Obstetrics and Gynaecology (rotation To Come) Flashcards
What would you expect to feel in a normal gravid abdomen of 14 weeks?
Uterus ..?
When you would be able to palpate a gravid uterus above the pubic symphysis
12 weeks
What usually happens with thyroid function during pregnancy?
Increased excretion of iodine; hypothyroidism.
What are the risks of poorly controlled hypothyroidism in pregnancy?
High blood pressure
Anaemia
muscle pains
Is gastric reflux common in pregnancy?
Yes, very common
How would you manage this in pregnancy?
Eat smaller meals, more frequently.
Eat more slowly.
Proton pump inhibitors e.g. Omeprazole
Antacids
What is the COCP?
Give 2 advantages and 2 disadvantages
Combined oral contraceptive pill:
oestrogen and progesterone.
Advantages: Can be used to make periods lighter, less painful, helps with acne,
Disadvantages: Does not protect against STDs, if you miss a pill = reduced effectiveness.
Give x2 examples of a combined oral contraceptive pill (COCP).
Microgynon
Yasmin
What is common a disadvantage to the trans-dermal patch, subdermal ptach and intra-muscular injection?
Do not protect against STDs.
What is the mechanism by which a lot of contraceptive medications work?
Thickens cervical mucus thinnens the endometrial lining.
What is Cerazette?
Progesterone only pill (POP).
What is the progestogen IUS?
Progestogen intrauterine system
What is a salpingectomy?
Surgical removal of the fallopian tube.
What is an ectopic pregnancy and what do we worry about with it?
We worry about a ruptured fallopian tube; fertilised egg implants itself outside of the womb.
A 28-year-old woman has 4 days of lower abdominal pain, vaginal discharge and deep
dyspareunia can be signs of what.
Pelvic inflammatory disease. treat with antibiotics e.g. ceftriaxone, doxycycline.
Give x3 main signs of an ectopic pregnancy
Vaginal bleeding with or without clots
Amenorrhoea/ missed periods
Abdominal or pelvic pain
Pelvic tenderness
Which condition can have similar symptoms to a gastrointestinal infection/ UTI?
Ectopic pregnancy
How many women with ectopic pregnancy will have no known risk factors?
1/3
Define gestation.
The period between conception and birth.
What is the key test in assessing potential ectopic pregnancy/ miscarriage.
Transvaginal ultrasound.
What is the most accurate way to determine gestational age of a foetus?
Crown-rump length on an ultrasound.
= from top of its head to bottom of torso.
Which are the two most important diagnostic factors in determining miscarriage/ ectopic pregnancy?
hCG levels and ultrasound
What is the role of hCG?
Maintains the corpus luteum which allows for production of progesterone = thickens uterus lining to sustain growing foetus.
What level of hCG is likely to point toward a miscarriage?
A reduction of 50% or greater hCG after 48 hours.
Which medication do we give to treat a miscarriage?
Misoprostol 800mcg (if single use dose)
How do we differently treat missed and incomplete miscarriages?
Missed miscarriage = single dose 800mcg misoprostol
Incomplete miscarriage = single dose 600mcg misoprostol.
Which medication do we give to treat ectopic pregnancy?
Methotrexate.
How does methotrexate work in ectopic pregnancy?
Interferes with nucleic acid synthesis through competitive inhibition with folate dependent steps.
To women who have been treated surgically for an ectopic pregnancy or miscarriage, what can we additionally offer them?
Anti D Rhesus
What is endometriosis?
Growth of endometrial tissue outside of the uterus.
Give 3 risk factors for endometriosis.
Early menarche, prolonged menstruation, shortened menstruation, family history.
What is the word given to describe painful periods.
Dysmenorrhoea.
Define dysmenorrhoea
Pain during or before menstruation in the absence of endometriosis.
Give x3 symptoms of endometriosis
Pelvic pain before or during menstruation. (need to mention before or during menstruation).
Dyspareunia (pain during deep sex)
Dyschezia (pain upon defecation)
Subfertility
What is the word used to describe heavy bleeding?
Menorrhagia
How do we differentiate between fibroids and endometriosis?
