Obstetrics & Gynaecology

Question 1

Women with VWD with HMB

Answer 1

Women with VWD that suffer from heavy periods can be managed by a combination of:

Tranexamic acid

Mefanamic acid

Norethisterone

Combined oral contraceptive pill

Mirena coil

Hysterectomy may be required in severe cases.

Question 2

Fibroids

Answer 2

Epidemiology

Common, affecting 40-60% of women in later reproductive years. Oestrogen-sensitive (grow in response to oestrogen). More common in black women.

Aetiology

Benign tumours of the smooth muscle of uterus.

Clinical Features

Can be asymptomatic. Most common presentation is HMB.

Other features include: prolonged menstruation, bloating, urinary/bowel symptoms.

Investigations

Abdominal/Bimanual examination may reveal palpable pelvic mass and enlarged firm non-tender uterus.

Hysteroscopy - for submucosal fibroids.

TVUS - larger fibroids.

MRI - surgery.

Management

Asymptomatic - no treatment needed.

<3cm

Levonorgestrel IUS - Mirena Coil (no distortion of uterus present)

Symptomatic - NSAIDs and tranexamic acid

COCP

Cyclical oral progestogens

Surgical options: endometrial ablation, resection (submucosal) or hysterectomy

>3cm

Referral to gynaecology

Symptomatic management with NSAIDs and tranexamic acid

Mirena coil – depending on the size and shape of the fibroids and uterus

Combined oral contraceptive

Cyclical oral progestogens

Surgical options for larger fibroids

Uterine artery embolisation

Myomectomy (generally opted for if preservation of fertility)

Hysterectomy

Short-term: GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.

https://cks.nice.org.uk/topics/fibroids/

Question 3

Menorrhagia (HMB)

Answer 3

Epidemiology

>80ml blood loss.

Aetiology

Dysfunctional Uterine Bleeding (diagnosis of exclusion; no identifiable cause)

Clinical Features

Based on symptoms - changing pads every 1-2hrs, bleeding lasting >7d, passing large clots, Self-report of ‘very heavy periods’.

Investigations

Bimanual pelvic examination with speculum (unless young not sexually active or no RFs)

FBC (rule out IDA)

Outpatient Hysteroscopy: Submucosal fibroids, endometrial hyperplasia, IMB

Pelvic & TVUS: large fibroids (palpable mass), suspected Adenomyosis (pelvic pain/tenderness on examination), Examination difficult to interpret (obesity) or hysteroscopy declined.

Other investigations: swabs (abnormal discharge), coag screen (VWD FHx or HMB since menarche), Ferritin (signs of anaemia), TFTs (signs of hypothyroidism)

Management

No contraception wanted

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)

Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Contraception wanted/acceptable

1st Line: Mirena coil/LNG-IUS

COCP

Cyclical oral progestogens (norethisterone 5mg three times daily from day 5-26)

POP/Depot

Referral for secondary care

treatment is unsuccessful

symptoms are severe

large fibroids (more than 3 cm)

Final management options

Endometrial ablation (balloon thermal ablation)

Hysterectomy

Question 4

Red Degeneration of Fibroids

Answer 4

Epidemiology

Likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy

Aetiology

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic.

Clinical Features

Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting.

Investigations

Clinical diagnosis.

Management

Management is supportive, with rest, fluids and analgesia.

Question 5

Placental Abruption

Answer 5

Epidemiology

1/200 pregnancies

Aetiology

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space. RFs include:

Previous placental abruption

Pre-eclampsia

Bleeding early in pregnancy

Trauma (consider domestic violence)

Multiple pregnancy

Fetal growth restriction

Multigravida

Increased maternal age

Smoking

Cocaine or amphetamine use

Clinical Features

Shock out of keeping with visible loss

Sudden onset abdomina pain that is constant

Tender, tense uterus (_‘woody’ abdomen_)

Normal lie and presentation

Fetal heart: absent/distressed

Coagulation problems

Beware pre-eclampsia, DIC, anuria

2 Forms:

Concealed (cervical os closed); severity of the bleeding may be underestimated

Revealed; blood loss is observed.

Investigations

Clinical diagnosis.

Management

Urgent involvement of a senior obstetrician, midwife and anaesthetist

2 x grey cannula

Bloods include FBC, UE, LFT and coagulation studies

Crossmatch 4 units of blood

Fluid and blood resuscitation as required

CTG monitoring of the fetus

Close monitoring of the mother

Fetus alive and < 36 weeks

Fetal distress: immediate C-section

No fetal distress: observe closely, steroids, NO tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

Fetal distress: immediate C-section

No fetal distress: vaginal delivery

Fetus dead

Induce vaginal delivery

Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.

