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Fifth Year Medicine > Obstetrics and Gynaecology > Flashcards

Obstetrics and Gynaecology Flashcards

1
Q

What is a bartholin abscess?

A

Acute infection of the bartholin gland duct by bacteria.

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2
Q

What is a bartholin cyst?

A

Chronic swelling after previous acute infection.

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3
Q

What is the management of a bartholin abscess?

A

Broad spectrum antibiotics.

Marsupialisation with general anaesthetic or word catheter with local anaesthetic.

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4
Q

What are the symptoms of lichen sclerosus?

A

Itching
Excoriation
Pain
Dyspareunia

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5
Q

How is lichen sclerosus diagnosed?

A

Usually clinical diagnosis.

Biopsy if unsure or suspicious areas.

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6
Q

What is the treatment for lichen sclerosus?

A

Topical steroid treatment.

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7
Q

Which virus usually causes genital herpes?

A

HSV-2

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8
Q

What is the appearance of genital herpes?

A

Painful vesicular rash
Dysuria
Dyspareunia

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9
Q

What is the management of genital herpes?

A

Oral aciclovir 400mg TID 5-10 days

Self care measures:
Oral analgesia
Apply salt water to help prevent infection and promote healing .
Vaseline or lidocaine 5% to help with painful micturition.
Increase fluid intake for dilute urine.
Urinate in bath to reduce stinging.

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10
Q

What is cervical ectropian?

A

Columnar cells from canal everted to cervix.

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11
Q

What are the symptoms of cervical ectopy?

A

Usually asymptomatic.
May get chronic discharge.
May get post-coital bleeding.

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12
Q

What is the treatment for cervical ectropian?

A

Cautery, cryotherapy or AgNO3, only if symptomatic.

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13
Q

What are the symptoms of cervical polyps?

A

Usually no symptoms

May be post-coital bleeding or post menopausal bleeding.

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14
Q

What are uterine fibroids?

A

Benign tumours of the myometrium.

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15
Q

Which different sites can fibroids be found?

A

Sub-mucosal
Intramural
Sub-serosal

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16
Q

What does the growth of fibroids depend on?

A

Oestrogen:

Grow during pregnancy, shrink after menopause.

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17
Q

Who gets fibroids?

A

70-80% of fifty year olds.

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18
Q

What are the symptoms of fibroids?

A 
Heavy menstrual bleeding
Abdominal swelling
Pressure symptoms (e.g. ureteric obstruction)
Subfertility
Difficulties in pregnancy
Pain (rare) - torsion or degeneration.
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19
Q

What are the signs of fibroids?

A

Abdominal or pelvic mass

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20
Q

How are fibroids diagnosed?

A

Clinical suspicion
Confirm by ultrasound
MRI to plan patient management.

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21
Q

How are fibroids managed?

A

Usually conservative management.
Medical management: - to control symptoms e.g. HMB
- prior to surgery e.g. GnRH analogues, uipristal acetate.

Surgical management:
Hysterectomy
Myomectomy (only to preserve fertility)

Uterine artery embolization

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22
Q

What are the symptoms of endometrial polyps?

A

Post menopausal bleeding.
Inter-menstrual bleeding.
Heavy menstrual bleeding.

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23
Q

How are endometrial polyps diagnosed?

A

May be suspected by transvaginal ultrasound.
Hysteroscopy
Histology

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24
Q

What is the treatment for polyps?

A

Usually hysteroscopy and polypectomy

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25
Q

What is pelvic inflammatory disease?

A

Ascending infection from cervix e.g. salpingitis, tubo-ovarian abscess

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26
Q

What causes pelvic inflammatory disease?

A

Chlamydia
Gonorrhoea
E coli
Anaerobes

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27
Q

What are the complications of pelvic inflammatory disease?

A

Infertility (20%)
Ectopic pregnancy (10%)
Chronic pelvic pain (20%)

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28
Q

What are the symptoms of pelvic inflammatory disease?

A 
Symptomless in 65%
Anorexia and general malaise
Lower abdominal pain (bilateral, acute abdomen if abscess)
Deep dyspareunia
Variable discharge (often purulent)
Post coital bleeding 
Intermenstrual bleeding
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29
Q

What are the signs of pelvic inflammatory disease?

A 
Pyrexia
Tachycardia
Abdominal distension and tenderness
Rebound and guarding
RUQ tenderness
Very tender on vaginal examination
Sepculum - discharge
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30
Q

What are the investigations of pelvic inflammatory disease?

A

Urine pregnancy test (PID rare with intrauterine pregnancy)
FBC + CRP (WCC and CRP raised in severe disease)
MSU (exclude UTI)
Swabs (chlamydia, GC, anaerobes)
Transvaginal ultrasound (tubo-ovarian abscess)
Laparoscopy (if diagnosis uncertain)

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31
Q

What is the management of pelvic inflammatory disease?

A

Empirical antibiotics: ceftriaxone 500mg IM stat, then oral doxycycline 100mg BD + metronidazole 400mg BD both for 14 days.

Pain relief - ibuprofen or paracetamol

Refer to GU medicien to screen for other infections and contact tracing.

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32
Q

What is hydrosalpinx?

A

A condition in which the fallopian tube becomes blocked and filled with fluid, often becomes distended.

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33
Q

What are the symptoms of hydrosalpinx?

A

Usually none after acute infective phase.
Occasional pelvic pain
Often subfertilitly/infertility.

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34
Q

How is hydrosalpinx diagnosed?

A

May be suspected by transvaginal ultrasound.
Laparoscopy
Hysterosalpingogram

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35
Q

What is the treatment for hydrosalpinx?

A

If symptoms free - conservative.
If pelvic pain - bilateral salpingectomy
If infertility - IVF, usually after salpingectomy

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36
Q

What are the types of ovarian cyst?

A

Functional cyst
Dermoid cyst
Epithelial cyst
Endometriotic cyst

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37
Q

What are the clinical features of ovarian cysts?

A

None
Pain
Abdominal or pelvic swelling

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38
Q

How are ovarian cysts diagnosed?

A

Ultrasound or CT or MRI

CA125 and other markers (CEA, aFP, hCG)

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39
Q

What is the management of ovarian cysts?

A

If symptom free and <6cm, conservative.

Usually remove if >6cm and/or symptomatic

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40
Q

How are ovarian cysts removed?

A

Ovarian cystectomy or oopherectomy.
Laparoscopic if possible, or open.
Histology essential.

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41
Q

What are the types of functional ovarian cyst?

A

Follicular
Luteal

Both related to menstrual cycle and usually resolve in 6-12 weeks.

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42
Q

What is a benign cystic teratoma also known as?

A

A dermoid cyst

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43
Q

What do dermoid cysts often contain?

A

Hair
Bone
Teeth

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44
Q

How are dermoid cysts diagnosed?

A

Ultrasound +/- CT

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45
Q

What is the management of a dermoid cyst?

A

Ovarian cystectomy or oophorectomy

Laparoscopic or open

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46
Q

What are the types of epithelial ovarian cysts?

A

Serous or mucinous cystadenomas.

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47
Q

What are the symptoms of an epithelial ovarian cyst?

A

Abdominal swelling

Pain (torsion)

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48
Q

What are the investigations of an ovarian cyst?

A

Imaging - US, CT/MRI

Tumour markers - esp. CA125

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49
Q

What is the management of epithelial ovarian cysts?

A

Surgical - usually open.

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50
Q

What are the complications of cysts?

A

Torsion
Rupture
Haemorrhage
Infection

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51
Q

What are the signs and symptoms of a complication with a cyst?

A

Lower unilateral abdominal pain

Abdominal and perivaginal tenderness.

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52
Q

What are the investigations of a cyst ‘accident’?

A 
Pregnancy test
MSU to rule out UTI
Vaginal/cervical swabs - ?PID
FBC and CRP
CA125
TV ultrasound
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53
Q

What is the management of a cyst ‘accident’?

A

Oophorectomy or salpingo-oophorectomy

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54
Q

What is endometriosis?

A

An oestrogen-dependent benign
inflammatory disease characterised by
ectopic endometrium, often
accompanied by cysts & fibrosis.

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55
Q

What are the causes of endometriosis?

A

Uncertain - several theories.
Heritable component.
Retrograde menstruation plays a part.

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56
Q

What are the three types of endometriosis?

A

Superficial peritoneal lesions (minimal and mild)
Deep infiltrating lesions (moderate and severe)
Ovarian cysts (endometriomas)

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57
Q

How common is enddometriosis?

A

1.5-15% of women

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58
Q

How is endometriosis diagnosed?

A

May be suspected from history and VE.
TVU helpul.
CA125 often raised.
Laparoscopy and biopsy only reliable investigation.

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59
Q

What are the symptoms of endometriosis?

A

Dysmenorrhoea
Dyspareunia
Pelvic pain
Subfertility

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60
Q

What are the signs of endometriosis?

A

Fixed, tender, retroverted uterus

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61
Q

What is the management for endometriosis?

A

If symptom free - conservative.
Medical for symptom relief - NSAIDs, progestogens, COCP, mirena
Prior to surgery - GnRH analogues
Definitive treatment is surgical - cautery if mild, ovarian cystectomy if endometrioma
If infertility - IVF

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62
Q

What is vulvodynia?

A

Sensation of vulval burning and soreness - but no obvious skin problem. No itching.
Hypersensitivity of vulval nerve fibres.

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63
Q

What is the management of vulvodynia?

A

Low dose tricyclic antidepressants.
Lubricants
Vulval care advice.

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64
Q

What is chronic pelvic pain syndrome?

A

Intermittent or constant lower abdo pain for more than six months.
Physical, psychological and social factors.

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65
Q

Which HPV subtypes are highest risk for cervical cancer?

A

16, 18

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66
Q

What are the risk factors for cervical cancer?

A 
HPV
Smoking
Early first episode of sexual intercourse
Combined oral contraceptive pill use. 
Multiple sexual partners
Immunosuppression
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67
Q

What is the pathophysiology of HPV leading to cervical cancer?

A

HPV enters cervical cells, releases proteins E6 and E7 which are essential for keeping HPV inside cells.
E6 and E7 bind to tumour suppressor protein p53, Rb.
Cervical cells now vulnerable to unchecked genetic changes and cancer.

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68
Q

What is the HPV vaccination programme?

A

All girls aged 11-13 years vaccinated in school. Two injections at least 6 months apart.

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69
Q

Which conditions does the HPV vaccine protect against?

A

Cervical, vulval, vaginal, anal cancer and genital warts.