We see menorrhagia in fibroids but not in endometriosis.
How do we investigate endometriosis and what may we find?
Bimanual examination and speculum Transvaginal ultrasound (TVUSS) Gold standard = laparoscopy - reduced mobility - retroverted uterus - endometriotic lesions
What is the gold standard in investigating endometriosis?
Laparoscopy where we will see red vesicles.
White scars/brown spots = less active endometriosis.
How can we treat endometriosis?
Paracetamol + NSAIDS = block prostaglandins = helps with pain. COCP to control cycle Laparoscopic ablation Hysterectomy GnRH analogues = shrink endometriosis.
What is leuprorelin?
A GnRH analogue.
What is the parametrium?
The fat connective tissue around the uterus.
What is a total hysterectomy?
Uterus and cervix is removed.
When will a smear be needed?
As long as the cervix is left intact and not removed. e.g. subtotal hysterectomy.
What are the ways in which a hysterectomy may be performed?
Vaginal (quicker healing and recovery)
Laparoscopic
Name two indications for a hysterectomy.
Uterovaginal prolapse
Cervical carcinoma
What is a hysteroscopy?
Passing a small telescope through the cervix to inspect the uterus.
What is the order superior to posterior for the cervix, uterus and vagina?
Uterus
Cervix
Vagina
Name 3 indications for a hysteroscopy.
HMB (menorrhagia)
PCB (post-coital bleeding)
PMB (pre-menstrual bleeding)
What is Asherman’s syndrome?
Having scar tissue in the uterus/cervix.
What is the cervix?
The opening to the uterus.
Which signs are characterised by overflow incontinence?
Urinary straining
Poor flow
Incomplete emptying
Which medication may we avoid in elderly people due to an increased risk of falls?
Oxybutynin
What is the largest increased risk of ovarian cancer?
Early menarche
What do we commonly prescribe against nausea and vomiting?
Ondansetron
Which medication do we use to manage miscarriages?
Misoprostol
Bladder training is advised for which type of incontinence?
Urge incontinence
Pelvic floor muscle training is advised for which type of incontinence?
Stress incontinence
Bladder leakage made worse by coughing or sneezing is most likely to be due to which type of incontinence?
Stress incontinence
Which medication can we use to treat stress incontinence?
Duloxetine
The ‘whirlpool sign’ is a sign of what?
Ovarian torsion
What affect does the COCP have on endometrial cancer risk?
Combined oral contraceptive pill is protective against endometrial cancer.
Name one form of emergency contraception.
Levonorgesterol (within 72 hours) Copper IUD (a LARC)
What is a LARC?
Long acting reversible contraception (does not protect against STIs).
How does the Copper IUD work?
Spermicide and prevents implantation, whereas levonorgesterol stops ovulation and prevents implantation.
What form of contraception is Microgynon 30?
COCP
The COCP increases the risk of ovarian cancer. True or false.
False. Reduces the risk of ovarian and endometrial cancer.
Increases the risk of breast cancer, VTE and stroke.
Which drug can cause endometrial hyperplasia?
Tamoxifen; on endometrium = pro-oestrogenic effects.
What do cervical smears test?
high risk HPV.
What is Clomiphene?
Ovarian induction therapy
What are patients on ovarian induction therapy at risk of developing?
Ovarian hyperstimulation syndrome; Clomiphene is an oestrogen receptor modulator. When Clomiphene binds to the oestrogen receptor, it stimulates LH and FSH = stimulates ovarian follicle development.
Patients on IVF may be at risk of developing…?
Ovarian hyperstimulation syndrome.
What is stress incontinence characterised by?
Associated with raised abdominal pressure e.g. sneeze, cough.
What is urge incontinence characterised by?
A sudden need to urinate
Give three characteristics of PCOS.
Infertility issues
Hirsutism
Weight gain
Acne
How can the COCP mask PCOS?
COCP will reduce hirsutism due to oestrogen, and will regulate periods
What is Mittelschmerz?
Small amount of fluid released during ovulation. Pain typically over 24-48 hours, sharp onset pain.