Antenatal steroids are offered between 24 and 34 + 6 weeks gestation to mature the fetal lungs in anticipation of preterm delivery.

Rhesus-D negative women require anti-D prophylaxis when bleeding occurs. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Emergency caesarean section may be required where the mother is unstable, or there is fetal distress.

There is an increased risk of postpartum haemorrhage after delivery in women with placental abruption. Active management of the third stage is recommended.

https://zerotofinals.com/obgyn/antenatal/placentalabruption/

Question 6

Placenta Praevia

Answer 6

Epidemiology

5% when scanned. RFs include Previous C-section and multiparity.

Aetiology

Placenta overlying the lower uterus. Grading:

I - placenta reaches lower segment but not the internal os

II - placenta reaches internal os but doesn’t cover it

III - placenta covers the internal os before dilation but not when dilated

IV (‘major’) - placenta completely covers the internal os

Associated with placenta accreta (invades myometrium).

Clinical Features

Painless bright red bleeding

Shock in proportion to blood loss

Investigations

Incidental finding on 20 week scan

Definitive:TVUS

Management

Low-lying placenta at the 20-week scan

Rescan at 34 weeks

No need to limit activity or intercourse unless they bleed

if still present at 34 weeks and grade I/II then scan every 2 weeks

Final ultrasound at 36-37 weeks to determine the method of delivery

Elective caesarean section for grades III/IV between 37-38 weeks

Grade I then a trial of vaginal delivery may be offered

• if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of PPH.*
• If the placenta covers the internal cervical os or the placental edge is within 2cm of the os, the foetus will need to be delivered by caesarean section*

Placenta praevia with bleeding

Admit

ABC approach to stabilise the woman

if not able to stabilise → emergency caesarean section

if in labour or term reached → emergency caesarean section

Prognosis

death is now extremely rare

major cause of death in women with placenta praevia is now PPH

Question 7

Placenta Praevia vs. Placental abruption

Answer 7

Placental abruption

shock out of keeping with visible loss

pain constant

tender, tense uterus*

normal lie and presentation

fetal heart: absent/distressed

coagulation problems

beware pre-eclampsia, DIC, anuria

Placenta praevia

shock in proportion to visible loss

no pain

uterus non-tender*

lie and presentation may be abnormal

fetal heart usually normal

coagulation problems rare

small bleeds before large

*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Question 8

Endometriosis

Answer 8

Epidemiology

Affects 1 in 10 women

Aetiology

Ectopic endometrial tissue deposited outside of the uterus.

Clinical Features

Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:

Cyclical abdominal or pelvic pain

Deep dyspareunia (pain on deep sexual intercourse)

Dysmenorrhoea (painful periods)

Infertility

Cyclical bleeding from other sites, such as haematuria

There can also be cyclical symptoms relating to other areas affected by the endometriosis:

Urinary symptoms: dysuria, urgency, haematuria.

Bowel symptoms: dyschezia (painful bowel movements)

Examination may reveal:

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix

A fixed retroverted cervix on bimanual examination

Tenderness in the vagina, cervix and adnexa

Investigations

Pelvic US - chocolate cysts and endometriomas

Definitive: Laparascopic surgery with biopsy

Management

Analgesia

1st line: NSAIDs & paracetamol

Hormonal management (can be tried before establishing a definitive diagnosis with laparoscopy):

COCP

POP

Medroxyprogesterone acetate injection (e.g. Depo-Provera)

Nexplanon implant

Mirena coil

GnRH agonists: Goserelin (Zoladex) or Leuprorelin (Prostap)

Surgical management options:

GOLD Standard: Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)

Hysterectomy

Question 9

Miscarriage Types

Answer 9

If this occurs < 12 weeks, a complete miscarriage is more likely as the placenta is unlikely to have been independently developed, thus being expelled together with the fetus.

If this occurs between 12-24 weeks, the gestation sac is more likely to rupture and the fetus then expelled while parts of the placenta remain in the uterus, classified as an incomplete miscarriage.

Miscarriage Types

Complete miscarriage

Both fetus and all pregnancy tissue expelled from the uterus

Bleeding stops and further treatment is not needed

Incomplete miscarriage

Fetus and parts of the membranes are expelled from the uterus

Placenta is not fully expelled and bleeding persists

Surgical management needed to remove the remaining products of conception

Missed miscarriage

Usually identified via ultrasound with a small for dates uterus

No foetal development or death

Often NO typical clinical symptoms of pain or vaginal bleeding

Threatened miscarriage

Viable pregnancy with symptoms (vaginal bleeding) and a closed cervical os

75% of threatened miscarriages will settle

Carry a higher risk of preterm delivery and PPROM

Inevitable miscarriage

Non-viable pregnancy with vaginal bleeding and open cervical os

Progresses to an incomplete or complete miscarriage

Recurrent miscarriage

Occurs in 1% of patients

3 or more consecutive miscarriages

Offered a referral for further investigation

Question 10

Miscarriage Types

Answer 10

If this occurs < 12 weeks, a complete miscarriage is more likely as the placenta is unlikely to have been independently developed, thus being expelled together with the fetus.