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70
Q

Which strains of HPV does the HPV vaccine protect against?

A

6, 11, 16, 18

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71
Q

Who is eligible for the cervical screening programme?

A

Ages 25-65 years.
Age 25-49 it is 3 years.
Age >50 it is 5 years.

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72
Q

What is the anatomy of the cervix?

A

Fibromuscular organ.
Inner surface (canal) is lined by columnar epithelium.
This is continuous with squamous epithelium lining the outer part of the cervix.
Junction is the transformation zone.

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73
Q

How does HPV affect the anatomy of the cervix?

A

Interferes with physiological metaplasia in the transformation zone. Leads to dysplasia (CIN) and squamous cell carcinoma (SCC).

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74
Q

What is the appropriate investigation if the cervix is visibly abnormal?

A

Biopsy:

  • punch
  • large loop excision of transformation zone (LLETZ)

Speculum is inappropriate for visible abnormality, screening tool only.

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75
Q

Who is referred for colposcopy?

A

People with an abnormal screening or smear.

People with suspicious symptoms or cervix.k

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76
Q

How does colposcopy work?

A 
Binocular microscope.
Apply acetic acid.
Observe for changes. 
Obtain biopsy. 
Treatment of HGCIN.
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77
Q

What is CIN 1?

A

Low grade changes and given time to resolve.

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78
Q

Which level of CIN is treatment offered?

A

2 and 3

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79
Q

What is the treatment for CIN?

A

Destructive - cold coagulation, cryotherapy

Excisional - LLETZ, cold knife cone, laser excision.

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80
Q

When is the follow up after treatment for cervical intraepithelial neoplasia?

A

Community smear at 6 months with hr HPV test.

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81
Q

What is the most common histopathological subtype of cervical cancer?

A

Squamous cell carcinoma.

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82
Q

What is the presentation of cervical cancer?

A 
Unscheduled vaginal bleeding
Sero-sanguinous offensive vaginal discharge
Obstructive renal failure. 
Supraclavicular node. 
Asymptomatic.
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83
Q

How is cervical cancer diagnosed?

A

Examination
PR to assess parametrium
Colposcopy to assess cervix and obtain a biopsy.

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84
Q

What are the types of biopsy used to assess the cervix?

A

Punch

LLETZ

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85
Q

Which imaging is used in the investigations for cervical cancer?

A

MRI
CT
PET-CT

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86
Q

What is the name of the staging for cervical cancer?

A

FIGO

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87
Q

What are the subtypes of stage 1 of cervical cancer?

A

IA1 - DOI <3mm, horizontal <7mm
IA2 - DOI 3-5mm, Horizontal <7mm
IB1 - visible lesion, <4cm
IB2 - >4cm

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88
Q

What are the subtypes of stage II cervical cancer?

A

IIA - involves upper 2/3 of vagina

IIB - parametrial involvement

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89
Q

What are the subtypes of stage III cervical cancer?

A

IIIA - involvement of lower 1/3 of vagina

IIIB - Extends to pelvic side wall, hydronephrosis, non-functioning kidney.

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90
Q

What are the subtypes of stage IV cervical cancer?

A

IVA - Tumour has spread to adjacent pelvic organs

IVB - Spread to distant organs

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91
Q

What is the management of cervical cancer?

A

Surgery

Chemotherapy (cisplatin, EBRT, VBT) Radiotherapy

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92
Q

What is the fertility sparing treatment for cervical cancer?

A

LLETZ

Trachelectomy with pelvic lymphadenectomy

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93
Q

What is the non-fertility sparing treatment for cervical cancer?

A

Hysterectomy

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94
Q

What are the risk factors for vulval cancer?

A

Smoking
HPV
Altered immune system
Lichen sclerosus

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95
Q

What type of cancer are most vulval cancers?

A

90% squamous carcinomas

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96
Q

What does VIN stand for?

A

Vulval intraepithelial neoplasia

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97
Q

Which VIN types are managed as high grade disease?

A

VIN 2, 3

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98
Q

What are the four pathological types of VIN?

A
  1. Usual type
  2. Warty
  3. Basaloid
  4. Differentiated
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99
Q

Describe usual type VIN.

A

Thickened
Keratinocytes are disorganised.
High nuclear:cytoplasmic ratio
Nuclear atypic and abnormal mitotic figures.

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100
Q

Describe warty type VIN.

A

Papillary configuration.

Multinucleate cells, koliocytes and dyskeratotic cells

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101
Q

Describe basaloid VIN.

A

Flat surface.

Less differentiated cells with a high nuclear:cytoplasmic ratio.

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102
Q

Describe differentiated VIN.

A

Thickened epidermis
Surface parakeratosis
Elongated rete ridges
Enlarged keratinocytes

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103
Q

How are VIN subtypes differentiated?

A

Immunohistochemistry.

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104
Q

What is the clinical presentation of VIN?

A 
Pruritus
Pain
Ulceration
Leukoplakia 
Lump/wart
20% asymptomatic
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105
Q

Where are the commonest sites for VIN?

A 
Labia majora
Labia minora
Posterior fourchette
Mons pubis
Clitoris
Perineal
Perianal
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106
Q

What is the appearance of VIN?

A

Red/white plaques

Papular, polypoid, verruciform

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107
Q

How is VIN diagnosed?

A

Biopsy
Incisional - original lesion remains to aid treatment planning
Excision

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108
Q

Which type of VIN is more likely to progress to malignancy?

A

Differentiated

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109
Q

What is the management of high grade VIN?

A

Surgical excision
Ablation
Imiquimod

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110
Q

How is imiquimod used in VIN?

A

Immune response modifier.
Topical 2-3 times per week.
16 weeks .
Local and systemic side effects affect compliance.

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111
Q

What are the symptoms of vulval cancer?

A 
Lump
Pain
Bleeding
Discharge
Swollen leg
Groin lump
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112
Q

What are the signs of vulval cancer?

A 
Mass
Ulceration
Colour changes
Elevation and Irregularity of surface
Inguinal lymphadenopathy
Lower limb lymphoedema
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113
Q

What are the investigations of vulval cancer?

A

Biopsy

Locoregional lymph nodes - ultrasound, CT, MRI

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114
Q

What is the staging for vulval cancer?

A

FIGO staging
Depth of invasion - measured from deepest point of tumour to the epithelial stromal junction.
Nodal status is critical in predicting survival.

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115
Q

Describe the FIGO staging of vulval cancer.

A

Stage 1:
IA - <2cm, DOI <1mm
IB - >2cm, DOI >1mm

Stage 2:
Involvement of lower vagina, urethra, anus

Stage 3:
Stage IIIA - spread to 1 lymph node and is 5mm/+ OR spread to 1/2 nodes but <5mm
Stage IIIB - 2/+ nodes and are > 5mm in size OR 3/+ nodes and <5mm
IIIC - in lymph nodes and spread is outside capsule
Stage IVA - spread upper vagina, upper urethra, bladder/anus. Attached to pelvic bone.
Stage IVB - spread to lymph nodes in pelvis/higher or other organs

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116
Q

What is the management of vulval cancer?

A

Surgical
Chemotherapy
Radiotherapy post op

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117
Q

What are the prognostic factors for vulval cancer?

A 
Depth of involvement
Involvement of other structures (clitoris)
Histological sub types
LVSI
Excision margins
Nodes
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118
Q

What is the surgical management of vulval cancer?

A

Vulvectomy +/- inguinal lymphadenectomy

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119
Q

What is the reconstruction after vulval cancer?

A

Grafts - split skin, full thickness

Flaps - myocutaneous, fasciocutaneous

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120
Q

What are the complications of lympadenectomy?

A 
Delayed wound healing
Infection
Wound breaking. 
Lymphedema
Recurrent infection
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121
Q

What is a sentinal node?

A

The first node in the lymphatic system that drains the locus of primary tumour.

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122
Q

What is the definition of subfertility?

A

The inability of the couple to achieve a clinical pregnancy after twelve months of regular unprotected sexual intercourse.

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123
Q

What is the chance of a couple becoming pregnant after one year of trying?

A

80%

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124
Q

What is the chance of a couple becoming pregnant after 2 years of trying?

A

90%

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125
Q

What are the factors affecting fertility?

A

Age (mostly women)
Duration of subfertility
Timing of intercourse
Female weight (less likely if BMI <20 or >30)

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126
Q

What pre-conception advice should be given to a subfertile couple?

A 
Stop smoking
Drink less than 2 units a week of alcohol
Don't take recreational drugs
If obese, lose weight. 
If underweight, gain weight.
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127
Q

How should a semen sample be provided?

A

After 2-5 days of abstinence.

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128
Q

What does the laboratory report show about semen?

A 
Concentration (15m/ml)
Total motility (>40%)
Normal forms (>4%)
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129
Q

What are abnormal semen results due to?

A

Low (or absent) sperm numbers.
Low motililty.
Poor quality sperm.

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130
Q

What does azoospermia mean?

A

Absent sperm

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131
Q

What does oligospermia mean?

A

Very few sperm

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132
Q

what does asthenospermia mean?

A

Very immotile sperm

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133
Q

What does teratospermia mean?

A

Abnormal morphology

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134
Q

What is male subfertility due to defects in?

A

Sperm transportation
Sperm production
Hypogonadotrophism (rare)

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135
Q

How should the subfertile male be assessed?

A 
Seminal analysis
History
Testicular examination
FSH
Karyotype if severe oligo or azoospermia
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136
Q

What would lead to a diagnosis of obstructive azoospermia?

A

Normal sperm production (normal FSH)
Normal testicular volumes
Sperm not present in ejaculate

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137
Q

What might cause obstructive azoospermia?

A

Blockage in epididymis or vas

Congenital absence of vas deferens.

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138
Q

What would lead to a diagnosis of non-obstructive azoospermia?

A 
Testicular failure (raised FSH)
Small testicular volumes
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139
Q

Which further investigations would be carried out in a subfertile man with small testicular volumes?

A

Biopsy (?any spermatogenesis)

Karyotype for XXY or Y microdeletions

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140
Q

What would cause failure to stimulate spermatogenesis?

A

Hypogonadotrophic hypogonadism

Low FSH

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141
Q

What is the fertility management for subfertile males?

A

Usually IVF with intra-cytoplasmic sperm injection

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142
Q

How do you check if a woman is releasing an egg?

A

Is the cycle regular?

Check mid-luteal phase progesterone if cycle is regular.

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143
Q

What is the WHO classification of anovulation?