How does ovarian torsion usually present?
Deep colicky pain associated with vomiting and distress. Vaginal examination may reveal adnexal tenderness. Diagnosed by laparoscopy.
What does the adnexa refer to?
Fallopian tubes, ovaries and ligaments.
What is a cervical ectropion?
Red cells inside the cervix grow on the outside - commonly increased risk with the COCP.
What is the first line investigation for menorrhagia?
Tranexamic acid if contraception is not needed.
Mirena coil if contraception is needed.
Norethisterone 5mg if short term.
How is menorrhagia defined?
> 80ml loss of blood per menses.
2 week history of light vaginal bleeding, and mild pain on intercourse. She is otherwise well. On vaginal examination she is tender and has slight dryness. Investigation of choice?
Transvaginal ultrasound.
What kind of presentation represents that of an ectopic pregnancy?
Amenorrhoea
Abdominal pain
Vaginal bleeding
What is an ectopic pregnancy?
Implantation of ovum outside of the uterus.
Which are the two types of cervical cancer?
Adenocarcinoma
Squamous cell carcinoma
Women who smoke are at a two-fold increased risk of developing cervical cancer than women who do not. True or false.?
True.
Positive hrHPV, normal cytology. When should next smear be performed?
In 12 months. As long as these results keep coming = keep repeating in 12 months.
With -hrHPV and normal cytology, what is the normal recall for smear testing?
3 years for 25-49 years.
5 years for 50+ years.
When may Duloxetine be used?
In stress incontinence for those who do not respond to pelvic floor muscle exercises.
Is oxybutynin used in stress or urge incontinence?
Urge incontinence
Cyst sometimes referred to as chocolate cysts due to the external appearance
Endometriotic cyst
Which is the most common ovarian cancer?
Serous carcinoma; most commonly epithelial in origin.
An ultrasound done on a 23-year-old female for recurrent urinary tract infections incidentally shows a 3 cm ‘simple cyst’ on the left ovary. She is asymptomatic. What type of cyst is this?
Follicular cyst.
Which is the most common type of cyst found on the ovary?
Follicular cyst.
Should we be worried about cysts found early in pregnancy?
No; these cysts are functional
Widely spaced nipples and amenorrhoea are seen in which condition?
Turner’s syndrome.
Associated with high FSH, LH.
What kind of bHCG levels point toward an ectopic pregnancy?
> 1,500 points.
In patients with urinary incontinence, which tests should we perform and why?
Urine dipstick and culture; rule out UTI.
What is a leiomyoma?
Fibroids of the uterus which are benign. Can increase the risk of infertility, miscarriage.
A 46-year-old female presents with a 6 month history of abdominal pain and menorrhagia. On examination the abdomen is non-tender and the uterus feels bulky. What is the most likely diagnosis?
Fibroids.
How do we medically manage miscarriages?
Misoprostol.
How do we define a threatened miscarriage?
The cervical os is closed.
How do we classify miscarriages?
By ultrasound to see if there is a fetal heartbeat, the size of the uterus and whether the cervical os is open or closed.
If a woman presents with abdominal pain and bleeding, what is the most important thing to rule out?
Ectopic pregnancy.
Which is the active ingredient in the mirena coil?
Levonorgesterel.
A patient presenting with ataxia and diplopia could have what diagnosis that we would want to exclude?
Wernicke’s Encephalopathy.
Treat with pabrinex (vitamin B and C).
Which is the marker for ovarian cancer?
CA 125.
CA 19-9 is a marker for which cancer?
Pancreatic cancer.
CEA is a marker for which cancer?
Bowel cancer.
What is the difference between primary and secondary amenorrhoea?
Primary amenorrhoea = Patient has not had period by age 14
Secondary amenorrhoea = Patient has not had period for >6 months but has had periods in the past
Give 3 causes of primary amenorrhoea.
Constitutional delay e.g. late bloomer
Anatomical e.g. mullerian agenesis = absence of female sexual organs.
Turner syndrome
Older woman with lymphadenopathy and a labial lump should make one question which diagnosis?
Vulval carcinoma
What is Bartholin’s cyst?
