

561
Q

Management of PCOS

A

Quesmed

Conservative - weight loss, exercise, healthy diet, education on increased CVD, diabetes and endometrial cancer risk

Medical if not planning pregnancy

  • Co-cyprindol: reduces hirsutism and promotes regular menstruation
  • COCP: regulates menstrual cycle, protection against endometrial cancer
    meno
  • Metformin: helps regulate menstruation, reducing hirsutism and acne

Medical if planning pregnancy

  • Clomiphene - induces ovulation
  • Metformin - improves chance of pregnancy. Alone or with clomiphene

Gonadotrophins - if above ineffective

561
Q

Causes of infertility

A
  • Sperm problems (30%)
  • Ovulation problems (25%)
  • Tubal problems (15%)
  • Uterine problems (10%)
  • Unexplained (20%)
  • 40% of infertile couples have a mix of male and female causes.
562
Q

Causes of infertility

A
  • Sperm problems (30%)
  • Ovulation problems (25%)
  • Tubal problems (15%)
  • Uterine problems (10%)
  • Unexplained (20%)
  • 40% of infertile couples have a mix of male and female causes.
563
Q

General lifestyle advice for infertility

A
  • 400mcg folic acid daily
  • Healthy BMI
  • Avoid smoking and drinking
  • Avoid stress
  • Intercourse every 2 to 3 days
  • Avoid timing intercourse

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