A

Group I - hypothalamic pituitary failure
Group II - hypothalamic-pituitary-ovarian axis dysfunction
Group III - ovarian failure

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144
Q

What do women with group I anovulation typically present with?

A

Amenorrhoea

Low gonadotrophins and oestrogen deficiency

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145
Q

What is the management for women with group I anovulation?

A

Increase BMI and decrease exercise (in moderation)
GnRH agonist:
- give in a pump for pulsatile release
Gonadotrophins

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146
Q

What is the most common type of anovulation in women?

A

Group II (hypothalamic-pituitary-ovarian axis dysfunction)

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147
Q

What causes group II anovulation in women?

A

Polycystic ovary disease
Hyperprolactinaemia
Thyroid or adrenal dysfunction

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148
Q

What is the name of the criteria used to diagnose polycystic ovary syndrome?

A

Rotterdam criteria

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149
Q

Which features lead to a diagnosis of polycystic ovary disease?

A

2 out of 3 of:

  1. Biochemical or clinical evidence of androgen excess
  2. Amenorrhoea or oligomenorhoea
  3. TV ultrasound features of PCOS (string of pearls)
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150
Q

What is the management of PCOS?

A

Weight reduction (even if normal BMI)
Drug therapy
Ovarian drilling
Assisted reproductive technology

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151
Q

What is traditionally first line therapy for PCOS?

A

Clomifene

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152
Q

What is clomifene?

A

A selective oestrogen receptor modulator

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153
Q

What is letrozole therapy?

A

Aromatase inhibitor used in PCOS (traditionally used in advanced breast cancer).

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154
Q

How does letrozole work?

A

Blocks oestrogen biosynthesis

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155
Q

What are the further management options for PCOS if clomifene or letrozole don’t work?

A

Add metformin
Ovarian drilling
Gonadotrophin therapy
In vitro fertilization

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156
Q

What is ovarian hyperstimulation?

A

Ovaries ‘over respond’ to gonadotrophin injections, can lead to systemic disease such as: thrombosis, renal dysfunction, liver dysfunction, adult respiratory distress syndrome.

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157
Q

What are the causes of ovarian failure?

A

Idiopathic (premature ovarian failure)
Autoimmune
Ovarian chemotherapy/radiation/surgery
Chromosomal (Turner syndrome or mosaic)

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158
Q

What are the clinical findings in women with ovarian failure?

A

Amenorrhoea
Increased FSH
Decreased E2

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159
Q

What are the management options for women with ovarian failure?

A

May have functional Graafian follicles in the ovary - may conceive without treatment but pregnancy rates very low.
Assisted conception - IVF + oocyte donation

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160
Q

What is tubal subfertility?

A

Problems with ovum pick up or gamete transport.

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161
Q

What are the causes of tubal subfertility?

A

PID
Endometriosis
Tubes may not be blocked, just malfunctioning.
May be history of previous infections or ectopic pregnancy.

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162
Q

What are the investigations of tubal subfertility?

A 
Chlamydia
TV ultrasound
Hystero-salpingo-gram (x-ray with radio-opaque dye into uterus)
Hysterosalpingo-contrast-ultrasonography
Laparoscopy and dye test.
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163
Q

What is the management for tubal subfertility?

A

IVF

If hydrosalpinges, consider salpingectomy or clipping

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164
Q

What is the management of endometriosis related subfertility?

A

Expectant
Medical - for symptom relief only
Surgical - diathermy, ovarian cystectomy
IVF

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165
Q

What percentage of people with subfertility will have unexplained subfertility?

A

25%

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166
Q

What does assisted reproductive technoloy (ART) consist of?

A

Ovulation induction

IVF

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167
Q

What is the live birth rate from use of ART?

A

25% each cycle

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168
Q

What is the eligibility criteria for IVF in Scotland?

A 
Co-habiting in a stable relationship >2 years
<42 years of age
BMI >18.5 and <30
Both partners non-smokers
At least partner with no child
Not sterilised
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169
Q

Describe the micturition cycle.

A 
Bladder fills:
 - detrusor muscle relaxes
- urethral sphincter contracts
 - pelvic floor contracts
First sensation to void:
 - bladder half full, urination voluntarily inhibited until appropriate time
Normal desire to void
Micturition:
 - detrusor muscle contracts
 - pelvic floor muscle relaxes
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170
Q

What are the types of urinary incontinence in women?

A

Urgency incontinence
Mixed incontinence
Stress incontinence

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171
Q

What is the definition of incontinence?

A

Involuntary loss of urine which can be objectively demonstrated and which is a social or hygienic problem.

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172
Q

What is overactive bladder

A

The symptoms of urgency with or without urge incontinence, usually with frequency and nocturia.

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173
Q

What is urge incontinence?

A

Leakage of urine in response to an involuntary contraction of the detrusor muscle.

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174
Q

What is the most common cause of incontinence in adult women?

A

Stress urinary incontinence

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175
Q

What happens in stress urinary incontinence?

A

Leakage occurs with rise in intra-abdominal pressure without a detrusor contraction (coughing, laughing, running, walking)

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176
Q

What is the definition of stress urinary incontinence?

A

Sign or symptom of urinary leakage with increased intra-abdominal pressure.

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177
Q

What is the definition of urodynamic stress incontinence?

A

Urodynamic proven leakage of urine with increased intra-abdominal pressure.

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178
Q

What percentage of women with incontinence of coexisting stress urinary incontinence and overactive bladder?

A

30%

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179
Q

What are the potential causes of overactive bladder?

A 
Neurological
Constipation
Previous surgery
UTI
Caffeine
Alcohol
Bladder abnormalities
High urine production due to medication, excess fluid intake, diabetes, poor kidney function
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180
Q

What is the aetiology of stress urinary incontinence?

A

Loss of suburethral support causing increased urethral mobility (urethral hypermobility) leads to movement of proximal urethral sphincter out of the abdominal space, so increased intraabdominal pressure not spread evenly throughout bladder.

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181
Q

How should women with incontinence be examined?

A 
Abdominal/bimanual examination: 
 - pelvic masses
 - palpable bladder
 - impression of pelvic floor tone
Vaginal examination
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182
Q

Which investigations should be carried out on women with incontinence?

A

Urinary dip +/- culture
Bladder diary (minimum 3 days)
Cystoscopy and renal tract imaging
Urodynamic testing

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183
Q

What can be used to measure study of bladder function?

A

Uroflowmetry

Filling and voiding cystometry (measures pressures in bladder and abdomen)

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184
Q

What is the management of incontinence?

A 
Conservative:
 - continence advice and lifestyle changes
 - physiotherapy (kegel exercises)
 - bladder retraining
Medical 
 - antibiotics
 - anticholinergics
 - B3 agonists
 - duloextine
Surgical
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185
Q

What is bladder retraining?

A

Minimum of 6 weeks of relearning higher cortical control of detrusor muscle.
Patient empties bladder to strict time schedule (usually hourly) with time between voids increasing gradually.
Techniques to aid training:
- distraction
- sit on a hard seat
- pelvic floor squeezes

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186
Q

What are the common side effects of anticholinergics?

A

Dry mouth
Dry eyes
Constipation

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187
Q

How long should treatment with anticholinergics last to elicit a response?

A

4-6 weeks.

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188
Q

What is the medical management of stress urinary incontinence?

A

Vaginal oestrogen if post menopausal

Duloxetine

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189
Q

What is the surgical management of an overactive bladder?

A

Botox injections to detrusor muscle - effects last 3 to 13 months. Need to be able to perform self catheterisation.
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion.

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190
Q

What is the surgical management of stress urinary incontinence?

A

Synthetic tapes.
Colposuspension
Biological slings
Intramural bulking agents.

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191
Q

What is prolapse?

A

Prolapse is defined as protrusion of the uterus and/or vagina beyond normal anatomical confines.

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192
Q

Which structures provide support to the uterus?

A

Vaginal walls
Transverse cervical ligaments
Round and broad ligaments
Indirect support from pelvic floor

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193
Q

Which structures provide support to the cervix and upper 1/3 of the vagina?

A

Transverse cervical ligament

Uterosacral ligaments

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194
Q

What are the risk factors for prolapse?

A

Age
Vaginal delivery
Increasing parity
Raised intra-abdominal pressure (obesity, chronic cough, chronic constipation)

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195
Q

What are the clinical features of uterovaginal prolapse?

A

Vaginal:
- sensation of pressure, fullness, heaviness.
- sensation of a bulge, ‘something coming down’
- worse at the end of the day, better when lying down
- bleeding
-discharge
- backache
Coital difficulty - dyspareunia
Urinary incontinence/urgency/frequency
Bowel: constipation/incontinence/incomplete evacuation
May be asymptomatic

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196
Q

What is the grading for vaginal prolapse?

A

Pelvic organ prolapse quantification (POPQ), grade 1-4

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197
Q

What is a stage 1 prolapse?

A

More than 1cm above hymenal ring.

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198
Q

What is a stage 2 prolapse?

A

Prolapse extends from 1cm above to 1cm below hymenal ring

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199
Q

What is a stage 3 prolapse?

A

Prolapse extends 1cm or more below hymenal ring (no vaginal eversion)

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200
Q

What is a stage 4 prolapse?

A

Vagina completely everted.

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201
Q

What is a cystocele?

A

Bladder protrudes

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202
Q

What is a urethrocele?

A

Descent of the anterior vaginal wall where the urethra sits.

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203
Q

What is a rectocele?

A

Rectum protrudes.

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204
Q

What is an enterocele?

A

Upper vagina, descent of vagina and peritoneal sac

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205
Q

What is the commonest type of prolapse?

A

A cystocele

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206
Q

What is the management of a vaginal vault prolapse following a hysterectomy?

A

Conservative:

  • lifestyle advice
  • pelvic floor exercises
  • pessaries
  • vaginal oestrogens

Surgical:

  • vaginal
  • abdominal
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207
Q

Where is a ring pessary placed?

A

Between the posterior aspect of the symphysis pubis and the posterior fornix of the vagina.

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208
Q

What are the complications of a pessary?

A 
May interfere with sexual intercourse. 
Ulceration
Infection
Difficulty and discomfort during removal
Fistula if neglected.
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209
Q

When is surgical management of a prolapse indicated?

A

If pessaries have failed
Patient wants definitive treatment.
Prolapse is combined with urinary or faecal incontinence.

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210
Q

What is the name of the surgery to repair and anterior compartment defect?

A

Anterior colporrhaphy

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211
Q

What are the possible complications of an anterior compartment defect?

A

Dysparaeunia
Incontinence
Failure
Recurrence (30% within 5 years)

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212
Q

What is the name of the surgery given to treat a rectocele?