Small fluid-filled cyst.
If a woman is reluctant to go on to HRT, which medication can she be prescribed to control hot flushes?
Fluoxetine i.e. An SSRI - selective serotonin reuptake inhibitor.
Which drug is most likely to help restore normal ovulation in a case of PCOS struggling to conceive?
Metformin to lose weight.
What is a Bartholin’s cyst?
Painful, soft lump on examination as well as being fluid-filled.
How can we differentiate between ovarian torsion and an ectopic pregnancy clinically?
Ectopic pregnancy is likely to present with vaginal bleeding and amenorrhoea, whereas ovarian torsion = vaginal bleeding likely.
What is the typical treatment for endometrial hyperplasia in post menopausal women?
Total hysterectomy with bilateral salpingo-oophorectomy; risk of malignancy progression.
What is the cut off for ectopic pregnancies to be managed surgically in size and hCG levels?
> 35mm and serum B-hCG >1500IU/L.
When would you recall a smear in 12 months?
Normal cytology, positive hRHPV.
What is a major side effect of ovarian induction?
Ovarian hyperstimulation syndrome.
= ovarian enlargement, cystic spaces, increased capillary permeability = fluid shift from intravascular to extravascular spaces.
Which medication can cause ovarian hyperstimulation syndrome?
Gonadotrophin therapy.
Which medication is used for ovarian induction?
Gonadotrophin therapy = risk of ovarian hyperstimulation syndrome
A 22-year-old woman requests emergency contraception. She had unprotected sex 4 days
ago. She does not want to have a coil fitted. What is the most appropriate management?
Ulipristal Acetate (EllaOne) NOT Levonorgestrel.
Levonorgestrel is only effective within 72 hours.
When are miscarriages most likely to happen?
1st trimester
Which is Trisomy 18?
Edward’s syndrome
What is Klinefelter’s syndrome?
Extra X Chromosome
What is Trisomy 13?
Patau syndrome - during embryogenesis, the face doesn’t develop properly = ‘cyclops face’
What is Monosomy X?
Turner’s syndrome
What is molar pregnancy?
Egg ejects material and DNA meets egg without genetic material. When sperm and egg meet, only spermatic material so sperm material only duplicates = double paternal genes.
= no foetus.
Rapidly growing uterus but no baby on ultrasound scan
How will a molar pregnancy come up on ultrasound?
Snowstorm appearance on ultrasound
What is a partial mole?
3 sets of genes - 2 paternal and 1 maternal. Non viable foetus.
Needs a termination of pregnancy and evacuation.
What shows a snowstorm appearance on ultrasound?
Complete Mole
Where can ectopic pregnancies occur?
Ovarian, cervical, tubal, interstitial
Where is the most common site for ectopic pregnancies to occur?
Ampullary
Which is the first line investigation for ectopic pregnancies?
Laparoscopy
What is placenta previa?
Placenta covers the exit for the baby = massive blood loss.
What is placental abruption?
Placenta comes away from wall and causes severe blood loss. cocaine a big risk factor.
Which placenta invades through the endometrium but not into the myometrium?
Placenta accreta
Which placenta goes through the uterine serosa all the way into abdomen?
Placenta percreta
Which placenta is implanted over the cervical os?
Placentra Praevia
Which placenta invades through the endometrium into the myometrium?
Placenta increta
What is Mullerian duct anomaly?
Presence of AMH - anti-mullerian hormone = develop testes.
Describe the 3 stages of uterus formation.
2 separate sections should fuse with middle part of the uterus becoming resorbed
Name some abnormalities of the uterus.
Unicornuate uterus, unicornuate with a horn
Give some causes of primary amenorrhoea.
Mullerian agenesis
Damage to which embryological structure will result in renal agenesis?
Metanephros
Bicornuate uterus may arise as a result of…
Failure of mullerian duct fusion
CBAVD (congenital bilateral absence of vas deference) is often seen in cystic fibrosis. Which embryological structure has been affected?
Wolffian duct (made from mesonephric tissue)
What is the Wolffian duct made from?
Mesonephros
How many umbilical arteries and veins are there?