A

Posterior colporrhaphy

213
Q

What are the complications of posterior colporrhaphy?

A

Dyspareunia

214
Q

What is a Manchester repair?

A

Cervical amutation

Shortening of transcervical ligaments

215
Q

What is a sacrohysteropexy?

A

Mesh is used to attach the uterus to the anterior longtiduinal ligament over the sacrum.

216
Q

What is a sacrospinous ligament fixation?

A

Vaginal vault sutured to sacrospinour ligaments using a vaginal approach
Success rate 70-85%

217
Q

What is a sacrocolpopexy?

A

Open/laparoscopic
Vault attached to sacrum using mesh.
Success rate 90%

218
Q

What is a colpocleissi?

A

Vaginal closure:
For women who do not desire future vaginal intercourse
Success rate 85-95%

219
Q

What can be done to help prevent prolapse.

A

Weight reduction
Treatment of constipation
Treatment of chronic cough and smoking cessation
Avoidance of heavy lifting
Encourage pelvic floor exercises - lifelong
Good intrapartum care.

220
Q

What is chronic hypertension in pregnancy?

A

The presence of hypertension before 20 weeks in the absence of hydatidiform mole
or
persistent hypertension beyond 6 weeks post partum.

221
Q

What is pre-eclampsia?

A

Hypertension developing after 20 weeks gestation with one or more of proteinuria, maternal organ dysfunction, or fetal growth restriction.

222
Q

What are the potential forms of maternal organ dysfunction in pre-eclampsia?

A

Renal insufficiency
Liver involvement
Neurological complications
Haematological complications.

223
Q

What is eclampsia?

A

Generalised tonic-clonic convulsions in women with pre-eclampsia, if the seizures cannot be attributed to any other causes (epilepsy, cerebral infarction, tumour, ruptured aneurysm).

224
Q

What is are the phases of pre-eclampsia?

A

Abnormal placentation - inadequate trophoblast invasion, causing inadequate placental perfusion.
Endothelial dysfunction - likely mediated by oxidative stress from ischaemic placenta, exaggerated maternal systemic inflammatory response, increased thromboxane.

225
Q

What percentage of pregnancies are complicated by hypertensive disorders?

A

10-15%

226
Q

What are the risk factors for hypertensive disorders of pregnancy?

A

First pregnancy
Family history
Extremes of maternal age
Obesity
Medical factors (hypertension, renal disease, diabetes)
Obstetric factors (multiple pregnancy, previous pre-eclampsia, triploidy)

227
Q

What are the symptoms of hypertensive disorders of pregnancy?

A

Severe headache
Severe right upper quadrant pain and/or epigastric pain
Sudden swelling of the hands, face or feet
Visual disturbance including blurring, flashing, scotoma
Vomiting
Restlessness or agitation

228
Q

What are the signs of hypertensive disorders of pregnancy?

A 
Hypertension and proteinuria
Hyperreflexia
Serum creatinine raised
Platelet count decreased
Clonus
Haemolytic anaemia
Elevated liver enzymes
Retinal haemorrhages and papilloedema
229
Q

What are the clinical investigations of hypertensive disorders of pregnancy?

A

BP
Urinalysis for proteinuria (abnormal if >30ml/dl)
Blood tests (AST and transaminases indicate hepatocellular damage)
Elevated urea, creatinine
Consider HELLP (haemolysis, elevated liver enzymes and low platelets)
Measure urine output (may be reduced)

230
Q

How is the foetus assessed in pre-eclampsia?

A

Symphysial fundal height
Ultrasound for foetal growth, liquor volume and umbilical artery doppler.
If there is foetal compromise - delivery.

231
Q

How can pre-eclampsia be prevented?

A

Low dose aspirin should inhibit the vascular and prothrombotic effects of thromboxane A2 in women at risk of pre-eclampsia.
75mg aspirin from 12 weeks gestation leads to a 15% reduction in incidence of pre-eclampsia.

232
Q

What should the blood pressure be controlled to in pre-eclampsia?

A

<150/100

233
Q

What can be used to prevent seizures in pre-eclampsia?

A

Magnesium sulphate

234
Q

What are the symptoms of hypertensive disorders of pregnancy?

A

Severe headache
Severe right upper quadrant pain and/or epigastric pain
Sudden swelling of the hands, face or feet
Visual disturbance including blurring, flashing, scotoma
Vomiting
Restlessness or agitation

235
Q

What are the foetal indications for delivery in pre-eclampsia?

A

Abnormal foetal heart rate

Deteriorating foetal condition.

236
Q

What are the clinical investigations of hypertensive disorders of pregnancy?

A

BP
Urinalysis for proteinuria (abnormal if >30ml/dl)
Blood tests (AST and transaminases indicate hepatocellular damage)
Elevated urea, creatinine
Consider HELLP (haemolysis, elevated liver enzymes and low platelets)
Measure urine output (may be reduced)

237
Q

How is the foetus assessed in pre-eclampsia?

A

Symphysial fundal height
Ultrasound for foetal growth, liquor volume and umbilical artery doppler.
If there is foetal compromise - delivery.

238
Q

How can pre-eclampsia be prevented?

A

Low dose aspirin should inhibit the vascular and prothrombotic effects of thromboxane A2 in women at risk of pre-eclampsia.
75mg aspirin from 12 weeks gestation leads to a 15% reduction in incidence of pre-eclampsia.

239
Q

What should the blood pressure be controlled to in pre-eclampsia?

A

<150/100

240
Q

What can be used to prevent seizures in pre-eclampsia?

A

Magnesium sulphate

241
Q

What are the maternal indications for delivery in pre-eclampsia?

A 
Gestation >37 weeks
Failure to control hypertension
Deteriorating liver/renal function
Progressive fall in platelets
Neurological complications
242
Q

What are the options for drug treatment in hypertension in pregnancy?

A

Methyldopa
Labetalol
Hydralazine
Nifedipine

243
Q

What are the maternal complications of pre-eclampsia?

A 
Placental rupture
DIC
HELLP
Pulmonary oedema
Aspiration
Eclampsia
Liver failure
Stroke
Death
Long term cardiovascular morbidity
244
Q

What are the fetal complications of pre-eclampsia?

A 
Pre-term delivery
IUGR
Hypoxia-neurological injury
Perinatal death
Long term cardiovascular morbidity
245
Q

What happens in HELLP syndrome?

A

Haemolysis
Elevated liver enzymes
Low platelets

246
Q

What is the morbidity associated with HELLP syndrome?

A

DIC
Placental abruption
Acute renal failure

247
Q

How does insulin production change in pregnancy?

A

Normal women double insulin production from 1st to 3rd trimester.

248
Q

Why does insulin resistance increase in pregnancy?

A

The placenta produces human placental lactogen which increases insulin resistance and human somatomammotrophin which increases production of insulin

249
Q

At how many weeks does a foetus start producing its own insulin?

A

10 weeks

250
Q

How do insulin requirement change with gestation?

A

1st trimester - static or decrease
2nd trimester - increase
3rd trimester - increase and may reduce slightly towards term

251
Q

What are the gestational complications of diabetes?

A

Polyhydramnios - may result in unstable lie, malpresentation and pre-term labour.

252
Q

What should the HbA1c target be pre-conception?

A

48mmol/mol

253
Q

How long does it take insulin to go back to pre-pregnancy levels after delivery of baby?

A

Immediately

254
Q

What are the risk factors for gestational diabetes?

A

BMI above 30kg/m
Previous macrosomic baby weighing 4.5kg or above.
Previous gestational diabetes.
Family history of diabetes (first-degree relatives with diabetes)
Minority ethnic family origin with a high prevalence of diabetes.

255
Q

How is gestational diabetes diagnosed?

A

2 hour 75g OGTT:
a fasting plasma glucose level of 5.6mmol/litre or above
a 2-hour plasma glucose level of 7.8 mmol/litres or above.

256
Q

What is the follow up of women with gestational diabetes?

A

Offer women with a diagnosis of gestational diabetes a review with the joint diabetes and antenatal clinic within 1 week.

257
Q

What is the antenatal management of gestational diabetes?

A

Diet and exercise
Metformin, glibenclamide, insulin
Advise delivery no later than 40+6

258
Q

How does pregnancy affect thyroid function?

A

Total thyroid hormone concentrations in blood are increased in pregnancy.
Thyroxine T4 levels rise from about 6-12 weeks, and peak by mid-gestation; reverse changes are seen with TSH.

259
Q

What is the post-partum management of gestational diabetes?

A

Stop all treatment and offer lifestyle advice.
6 weeks fasting blood glucose +/- HbA1c.
Annual review (community)

260
Q

When does the fetal thyroid gland become functional?

A

12 weeks

261
Q

What is thyroxine important for in the foetus?

A

Neurodevelopment

262
Q

Where is iodide lost in in pregnancy?

A

Urine

Feto-placental unit

263
Q

What is the iodide intake recommended in pregnancy?

A

250 micrograms

264
Q

What are the consequences of suboptimal treatment of thyroid function in pregnancy?

A 
Mainly in first trimester
Abnormal neuropsychological development 
Miscarriage and stillbirth
Placental abruption
Prematurity
265
Q

What are the clinical features of hyperthyroidism in pregnancy?

A

Weight loss
Eye signs
Pre-tibial myxoedema
Tremor

266
Q

What are the effects of thyrotoxicosis on pregnancy?

A

Increase miscarriage
Increase IUGR
Increase preterm delivery
Increase perinatal mortality

267
Q

How can hyperthyroidism be treated in pregnancy?

A

Lowest effective dose of carbimazole or PTU.
B blockade with propanolol.
Serial biochemical monitoring (at least monthly)
Often requirements reduced in pregnancy.

268
Q

What are the effects of sodium valproate on the developing foetus?

A 
Neurocognitive impairment
Autism spectrum disorders
Attention deficit disorders
Neural tube defects (1.5%)
Hypospadias
Heart defects
Craniofacial anomalies
Skeletal anomalies
Developmental delay
269
Q

How much folic acid should women with epilepsy take prior to conception?

A

5mg/day at least 1 month prior to conception

270
Q

What should be given for seizure termination in pregnant women?

A

Benzodiazepines

271
Q

What are the effects of foetal varicella syndrome?

A

Skin scarring, eye defects, limb hypoplasia, neurlogical abnormalities

272
Q

How should chicken pox in the newborn be treated?

A

Aciclovir

273
Q

How is HIV transmitted in pregnancy?

A

Highest risk during birth (perinatal vertical transmission)
Prenatal transmission is possible
Risk depends on maternal viral load

274
Q

How can risk of HIV transmission be reduced during pregnancy?

A

Antiretroviral therapy is recommended throughout pregnancy.

Low risk of transmission if viral load <50 HIV RNA copies/ml

275
Q

How can risk of HIV transmission be reduced at delivery of baby?

A

Viral load < 50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, a planned vaginal delivery is recommended.
Viral load > 50 HIV RNA copies/mL at 36 weeks, planned caesarean section.
Cesarean delivery should be scheduled at 38 weeks

276
Q

How can vertical transmission of HIV be reduced postnatally?

A

HIV post-exposure prophylaxis with zidovudine for the newborn
Neonatal post exposure prophylaxis (PEP) should be commenced very soon after birth, certainly within 4 hours.
Neonatal PEP should be given for 4 weeks.
Breastfeeding should generally be avoided , because risk of transmission is 5–20%

277
Q

When should neonatal molecular diagnostics for HIV infection be performed?

A

During the first 48 hours and prior to hospital discharge

2 weeks post cessation of infant prophylaxis (6 weeks of age)

2 months post cessation of infant prophylaxis (12 weeks of age)

HIV antibody testing for seroreversion should be performed at age 18 months

278
Q

What are the antenatal complications of rhesus disease?

A 
Polyhydramnios
Thickened placenta
Hydrops - sub-cut oedema
	pleural/pericardial effusions
	ascites
	hepato-splenomegally
In-utero demise
279
Q

What are the post natal complications of rhesus disease?

A 
Jaundice
Hepato-spenolmegally
Pallor
Kernicterus
Hypoglycaemia
280
Q

When is Anti-D required?

A

If mother is Rh negative.

281
Q

Is anti-D required if mother is Rh +ve and father is Rh-ve?

A

No, mother will not make antibodies.

282
Q

Is anti-D required if mother Rh -ve and father is Rh -ve?

A

Probably not required, Rh is recessive inheritance therefore baby will be Rh -ve also.

283
Q

Will anti-D be required if mother is Rh -ve and father is Rh +ve?

A

Check infants Rh status. 50/50 chance if father Dd. 100% chance if father DD.

284
Q

List some common skin problems in pregnancy.

A 
Hyperpigmentation
Striae gravidarum
Hair and nail changes
Vascular – angiomas, spider naevi
Greasier skin 
Pruritis
Atopic eruption of pregnancy
Acne vulgaris or rosacea
Psoriasis (emmolients/steroids/dithranol/UVB)
Infections (candida, viral warts, varicella)
Infestations (scabies)
Autoimmune (SLE, pemphigus)
285
Q

List 3 specific dermatoses of pregnancy.

A

Atopic eruption of pregnancy (AEP)
Polymorphic Eruption of pregnancy (PEP)
Pemphigoid Gestationis (PG)

286
Q

What is the commonest pregnancy rash?

A

Atopic eruption of pregnancy

287
Q

What are the treatments for atopic eruption of pregnancy?

A 
Emollients 
Aqueous cream and menthol 1-2%
Topical steroids
Antihistamines
Narrow band UVB 2nd line
Oral steroids if severe (30mg pred)
288
Q

What are the clinical signs of polymorphic eruption of pregnancy?

A

Pruritic eruption lower abdomen and striae with umbilical sparing and distant spread.

289
Q

What is the treatment for polymorphic eruption of pregnancy?

A

Provide self-care advice to relieve itching

Prescribe symptomatic treatment where necessary

Emollients can be used liberally to soothe the skin

Moderately-potent topical corticosteroids can be used to reduce inflammation

Offer a sedating antihistamine (such as chlorphenamine or promethazine) if itch is causing sleeping difficulties (off-label indication)

290
Q

How common is pemphigoid gestationis?

A

1:60,000

291
Q

What are the signs of pemphigoid gestationis?

A

Urticarial lesions
Wheals and bullae
Umbilical area.

292
Q

What causes pemphigoid gestationis?

A

Autoimmune - binding of IgG to basement membrane.

293
Q

What are the risks of pemphigoid gestationis?

A

Premature delivery
Fetal growth restriction
Transient blistering on the infant that resolves with clearance of maternal antibodies (about 3-4 months) – 10%
Secondary infection, which may leave scarring

294
Q

What is the treatment for pemphigoid gestationis?

A

Refer to dermatology and obstetrics.
Topical corticosteroids and antihistamine in mild cases.
Moderate and severe cases can be treated by specialists with systemic corticosteroids.
Additional antenatal surveillance may be advised.

295
Q

How much does plasma volume change over the course of pregnancy?

A

About 50%

296
Q

What happens to serum iron during pregnancy?

A

It falls

297
Q

Which kind of infections are women more at risk of during pregnancy?

A

Urinary tract infections

298
Q

What effect does pregnancy have on the GI tract?

A

Relaxation of smooth muscles results in:
Decreased lower oesophgeal sphincter pressure
Decreased gastric peristalsis
Delayed gastric emptying
Increased small and large bowel transit times

Symptomatically this causes reflux, nausea, vomiting and constipation.

299
Q

Which skin changes are common in pregnancy?

A

Hyperpigmentation of the umbilicus, nipples, abdominal midline and face.
Spider naevi
Palmar erythema
Striae gravidarum

300
Q

What are the musculoskeletal changes of pregnancy?

A

Increased ligamental laxity

301
Q

What is the aim of the antenatal booking appointment?

A

Identify risks, including domestic abuse.
Screen for abnormalities or illnesses.
Develop rapport and encourage future attendance.
Provide key health promotion messages; smoking cessation, dietician, dental care, folic acid, alcohol, food hygiene.
Social work involvement if required.
Initial observations of mother - BMI, BP, HR, abdo exam, urinalysis
Determine likely gestation.

302
Q

What are the risk factors for a higher risk pregnancy?

A 
Age >40 or <18
para 6+ or para 0
Extremes of BMI
Low socio-economic status
Drug and alcohol misuse
Previous obstetric problems
Vulnerable groups e.g. asylum seekers
Pre-existing medical problems e.g. diabetes, epilepsy, hypertension
303
Q

Which fetal screening is offered?

A

Nuchal translucency 11-14 weeks

Fetal anomaly scan 18-22 weeks

304
Q

At how many weeks can chorionic villus sampling happen?

A

11 weeks

305
Q

At how many weeks can amniocentesis happen?

A

15 weeks

306
Q

When is the second trimester?

A

12-20 weeks

307
Q

When is the third trimester?

A

20 weeks - term

308
Q

What are the clinical signs of polyhydramnios?

A

Large for dates
Tense abdomen
Unable to feel fetal parts.

309
Q

What is the investigation for polyhydramnios?

A

Ultrasound

310
Q

What is polyhydramnios associated with?

A 
Placental abruption
Malpresentation
Cord prolapse
Large for gestational age infant
Requiring caesarean section
Postpartum haemorrhage
Premature birth and perinatal death
311
Q

What is oligohydramnios associated with?

A 
Poor perinatal outcomes
Prolonged pregnancy
Ruptured membranes
IUGR
Fetal renal congenital abnormalities
My cause hypoxia due to cord compression
312
Q

What are the symptoms of pre-eclampsia?

A

Headache
Visual disturbance
Severe upper abdominal pain
Significant facial/hand/ankle oedema

313
Q

What are the risk factors for pre-eclampsia?

A

Para 0
Family history
Extremes of maternal age
Obesity
Medical factors - hypertension, renal disease, thrombophilia, SLE, diabetes
Obstetric factors - multiple pregnancy, previous pre-eclampsia, hydatidiform mole, hydrops

314
Q

At what Hb level is anaemia in pregnancy?

A

<105g/L

315
Q

What are the risk factors for impaired glucose tolerance in pregnancy?

A

Family history of diabetes
BMI >30
Previous macrosomic baby (>4.5kg)
Previous GDM

316
Q

What are the bones of the fetal skull called?

A

Occipital bone
Parietal bones
Frontal bone

317
Q

What are the joins between the bones of the fetal skull called?

A

Posterior fontanelle
Sagittal suture
Anterior fontanelle
Frontal suture

318
Q

Which pro-pregnancy factors are involved in labour?

A

Progesterone
Nitric oxide
Catecholamines
Relaxin

319
Q

Which pro-labour factors are involved in labour?

A 
Oestrogens
Oxytocin
Prostaglandins and prostaglandin dehydrogenase
Corticotrophin-releasing hormone
Inflammatory mediators
320
Q

What effect does oxytocin have on contractions?

A

Increases frequency and force of contractions

321
Q

What effect do prostaglandins have on labour?

A

Promote cervical ripening and stimulate uterine contractility.

322
Q

What effect do inflammatory cells have on labour?

A

Contribute to cervical ripening and membrane rupture via increase in collagenase activity.

323
Q

How do prostaglandins increase cervical ripening?

A

They inhibit collagen synthesis and stimulate collagenase activity to break down the collagen in the cervix. This allows the cervix to become softer and ready to dilate.

324
Q

Which score is used to assess cervical ripening?

A

The Bishop score

325
Q

Which factors does the Bishop’s score take into account?

A 
Cervical dilatation
Length of cervix
Station of presenting part
Consistency
Position
326
Q

What is required for a woman to be diagnosed as being in labour?

A

Regular contractions and a fully effaced cervix.
OR
Spontaneous rupture of membranes plus regular uterine activity.

327
Q

What are the risks associated with prelabour rupture of membranes?

A

Ascending infection

Chorioamnionitis

328
Q

When would conservative management be appropriate in the case of prelabour rupture of membranes?

A

Mother apyrexial
Baby cephalic
Clear liquor
Normal fetal monitoring

329
Q

What is the first stage of labour?

A

From the onset of labour until the cervix is fully dilated.

330
Q

What is the second stage of labour?

A

From full cervical dilatation until the head is delivered.

331
Q

What is the third stage of labour?

A

From delivery of the baby until expulsion of the placenta and membranes.

332
Q

What might meconium staining on vaginal examination indicate in pregnancy?

A

Fetal distress

333
Q

What is precipitate labour?

A

Expulsion of the fetus with less than 2-3 hours of the onset of contractions.

334
Q

What problem can be associated with precipitate labour?

A

Fetal distress

335
Q

What is considered a slow labour?

A

Less than 2cm cervical dilatation in 4 hours.

336
Q

What can be used to help a slow labour?

A

ARM +/- oxytocin infusion

337
Q

What is a prolonged pregnancy?