2 umbilical arteries, one umbilical vein
Which structure does ductus arteriosus become? (PDA)
Ligamentum arteriosum
What can we use to keep a shunt open a little longer e.g. if we still need a blood supply?
NSAIDS - indomethacin
How does the foramen ovale close? Which structure does this leave?
Foramen ovale is a R-L shunt. After first breath, pressure in left atrium increases and shuts the flap.
Fossa ovalis
What is the ductus venosus? Which structure does it become?
Which structure becomes the ligamentum teres?
Shunt in the liver which becomes ligamentum venosum.
The umbilical vein becomes the ligamentum teres.
What happens to the umbilical arteries during feotal circulation development?
Umbilical arteries regress and become medial umbilical ligaments.
Which structure becomes the ligamentum venosum?
Ductus venous
Which structure becomes the ligamentum teres of the liver?
Umbilical vein
Which structure becomes median umbilical ligament?
medial = umbilical arteries
Allantoic duct
12yo female presents to ED with severe acute pelvic pain. She has been getting worsening monthly discomfort for the last 3 months. Likely diagnosis?
Imperforate hymen; happens monthly (in relation to cycle)
19yo pregnant patient presents with severe vomiting and a “large for dates” uterus. Ultrasound shows a “snowstorm” appearance. What is the karyotype?
Complete mole = 46XX
Name the 7 layers of the abdominal wall
Below the arcuate line: Skin fat rectus sheath rectus peritoneum (parietal and visceral) uterus muscle layer
Which are the most common types of incision for C Section?
Pfannenstiel or Joel-Cohn
Which arteries supply the abdominal wall?
Superior and inferior epigastric arteries (have to take great care not to rupture these in laparoscopy)
What is Palmer’s point?
3cm below costal margin at the left midclavicular line
With multiple C sections can get adhesions so can use palmer’s point to place camera inside.
Name the borders of the pelvic inlet
sacral promontory
arcuate line
pubic symphysis
Name the borders of the pelvic outlet
Pubic arch
Ischial tuberosity
Tip of coccyx (posterior border)
What are the two triangles of the perineum?
Urogenital triangle
Anal triangle
What is a pudendal nerve block?
The pudendal nerve supplies which structures?
Clitoris, perineum and anus
Do we ever do an episiotomy prophylactically?
Never.
When do we do an episiotomy?
To avoid tearing
name the layers cut in a c section
skin anterior rectus sheath visceral peritoneum parietal peritoneum etc. (7 layers)
What is the posterior corner of the perineal diamond/ anal triangle?
Coccyx
Midline episiotomies are no longer recommended by RCOG. What structure would be damaged in this procedure?
Perineal body
Name the muscles of the levator ani.
Puborectalis
iliocococcygeus
Pubococcygeus
Name the herniation of the bladder through the levator hiatus.
Cystocele
When does progesterone peak in the cycle?
1 week after LH surge
Which hormone does not peak at day 14 of the menstrual cycle?
Progesterone
Which is the structure of progesterone production during pregnancy?
Corpus luteum > placenta
What problem is most associated with a patent foramen ovale?
Stroke NOT pulmonary issues!
Give one indication of an episiotomy.
Prior to instrumental delivery
Which hormone is responsible for preparing the endometrial lining for implantation and for secondary sexual characteristics?
Estradiol. = makes endometrial lining grow
breast development
Name which infections are screened for antenatally.
HIV, rubella, syphillis, hepatitis B NOT hepatitis C.
A woman with a history of epilepsy takes levetiracetam 250mg twice daily and is trying to conceive. What should she be advised?
Take folic acid 5mg OD before conception until 12 weeks of pregnancy.
Epileptic patients require a higher dose of folic acid.
What is the standard dose of folic acid for pregnant women vs. epileptic women?
Normal: Take 400mcg OD from conception up to 12 weeks pregnant.
Epileptic women: Take 5mg OD from conception up to 12 weeks pregnancy.
What defines gestational diabetes?
Glucose >7mmol/L.
When is a nuchal scan performed?
11-13 weeks.
What is the name for difficult or slow labour?