A

Pregnancy longer than 42 weeks.

338
Q

When is induction of labour offered?

A

Between 41 and 42 weeks.

339
Q

What are the potential indications for induction of labour?

A

Maternal diabetes
Twin pregnancy
Pre-labour rupture of membranes
Fetal growth restriction and suspected fetal compromise
Hypertensive disorders of pregnancy including pre-eclampsia
Deteriorating maternal medical conditions.
Maternal request

340
Q

What are contraindications to induction of labour?

A

Situations where vaginal delivery is contraindicated.
Caution in previous caesarean section or uterine surgery.
Risk of hyperstimulation in those how have had a previous precipitate labour.

341
Q

Which methods of induction of labour are used in a Bishop’s score of <6?

A

Porstaglandins

342
Q

Which methods of induction of labour used in a Bishop’s score of >6?

A

Artificial rupture of membranes (ARM)

Syntocinon

343
Q

What are the non-pharmacological methods of pain relief in labour?

A

Maternal support
Environment
Birthing pools
Education

344
Q

What are the pharmacological methods of pain relief in labour?

A 
Inhaled analgesics
Systemic opioid analgesia
Pudendal analgesia
Regional analgesia: epidural, spinal
General anaesthesia
345
Q

What are the methods of regional analgesia in delivery?

A

Epidural

Spinal

346
Q

What are the potential complications of regional analgesia?

A 
Dural puncture headache
Hypotension
Local anaesthetic toxicity
Accidental total spinal block
Neurological complications
Bladder dysfunction
347
Q

What is the pathogenesis of a dural puncture headache?

A

Occurs due to CSF leak from subarachnoid space. Headache when sitting upright and relieved by lying flat. Blood patch may be necessary.

348
Q

What is a first degree perineal tear?

A

Injury to the vaginal epithelium and vulval skin only.

349
Q

What is a second degree perineal tear?

A

Injury to the perineal muscles, but not the anal sphincter.

350
Q

What is a third degree perineal tear?

A

Injury to the perineum involving the anal sphincter complex.

351
Q

What is a fourth degree perineal tear?

A

Injury to the perineum involving the anal sphincter complex and anal/rectal mucosa.

352
Q

What are possible indications for an episiotomy?

A

A rigid perineum which is preventing delivery.
If it is judged that a larger tear is imminent
Most instrumental deliveries.
Suspected fetal compromise
Shoulder dystocia.

353
Q

What is the immediate post-birth care?

A

Skin to skin contact
Rhesus bloods and anti-D if required.
6 hour discharge if mother and baby are well.

354
Q

What is the immediate post birth care of the neonate?

A

Apgar score at 1, 5, 10 minutes.
Clamp and cut umbilical cord after 1 minute.
Measurement and recording of birth weight and temp.
Physical examination. Head and facial features, palate, limbs, digits, spine, external genitalia.
Record first micturition and feed.
Vit K consent and administer.

355
Q

What is the immediate post birth care of the mother?

A

Observation of vaginal blood loss, palpation of uterine fundus to assess contraction.
Examine for perineal, labial and vaginal trauma. Repair if required.
Support skin to skin offer breast if wishes.
Colour, BP, HR, resp rate, temp
Offer something to eat
Record first micturition after birth.
Categorise VTE risk and commence prophylaxis if required.

356
Q

What are the benefits of breastfeeding for the baby?

A 
Reduced risk of infections
Reduced risk of vomiting and diarrhoea
Reduced risk of childhood leukaemia
Reduced risk of obesity
Reduced risk of cardiovascular disease in adulthood
Available when needed
Strong emotional bond
357
Q

What are the benefits of breastfeeding for mum?

A 
Lower risk of breast cancer.
Lower risk of ovarian cancer.
Lower risk of osteoporosis.
Lower risk of cardiovascular disease.
Lower risk of obesity.
358
Q

How many visits from the midwife should take place in the first 10 days post-birth?

A

3 visits.

359
Q

What is discussed in the first 10 days post birth?

A

Discuss birth - PTSD.
Risk of postnatal depression.
Physical exam; HR, BP, temp. Any signs of haemorrhage, anaemia, sepsis. Abdominal exam.
Perineal examination.
Discuss contraception.
Physical examination of baby. Feeding, winding, changing, washing, safe sleeping.

360
Q

When is the late postnatal examination?

A

6 weeks post natal.

361
Q

What is discussed at the late postnatal examination?

A

Review the birth. Address questions, discuss future births.
Discuss physical symptoms; perineal pain, pain during intercourse, urinary/faecal incontinence, vaginal bleeding, breast pain.
FBC.
Cervical smear.
Discuss contraception.

362
Q

What are possible postnatal complications for the mother?

A 
Anaemia
Bowel problems
Breast problems
Perineal breakdown.
Incontinence
Peurperal pyrexia
Secondary PPH
VTE
Mental health problems
363
Q

What kind of breast problems can new mothers face?

A 
Nipple pain
Nipple cracks
Bleeding from the nipple.
Breast engorgement
Mastitis
Breast abscess.
364
Q

What causes mastitis?

A

Blocked mammary duct.

365
Q

How is mastitis treated?

A

Antibiotics aimed at staph aureus.

366
Q

How is peurperal pyrexia diagnosed?

A

Temp >38 degrees on any occasion in the first 14 days after birth.

367
Q

What are the possible causes of peurperal pyrexia?

A

Genital tract or urinary tact infections.
Infection of the breast/chest.
DVT/PE

368
Q

What are the risk factors for postnatal sepsis?

A

Maternal obesity

Delivery by caesarean section

369
Q

What are the main causes of secondary post partum haemorrhage?

A

Infection of the uterine cavity

Retained products of conception.

370
Q

What is the thromboprophylaxis for VTE?

A

Low molecular weight heparin.

371
Q

What are the baby blues?

A

50% of women will experience transient feelings of tearfulness and emotional lability in the first few days after birth.

372
Q

What percent of women will experience a depressive illness after giving birth?

A

10%

373
Q

When can post-natal depression occur?

A

Any time in the first year, but peaks at 3-4 months.

374
Q

What are the risk factors for post-partum psychosis?

A

Previous postpartum psychosis.
Bipolar affective disorder
Familly history of postpartum psychosis or bipolar.

375
Q

When does postpartum psychosis typically occur?

A

3-14 days post birth.

376
Q

What are the early signs of postpartum psychosis?

A

Perplexity, fear, agitation, insomnia.
Purposeless activity, disinhibition, uncharacteristic behaviours.
Fear for her own/baby’s health and safety.
Elation and grandiosity, suspiciousness, depression

377
Q

What is the treatment for postpartum psychosis?

A

Admission to a mother and baby unit.
Anti-psychotic or mood stabilising drugs. Antidepressants may also be indicated.
Consider breastfeeding when initiating medication.
Perinatal mental health team for community follow up.
When recovered, discussion re. future illness and ways to reduce risk.

378
Q

What is the definition of stillbirth?

A

A baby delivered with no signs of life that is known to have died after 24 completed weeks of pregnancy.

379
Q

What are the risk factors for stillbirth?

A 
50% unknown.
Advanced maternal age
Maternal obesity
Social deprivation
Smoking
Non-white ethnicity
Domestic violence.
380
Q

What are the fetal causes of stillbirth?

A 
Lethal congenital abnormality
Fetal growth restriction
Infection
Anaemia of fetal origin
Feto maternal haemorrhage
Twin to twin transfusion
Cord obstruction
381
Q

What are the maternal causes of stillbirth?

A

Metabolic disturbance
Reduced oxygen states e.g. pul. hypertension.
Antibody production.
Diabetes

382
Q

What are the placental causes of stillbirth?

A 
Placental abruption
Pre-eclampsia
Maternal renal disease
Antiphospholipid syndromes
Thrombophilia
Smoking
Cocaine use
383
Q

What are the structural causes of stillbirth?

A

Uterine abnormality
Uterine rupture
Placenta praevia
Vasa praevia

384
Q

What are the intrapartum causes of stillbirth?

A

Asphyxia

Trauma

385
Q

What are the processes of fertilisation and implantation?

A

Fertilisation occurs in tube.
Transportation of embryo along tube.
Implantation into endometrium approximately 6 days post fertilisation.

386
Q

What is the definition of miscarriage?

A

Any pregnancy loss before 24 weeks gestation.

387
Q

What is a threatened miscarriage?

A

Bleeding with continuing intrauterine pregnancy.

388
Q

What is an inevitable miscarriage?

A

Bleeeding with non-continuing intrauterine pregnancy (cervix may be open).

389
Q

What is an incomplete miscarriage?

A

Incomplete passage of pregnancy tissue.

390
Q

What is a complete miscarriage?

A

All pregnancy tissue expelled and uterus now empty.

391
Q

What is a delayed/missed/early embryonic demise?

A

Fetus has died in-utero prior to 24 weeks gestation.

392
Q

What is a septic misscariage?

A

Complicated by intrauterine infection.

393
Q

What is recurrent miscarriage?

A

3 or more consecutive miscarriages.

394
Q

What are the symptoms of a miscarriage?

A

Vaginal bleeding - brown spotting to heavy +/- tissue.
Pelvic discomfort or pain.
or asymptomatic.

395
Q

What are the investigations in miscarriage?

A 
Check mother is haemodynamically stable. 
Assess pain and bleeding. 
Removal of products of conception.
Ultrasound scan. 
Examination of products of conception.
Serum HCG tracking.
Assess FBC and blood group.
396
Q

How is a miscarrigae defined on ultrasound?

A

No fetal heart activity >7mm crown rump length of TV scan.
Empty sac when mean gestational sac diameter >25mm on TV scan.
Retained tissue - in incomplete miscarriage.
Empty uterus - complete passage of tissue, pregnancy too early to visualise on scan, ectopic pregnancy.

397
Q

How can a miscarriage be managed?

A

Expectant - intensive follow up and review every 7-14 days.
Medical
Surgical

398
Q

Describe medical management of miscarriage.

A

Misoprostol (oral or vaginal, dose depending on gestation)

70% success.

399
Q

Describe surgical management of miscarriage.

A

Requires cervical priming (usually misoprostol).
Electrical vacuum aspiration under general anaesthetic as daycase.
OR
Manual vacuum aspiration under local anaesthetic as outpatient.

400
Q

When is Anti-D required in miscarriage?

A

If mother Rh negative and if:
<12 weeks vaginal bleed and severe pain.
<12 weeks medical or surgical management.
Any potentially sensitising event >12 weeks.

401
Q

What are the risk factors for an ectopic pregnancy?