Dystocia
Which tests are involved in Down’s syndrome antenatal screening?
Nuchal translucency, B-hCG, PAPP-A
What is PAPP-A?
Pregnancy associated plasma protein A.
Which is the biggest risk factor for cord prolapse?
Artificial rupture of membranes
What is CTG?
Cardiotocography - measures pressure changes in the uterus.
What is the normal foetal heart rate?
100-160beats/min
What may variable decelerations (heart rate) in the foetus indicate?
Cord compression
Certain anti-epileptic medication should be stopped during pregnancy. True or false.
False; Breast feeding is acceptable with nearly all anti-epileptic drugs.
When is nuchal translucency done?
First trimester 11-14 weeks
When is amniocentesis usually carried out?
Between 15th-20th week i.e. 2nd trimester.
Define tocolytic
Medication used to suppress premature labour
Name five risk factors for Post partum haemorrhage
Macrosomia (big babies) Increased maternal age Multiple pregnancies Polyhydraminos Placenta praevia, placenta accreta
Epilepsy during pregnancy requires how much folic acid?
5mg OD
A23 year old with painless vaginal bleeding, excessive morning sickness and shortness of breath. Routine examination of the patient’s abdomen reveals a uterus which extends up to the umbilicus. Ultrasound revealed a solid collection of echoes with numerous small anechoic spaces. What is the most likely diagnosis?
Molar pregnancy - Hydatidiform mole
At what number of weeks can we put problems down to pregnancy e.g. high blood pressure?
20 weeks
What is the normal foetal heart rate?
100-160bpm
What does the cTG measure?
Foetal heart rate and uterine contractions
What is the frequency of contractions you would expect during labour?
1 contraction every 2 minutes
What defines a first, second and third degree tear?
First degree tear = tear in vaginal mucosa only
Second degree tear = tear into submucosal tissue
Third degree tear = tear in external anal sphincter
Fourth degree = through external anal sphincter and rectal mucosa
How many antenatal visits do NICE recommend in the first and subsequent pregnancies?
First pregnancy = 10 antenatal visits
Subsequent = 7 visits
At which week do we give anti-D prophylaxis?
28 weeks.
When does the first antenatal visit occur?
8-12 weeks - ideally less than 10 weeks
What is lochia?
Fluid that is discharged from the vagina for a week or so after childbirth.
Ultrasound required if >6 weeks
31 weeks gestation presents with vaginal bleeding and severe abdominal pain. It is a severe dull pain in the suprapubic region and doesn’t radiate anywhere. She says it is a 10/10 severity. She passed about 2 cupfuls of blood 1 hour previously. She also complains of back pain and is exquisitely tender on suprapubic palpation. Which is the most likely diagnosis?
Placental abruption
What is the difference in presentation between placental abruption and placenta praevia?
Placental abruption = pain
Placenta praevia usually presents without pain.
What is placental abruption?
Placenta separates from uterine wall = causes haemorrhage.
What are some causes of placental abruption?
Multiparity, increased maternal age, cocaine use.
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
Placenta praevia.
Key word: painless!
What is the pattern of the markers in Down’s syndrome?
High nuchal translucency
High b-hCG
low PAPP-A
low b-HCG is more indicative of Patau’s or Edward’s syndrome.
Which is the first line management for post partum haemorrhage?
Intrauterine balloon tamponade.
Which is the scale used for Post natal depression in pregnant women?
The Edinburgh scale
What are the stages of post-partum thyroiditis?
Starts off with thyrotoxicosis and then proceeds to hypothyroidism for the most part.
What is the timing for taking folic acid during pregnancy?
From gestation until 12 weeks.
So UNTIL 12 weeks.
How do we measure the symphysis-fundal height?
Top of the pubic bone to the top of the uterus.
Which is the first line to induce labour?
Prostaglandin E2 NOT oxytocin.
How do we first line manage Shoulder dystocia?
McRobert’s manoeuvre.
= bringing the mother’s thighs toward abdomen.
What is the first stage of labour and what is the exact measurement?
Cervical dilatation, 10cm
The birth of the foetus defines which stage of the labour?
End of second stage of labour.
What is the choice of first line investigation for mastitis?
Flucloxacillin
A 26-year-old primigravida presents at 39 weeks with rupture of membranes and bleeding. She describes a flood of cloudy fluid followed by continuous vaginal bleeding. She is very anxious but denies any localised pain or tenderness. Her pregnancy has so far been uncomplicated, but she has not attended her antenatal scans. Cardiotocography indicates bradycardia and late decelerations. What is the most likely diagnosis?
Vasa praevia; vaginal bleeding and foetal bradycardia.
What is the causative pathogen in Bartholin’s abscesses?
Neisseria Gonorrhoea
What is Bartholin’s cyst?
Painless fluid filled cyst near opening of the vagina
How do we investigate HSV?
Viral culture swabs
Serology
HSV DNA by PCR
Based on the nature of pain, how would you differentiate between pelvic pain caused by PID versus ovarian cyst?
PID = Pain less likely to migrate, absence of nausea and vomiting.
Ovarian cyst = sudden onset, stabbing - particularly women not using contraception; suppresses ovulation e.g. COCP, nausea and vomiting
Endometriosis = cyclical pain, dyspareunia.
What is the cause of most PID cases?
STIs (more than 85% are caused by STIs)
Which structure lubricates the vagina?
Bartholin’s abscess (makes sex more enjoyable)
What does Marsupilisation mean?
incision and drainage e.g. can be used in bartholin’s abscess
Benzylpenicillin is covering for which bacteria?
Group B Streptococcus
Give 3 criteria to diagnose acute PID
Uterine tenderness
Adnexal tenderness
Temperature
Raised CRP, ESR
What is one key sign which differentiates between PID and ovarian torsion?
Nausea and vomiting seen in ovarian torsion - much less so in PID.
Give two causes of a ‘heavier’ ovary.
Dermoid cyst, polycystic ovary
Name 3 differential cases where CRP would be raised in conjunction with abdominal pain in the pregnant lady.
Appendicitis
PID
Ovarian torsion
Give 2 gynaecological causes of bleeding.
Fibroids, trauma, retained products of conception (pregnancy), endometriosis
Which is the medication of choice to treat gestational hypertension for?
Labetalol
What is Chorioamnionitis?
Bacterial infection in the placenta/ amniotic fluid.
How does chorioamnionitis present?
Uterine tenderness and foul-smelling discharge.
What do we see in pre-eclampsia that we do not see in gestational hypertension?
Proteinuria in pre-eclampsia.
Why is magnesium sulphate given?
To reduce the risk of pre-eclampsia.
Give two indications for emergency C-section.
Late decelerations
Foetal bradycardia.
What does early deceleration indicate on the cTG?
Indicates head compression
Name two of the most common microorganisms to cause UTIs.
E. Coli, klebsiella
Give 3 questions we ask to assess for prolapse.
?Dragging
?Heavy sensation
?Lump in the vagina
Which standard routine investigation do we NOT do in urogynaecology?
Blood tests. Tests we do: - urine dipstick, MC+S - post void residual - cystoscopy
Why do we do cystoscopy?
To assess for haematuria to rule out bladder cancer.
Which is the first line surgery for stress incontinence?
Colposuspension
Which is the best medication for us to use for urge incontinence?
Mirabegron; other anti-cholinergics typically cause memory problems.
A lot of patients coming in for urge incontinence are > 60 years of age and so the risk of memory loss should be minimal.
What is lichen sclerosis?
Chronic inflammatory skin condition in the anogenital region.
Pruritus and white patches
What is HELLP?
Haemolysis, Elevated Liver enzymes, Low Platelets
When do we need to consider HELLP?
Pre-eclampsia
Which is the medication of choice for PPROM?
Erythromycin
What is the mechanism behind HELLP?
Endothelial damage
Schistocytes (fragmented red blood cells) on blood film
What is ‘station’ in obstetrics?
Measuring from the head to the ischial spine
What is the typical protocol for medical abortion?
Mifepristone and vaginal prostaglandins.
In Down’s and Edward’s will you see increased or decreased AFP?