A 
Previous ectopic pregnancy
Endometriosis
Pelvic infection
Pelvic surgery
Contraception (progesterone only pill, IUD/IUS)
Assisted conceptoin techniques
Cigarette smoking
402
Q

What is the clinical presentation of ectopic pregnancy?

A

Asymptomatic
Vaginal bleeding - brown spotting to heavy loss
Pelvic discomfort or pain - typically localised to one side +/- shoulder tip pain
Pain with opening bowels
Maternal collapse/hypovolaemic shock

403
Q

When does hCG tracking suggest ectopic pregnancy?

A

<66% increase or <15% decrease.

404
Q

What is the non emergency management of an ectopic pregnancy?

A

Conservative
Medical - methotrexate
Surgical - salpinostomy or salpingectomy

405
Q

What is the suitability criteria for methotrexate?

A 
Pain free
Unruptured ectopic <35mm no FH visible
Serum HCG <5000
Able to return for follow up
No medical contraindications (e.g. anaemia, renal, hepatic impairment, ulcerative colitis, peptic ulcer)
406
Q

How long should somebody wait to get pregnancy after methotrexate mediated miscarriage?

A

12 weeks after HCG <5

- time to replenish folic acid.

407
Q

What is the definition of gestational trophoblastic disease?

A

A group of conditions characterised by abnormal proliferation of trophoblastic tissue with production of HCG.

408
Q

What are the premalignant forms of gestational trophoblastic disease?

A

Partial hydatidiform mole

Complete hydatidiform mole

409
Q

What are the malignatn forms of gestational trophoblastic disease?

A

Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour

410
Q

What are the risk factors for gestational trophoblastic disease?

A

<20 years or >40 years
Previous molar pregnancy
Ethnicity (higher incidence in Korea, Philippines and China)

411
Q

What are the clincal features of gestational trophoblastic disease?

A 
PV bleeding
Enlarged uterus
Hyperemesis gravidarium
Hyperthyroidism
Early onset pre-eclampsia
412
Q

What are the ultrasound features of gestational trophoblastic disease?

A

Snowstorm appearance

413
Q

When does nausea and vomiting in pregnancy settle for most women?

A

16 weeks

414
Q

What is the definition of hyperemesis gravidarum?

A

Persistent vomiting in pregnancy causing weight loss (more than 5% of body mass) and ketosis.

415
Q

What can severe cases of hyperemesis lead to?

A 
Wenicke's encephalopathy
Central pontine myelinolysis
Maternal death (rare)
Higher incidence of intrauterine growth restriction
Significantly smaller at birth.
416
Q

What are the investigations in a woman with hyperemesis gravidarum?

A

Urine - ketones, other causes of vomiting e.g. UTI
Serum - renal function, liver function, thyroid function if clinical signs
USS - multiple pregnancy, molar pregnancy

417
Q

What is the management of hyperemesis gravidarum?

A 
Oral intake advice
IV fluids
Regular antiemetics
Ranitidine/omeprazole
Thromboprophylaxis
Vitamin replacement
Oral steroids
Total pareneteral nutrition (extreme)
Psychological support
Assessment of fetal growth
418
Q

What are the risk factors for having twins?

A

IVF
Maternal age
Ethnic origin - West African
Family history - maternal inheritance

419
Q

What is meant by zygosity?

A

Number of fertilised eggs

420
Q

What is meant by chorionicity?

A

Number of placentas

421
Q

What is meant by amnionicity?

A

Number of sacs

422
Q

What are the risks to the fetus in multiple pregnancy?

A 
Miscarriage
Congenital anomaly
Growth restriction
Pre-term delivery
Specific complications of twins: 
 - acute transfusion
 - twin-twin transfusion
 - twin reversed arterial persuion sequence
423
Q

What are the maternal complications of twins?

A 
Hyperemesis gravidarum
Pre-eclampsia
Gestational diabetes
Placenta praevia
All minor complications
424
Q

What is the management of delivery of twins?

A

Analgesia for mum - often epidural.
Monitoring during labour - maternal: BP, IV access, fluids, ranitidine
Fetal: continous CTG, abdominal and fetal scalp electrode (can be applied to bottoms)

425
Q

Why is there an increased risk of postnatal haemorrhaage with twins?

A

Tone - big floppy uterus
Tissue - double the placentas
Trauma - two babies to fit out

426
Q

What are the maternal postnatal risks in multiple pregnancies?

A

Increased risk of:
Postnatal depression and bereavement
Anxiety
Relationship difficulties

427
Q

What are the specific complications of monochorionic twins?

A

Acute transfusion
Twin-twin transfusion syndrome
Twin reversed arterial persuion sequence

428
Q

What is acute transfusion?

A

Death of one twin in utero leads to increased risk of hypoxic-ischaemic injury in survivor due to acute transfusion from healthy to dying twin.
Risk of exsanguination of healthy twin to dying twin.

429
Q

What is the management of acute transfusion?

A

Delivery needs to be expedited if compromise detected
- to save compromised twin if both twins alive
- to prevent problems in co-twin
If intrauterine death has occured:
- delivery not indicated except near term
- increased monitoring of survivor for anaemia and transfusional brain injury

430
Q

What is twin to twin transfusion syndrome?

A

Chronic net shunting from one twin to the other:
Donor twin - growth restricted, oliguric, anhydramnios
Recipient twin - polyuric, polyhadramnios, cardiac problems, hydrops

431
Q

What is the presentation of twin to twin transfusion syndrome?

A

16-25 weeks

Different liquor volumes.

432
Q

How is twin to twin transfusion syndrome diagnosed using ultrasound?

A

Liquor volume
Bladders seen?
Cord dopplers
Oedema/ascites

433
Q

What is the Quintero staging of twin to twin transfusion syndrome?

A
  1. Discordant liquor volumes.
  2. Bladder not seen in donor.
  3. Abnormal dopplers
  4. Fetal hydrops.
  5. Death of one or both twins.
434
Q

How is twin to twin transfusion syndrome managed?

A

Fetoscopic laser ablation of anastamoses.
Cord occlusion
Management at quaternary referral centre.

435
Q

What is twin reversed arterial perfusion syndrome (TRAPS)?

A

2 cords linked by a big arterio-arterial anastamosis.

Retrograde perfusion - pump twin and perfused twin.

436
Q

How is TRAPS managed?

A

Ablation of anastamosis

437
Q

What are the risks associated with monoamniotic twins?

A

Cord entanglement

Perinatal mortality is high due to cord accidents.

438
Q

What are the risk factors for breech presentation?

A 
Multiple pregnancy
Bicornuate uterus
Fibroids
Placenta praevia
Polyhydramnios
Oligohydramnios
Fetal anomaly
439
Q

What are the risks to the fetus of a vaginal breech delivery?

A 
Intracranial injury
Widespread bruising
Damage to internal organs
Spinal cord transection
Umbilical cord prolapse
Hypoxia
440
Q

What is the management of breech presentation at term?

A

All women should be offered external cephalic version unless contraindicated.
Success rate 50%.

441
Q

What are the absolute contraindications to external cephalic version?

A

When caesarean required regardless of presentation.
Antepartum haemorrhage within the last 7 days.
Abnormal CTG
Major uterine anomaly.
Ruptured membranes.
Multiple pregnancy (except delivery of second twin)
Absence of maternal consent.

442
Q

What are the relative contraindications to external cephalic version?

A 
Nuchal cord
Fetal growth restriction
Proteinuric pre-eclampsia
Oligohydramnios
Major fetal anomalies
Hyperextended fetal head
Morbid maternal obesity
443
Q

What is pre-term?

A

Gestation less than 37 completed weeks.

444
Q

What is low birth weight?

A

<2501g

445
Q

What is the incidence of preterm birth?

A

10%

446
Q

How can the incidence of respiratory distress syndrome be reduced in babies that need to delivered early?

A

Maternal corticosteroid injections

447
Q

What are the local causes of antepartum haemorrhage?

A

Vulva
Vagina
Cervix - cervical ectropion or cervical polyp
Rare - cervical carcinoma

448
Q

What are the placental causes of antepartum haemorrhage?

A

Placenta praevia

Placental abruption

449
Q

What is placenta praevia?

A

Placenta in lower segment of uterus, with lower segment extending 5cm from the internal cervical os.

450
Q

What is the management of placenta praevia?

A

May be admitted from 30-32 weeks until delivery, but often outpatient management if no bleeding.
Elective delivery at 38-39 weeks.
Earlier emergency delivery may be required if haemorrhage occurs.

451
Q

What is an abnormally invasive placenta?

A

Placenta invades the myometrium and cannot be readily separated from the uterus following delivery.

452
Q

What are the risks of an abnormally invasive placenta?

A

Increased risk of massive postpartum haemorrhage.

May require hysterectomy.

453
Q

What are the risks associated with placental abruption?

A

Placental separation results in reduced area for gas exchange between fetal and maternal circulation. Predisposes to fetal hypoxia and acidosis.

454
Q

What are the risk factors for placental abruption?

A 
Previous abruption
Hypertension
Thrombophilia
Premature rupture of membranes
Multiple pregnancy
Folic acid deficiency
Cocaine
Smoking
Social deprivation
455
Q

What is the management of placental abruption in cases of light bleeding?

A

A brief episode of inpatient observation and surveillance of fetal growth with ultrasound fetal biometry.
Repeated episodes may lead to a decision to deliver early.

456
Q

What are the clinical features of a major concealed abruption?

A

Pain
Uterine tenderness
Hypovolaemic shock

457
Q

What is the management of a major abruption?

A

Delivery

458
Q

What is the presentation of placenta praevia?

A

Painless bleeding
Non-engaged presenting part
Soft uterus

459
Q

What is the presentation of placental abruption?

A

Painful bleeding

Hard “woody” uterus

460
Q

Which part of the uterus is sloughed each month in the menstrual cycle?

A

The endometrium

461
Q

What counts as heavy menstrual bleeding?

A

Bleeding that has an adverse impact on a woman’s QOL.

462
Q

What are the causes of heavy menstrual bleeding?

A 
Uterine causes:
 - Fibroids
 - Endometrial polyps
 - Adenomyosis
 - Pelvic infection
 - Endometrial malignancy
Medical disorders:
 - Clotting disorders
In absence of pathology:
 - anovulatory
 - ovulatory
463
Q

How should heavy menstrual bleeding be investigated?

A 
Test for coagulation disorders
Serum ferritin test
Female hormone testing
Thyroid testing
Endometrial biopsy should be taken
Ultrasound
464
Q

What is the pharmacological treatment for heavy menstrual bleeding?