Decreased AFP.
Give two examples of where you will see raised AFP.
Neural tube defect
Abdominal wall defect e.g. omphalocele
What is the first line medication for dysmenorrhoea?
Mefenamic acid (an NSAID).
What is the first line treatment for menorrhagia?
IUS e.g. mirena
Which cancer is the a patient more at risk at with increased progestogen?
Breast cancer
How can endometriosis present in a patient?
Tender nodularity in posterior fornix
Dyspareunia with deep penetration
A 25-year-old G1P0 woman who is 30 weeks pregnant presents to her GP complaining of intense itching of her palms. She also complains of fatigue but has been struggling with this throughout her pregnancy. On examination, you cannot see any rash on her hands.
Given the likely diagnosis, which of the following is she at an increased risk of?
Stillbirth; cholestasis.
What is hyperemesis gravidarum?
Extreme version of morning sickness.
What is a risk factor for hyperemesis gravidarum?
Multiple pregnancies
What is an important cause of antepartum haemorrhage?
Placenta praevia
Low-lying placenta at the 20-week scan. What can be the diagnosis?
Placenta praevia.
Which markers will reduce in pregnancy?
Urea, creatinine
Which test do we do to investigate foetal movements?
Ultrasound
What is the first line investigation for those who do not respond to pelvic floor muscle exercises?
Duloxetine
Where are pelvic floor exercises recommended comparative with bladder retraining?
Pelvic floor exercises = stress incontinence
Bladder retraining = urge incontinence
HPV positive and normal cytology. What is the action that should be taken?
Smear should be repeated in 12 months.
What is the typical history of someone with ectopic pregnancy?
6-8 weeks amenorrhoea with lower abdominal bleeding and vaginal bleeding.
What is adenomyosis?
Endometrium grows into the myometrium.
Which is the best imaging technique for adenomyosis?
MRI
‘Enlarged boggy uterus’, dysmenorrhoea, menorrhagia. Which diagnosis?
Adenomyosis.
What is the trend of endometriosis during menarche and menopause?
Endometriosis relies on oestrogen and so regresses following menopause.
How would ovarian cancer present?
Abdominal and pelvic pain
Abdominal distension
- notoriously vague
A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. What is the most appropriate action?
Obstetric cholestasis
How do we define an ectopic pregnancy?
<35mm
No foetal heartbeat
bHCG <1000
What is the treatment for uterine atony (number one cause of PPH) in a haemodynamically stable patient?
Uterine massage
What actually decreases in the incidence of hyperemesis gravidarum?
Smoking; smoking is anti-oestrogenic.
Hyperemesis gravidarum is due to sudden increase in oestrogen and bHCG.
A 28-year-old woman presents the Emergency Department at 35-weeks gestation with lower abdominal pain and vaginal bleeding. Physical examination revealed a heart rate of 115 bpm, blood pressure of 90/60 mmHg and O2 saturation of 99%. On neurological exam, her pupils were dilated and her reflexes were brisk. Potential diagnosis and most likely cause? Platelets are normal.
Placental abruption - cocaine use. Not HELLP which is also a cause due to normal platelets.
dilated pupils and hyperreflexia. question what?
Cocaine abuse.
(heroin = pinpoint pupils).
Cocaine use is a risk factor for which condition?
Placental abruption.
When is progesterone measured i.e. highest in the cycle?
1 week before period i.e. day 21
A 67-year-old woman attends your GP surgery complaining of three episodes of postmenopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness. What do you want to rule out?
Endometrial cancer - so perform TVUS.
What is infibulation?
Excision of the clitoris
A 32-year-old pregnant woman presents to the GP with jaundice and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation. On examination, the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. Likely diagnosis?
Obstetric cholestasis; build up of bile salts can deposit on skin = intense pruritus.
Which medication is given to prevent chorioamnionitis?
Oral erythromycin; PPROM predisposes to chorioamnionitis
Which medication is given to prevent Group B streptococcus infection? (GBS)
IV Benzylpenicillin
Give two causes of oligohydramnios
PPROM
Pre eclampsia