A

Mefenamic acid

  • prostaglandin synthase inhibitor
  • take during menses

Tranexamic acid

  • antifibrinolytic - inhibits plasminogen activator, reducing fibriolytic activity in endoemtrium
  • take during menses
465
Q

What is the medical hormonal management of heavy menstrual bleeding?

A

Combined oral contraceptive pill
Progestogens - POP, depo-provera, nexplanon
Local - LNG-IUS
GnRH analogues

466
Q

How do GnRH analogues work to treat heavy menstrual bleeding?

A

Usually pulsatile release of GnRH from hypothalamus.
Continuous levels ‘switch off’ FSH and LH release from pituitary.
Useful in the short term (6 months to 2 years)
Can shrink fibroids up to 40%.
Improve haemoglobin.
Can be combined with HRT
Administer by injection.

467
Q

What are progesterone rececptor modulators?

A

Bind principally to progesterone receptors.
Little effect on ovarian function.
Act directly on endometrium (mainly on blood vessels).
Induce amenorrhoea.
Shrink fibroids by 20-40%.
Well tolerated, oral medication.

468
Q

Give a non-pharmacological way of managing heavy menstrual bleeding?

A

Endometrial ablation

Hysterectomy

469
Q

What is amenorrhoea?

A

Absent menses.

470
Q

What is primary amenorrhoea?

A

Failure to menstruate by age 15 years.

May be associated with normal or delayed/absent development of secondary sexual characteristics.

471
Q

What is secondary amenorrhoea?

A

Established menses stop >6 months, in the absence of pregnancy

472
Q

What is oligomenorrhoea?

A

A cycle which is persistently greater than 35 days in length.

473
Q

What are the investigations of primary amenorrhoea?

A

Plasma FSH, LH oestradiol, prolactin, TFT
Karyotype
X-ray for bone age
Cranial imaging

474
Q

What is the most common cause of anovulatory infertility?

A

Polycystic ovarian syndrome.

475
Q

How is PCOS diagnosed?

A 
Rotterdam criteria:
Requires 2 of 3:
 - clinical or biochemical evidence of hyperandrogenism (high free androgen index)
 - oligomenorrhoea/amenorrhoea
 - ultrasound features of PCOS
476
Q

What are the consequences of PCOS?

A 
Reduced fertility
Insulin resistant diabetes
Hypertension
Endometrial cancer 'unopposed oestrogen'
Depression and mood swings
Snoring and daytime drowsiness
477
Q

What is the management of PCOS?

A

Education
Weight loss and exercise
Endometrial protection (progesterone or withdrawal bleed)
Fertility assistance
Lifetime awareness +/- screening for complications

478
Q

What is dysmenorrhoea?

A

Excessive menstrual pain.
Characteristically involves cramping lower abdominal pain that may radiate to the lower back and legs.
May be associated with GI symptoms or malaise.

479
Q

Describe primary dysmenorrhoea.

A

Begins with onset of ovulatory cycles.
Typically within the first 2 years of the menarche.
Pain is usually most severe on the day of or the day prior to the start of menstruation.

480
Q

What is the aetiology of primary dysmenorrhoea?

A

Prostaglandins involved - higher concentrations of PGE2 and PGF2.

481
Q

What is the management of primary dysmenorrhoea?

A

NSAIDs
COC
Depot progestogens
Intrauterine system.

482
Q

What is secondary dysmenorrhoea?

A

Dysmenorrhoea associated with pelvic pathology.

483
Q

Which pathologies commonly cause secondary dysmenorrhoea?

A

Endometriosis
Adenomyosis
Pelvic infection
Fibroids

484
Q

What counts as post menopausal bleeding?

A

Bleeding occuring >12 months after last menstrual period.

485
Q

What is the investigation of intermenstrual bleeding and post coital bleeding?

A

Cervical smear history (do not take if not due)
Speculum and bimanual examination
STD screen and treat
Urine pregnancy test

486
Q

What kind of bleeding would cause an urgent gynaecology referral?

A

Women over 35 with persisitent (over 4 weeks) post-coital or intermenstrual bleeding.

487
Q

What kind of bleeding would cause a routine gynaecology referral?

A

Women under 35 with postcoital or intermenstrual bleeding persisting for over 12 weeks.
A single heavy episode of post-coital or intermenstrual bleeding at any age.

488
Q

What are the investigations of post menopausal bleeding?

A

Biopsy if ET >3mm (non-HRT and CC-HRT users)
Biopsy if ET>5mm (sequential HRT users)
Hysteroscopy/biopsy in tamoxifen users

489
Q

What percentage of post menstrual bleeding presentations are due to cancer?

A

5%

490
Q

What is the most common type of ovarian tumour?

A

Epithelial ovarian cancer

491
Q

What are the two types of epithelial ovarian cancer?

A
  1. High grade serous - resembles falopian tube mucosa. P53 mutations
  2. Arise from ovarian surface epithelium and mullerian inclusion cysts - endeometriod, clear cell, mucinous, low grade serous.
492
Q

How does ovarian cancer spread?

A 
Direct extension (transcoelemic)
Exfoliation into the peritoneal cavity.
Lymphatic invasion.
493
Q

What are the risk factors for ovarian cancer?

A 
Low parity
Infertility
Tubal ligation
Early menarche
Late menopause
494
Q

Which genes and syndromes are associated with ovarian cancer?

A

BRCA1
BRCA2
Lynch syndrome

495
Q

What is the presentation of ovarian cancer?

A 
Vague non specific symptoms! 
Altered bowel habit
Abdominal pain/bloating
Feeling full quickly
Difficulty eating
Urinary/pelvic symptoms
Bowel obstruction
Shortness of breath
496
Q

What are the clinical signs of ovarian cancer?

A 
Abdominal distension
Upper abdominal mass
Pleural effusion
Nodules on PV examination
Rarely - paraneoplatic syndromes
497
Q

What are the investigations of ovarian cancer?

A

Ultrasound scan
CA125
Calculate RMI (risk of malignancy index)
CT

498
Q

What is CA125?

A

Glycoprotein antigen elevated in some malignancies (ovary, pancreas, breast, lung, colon)

499
Q

What is the management of ovarian cancer?

A

Surgery
Chemotherapy
Decided at MDT

500
Q

How is ovarian cancer diagnosed?

A

Cytology - pleural/ascitic fluid

Histology - biopsy

501
Q

What is the peak age at which endometrial cancer develops?

A

65 years

502
Q

What is the presentation of endometrial cancer?

A 
Postmenopausal bleeding
Post coital bleeding
Intermenstrual bleeding
Altered menstrual pattern
Persistent vaginal discharge
503
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma

504
Q

What are the two types of endometrial adenocarcinoma?

A

Type 1 - oestrogen excess (endometroid)

Type 2 - not oestrogen excess (papillary serous, clear cell)

505
Q

What are the risk factors for endometrial carcinoma?

A 
Obesity
Physical inactivity
HRT
Diabetes
Nulliparity
Longer menstrual lifespan
506
Q

What are the investigations in endometrial cancer?

A

Transvaginal scan
MRI
CT/PET CT
Biopsy (pipelle)

507
Q

What is the treatment for endometrial cancer?

A

Total hysterectomy + bilateral salpino oopherectomy + washings.

In advanced disease, also:
consider chemotherapy, radiotherapy, hormonal treatment

508
Q

What is meant by direct maternal death?

A

As a consequence of a disorder specific to pregnancy.

509
Q

What is meant by indirect maternal death?

A

Death resulting from previous existing disease

510
Q

What are the emergencies in obstetrics?

A 
Post partum haemorrhage
Antepartum haemorrhage
Eclampsia
Amniotic fluid embolus
Uterine inversion
Uterine rupture
Intra-abdominal bleeding
Genital tract haematoma
Fetal malpresentation
Fetal distress
511
Q

What are the emergencies in gynaecology?

A

Ectopic pregnancy
Miscarriage
Postoperative/intra-abdominal bleeding

512
Q

What is secondary post partum haemorrhage?

A

Occuring between 24 hours and 12 weeks postnatally.

513
Q

What are the four Ts that can cause post partum haemorrhage?

A

Thrombin (clotting disorders)
Tissue
Tone
Trauma

514
Q

How should post partum haemorrhage be managed?

A 
Bimanual uterine compression
Empty bladder
Oxytocin
Ergometrin 500mcg
Misoprostol
Hysterectomy
Uterine artery embolisation
515
Q

Which drugs can be used to promote uterine contractility?

A

Syntocinon
Ergometrine
Carboprost
Misoprostol

516
Q

What are the causes of secondary post partum haemorrhage?

A

Usually associated with infection +/- retained tissue.

517
Q

What are the specific causes of collapse in pregnancy?

A

Eclampsia

Amniotic fluid embolism

518
Q

What are the maternal complications of pre-eclampsia?

A 
Intracranial haemorrhage
Placental abruption and DIC
Eclampsia
HELLP syndrome
Renal failure
Pulmonary oedema
Acute respiratory arrest
519
Q

What are the fetal complications of pre-eclampsia?

A 
Intrauterine growth restriction
Oligohydramnios
Hypoxia from placental insufficiency
Placental abruption
Premature delivery
520
Q

What is the management of hypertension in moderate pre-eclampsia?

A

Oral labetalol if systolic BP reaches 150-160mmHg

521
Q

What is the management of hypertension in severe pre-eclampsia?

A

Oral/IV labetalol
Oral nifedipine
IV hydralazine

522
Q

What is eclampsia?

A

One or more convulsions in association with pre-eclampsia.

523
Q

Which drug is used to treat eclamptic seizures?

A

Magnesium sulphate

524
Q

When should magnesium sulphate be considered as treatment?

A

In women with severe pre-eclampsia where birth is planned within the next 24 hours.
After eclamptic fit.

525
Q

What are the signs of magnesium sulphate toxicity?

A

Loss of deep tendon reflexes.
Respiratory depression
Respiratory arrest
Cardiac arrest

526
Q

What is the average age of the menopause?

A

52 years

527
Q

What is considered premature menopause?

A

<40 years

528
Q

What are the symptoms of the menopause?

A 
Vasomotor symptoms (hot flushes, night sweats)
Vulvo-vaginal dryness
Sleep disturbance
Mood disturbance
Sexual dysfunction
529
Q

What are the methods for oestrogen replacement?

A 
Oral
Transdermal patch
Vaginal ring
Pessary
Gel 
Cream

Fifth Year Medicine (9 decks)

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