If this occurs between 12-24 weeks, the gestation sac is more likely to rupture and the fetus then expelled while parts of the placenta remain in the uterus, classified as an incomplete miscarriage.

Miscarriage Types

Threatened miscarriage

Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks

Bleeding is often less than menstruation

Cervical os is closed

Missed (delayed) miscarriage

Gestational sac which contains a dead fetus before 20 weeks without symptoms of expulsion

Light vaginal bleeding / discharge and symptoms of pregnancy which disappear.

Pain is NOT usually a feature

Cervical os is closed

Inevitable miscarriage

HMB with clots and pain

Cervical os is open

Incomplete miscarriage

Products of conception remain

Pain and vaginal bleeding

Cervical os is open

Question 11

Termination of Pregnancy (TOP)

Answer 11

Termination of Pregnancy

Limit of 24 weeks unless any of the following applies:

necessary to save the life of the woman

evidence of extreme fetal abnormality

risk of serious physical or mental injury to the woman

Key points

2 registered medical practitioners must sign a legal document (1 is needed in emergencies)

Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Method for TOP

< 9 weeks

Mifepristone (an anti-progestogen; stops pregnancy) followed 48 hours later by Misoprostol (prostaglandin analogue; soften cervix and increase contractions) to stimulate uterine contractions

< 13 weeks

Surgical dilation and suction of uterine contents

> 15 weeks

Surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

Rhesus negative women

Gestational age of 10 weeks or above having a medical TOP should be given anti-D prophylaxis.

Question 12

Molar Pregnancy (aka Gestational Trophoblastic Disease - GTD)

Answer 12

Epidemiology

Aetiology

A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. Two forms, complete and partial.

Clinical Features

Behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy vs. a normal pregnancy:

More severe morning sickness

Vaginal bleeding

Increased enlargement of the uterus

Abnormally high hCG

Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Investigations

US of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.

Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

Definitive Diagnosis: The products of conception need to be sent for histological examination to confirm a molar pregnancy.

Management

Evacuation of the uterus to remove the mole.

Patients should be referred to the gestational trophoblastic disease centre for management and follow up. The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.

Question 13

Ectopic Pregnancy

Answer 13

Epidemiology

Risk Factors

Previous ectopic

Previous PID

Previous surgery to the fallopian tubes

IUD (coils)

Older age

Smoking

Aetiology

Pregnancy implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.

Clinical Features

Presents around 6-8 weeks gestation.

The classic features of an ectopic pregnancy include:

Missed period

Constant lower abdominal pain in the RIF/LIF

Vaginal bleeding

Lower abdominal or pelvic tenderness

Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

It is also worth asking about:

Dizziness or syncope (blood loss)

Shoulder tip pain (peritonitis)

Investigations

TVUS

human chorionic gonadotropin (hCG) - less than double (<63%) after 48 hour repeat test may indicate ectopic pregnancy.

Management

Expectant (awaiting natural termination)

Medical

(methotrexate; halts pregnancy resulting in abortion)

IM Methotrexate, criteria are the same as expectant management, except:

HCG level must be < 5000 IU / l

Confirmed absence of intrauterine pregnancy on US

Surgical

(salpingectomy or salpingotomy)

Indications: Pain, Adnexal mass > 35mm, Visible heartbeat, HCG levels > 5000 IU / l

1st Line: Laparoscopic salpingectomy (removal of affected fallopian tube and ectopic)

Laparoscopic salpingotomy may be used in women with increased risk of infertility (aim to preserve affected fallopian tube). 1 in 5 failure rate.

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.

Question 14

Criteria for expectant management of Ectopic pregnancy

Answer 14

An unruptured embryo

<35mm in size

Have no heartbeat

Be asymptomatic

B-hCG level of <1,000IU/L and declining

Question 15

Miscarriage Management

Answer 15

Main types of management (3)

Expectant management

‘Waiting for a spontaneous miscarriage’

First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously

If unsuccessful then medical or surgical management may be offered

Some situations are better managed with medically or surgically. NICE list the following:
Increased risk of haemorrhage

Late first trimester

Coagulopathies or unable to have a blood transfusion

Previous adverse and/or traumatic experience associated with pregnancy (stillbirth, miscarriage or antepartum haemorrhage)

Evidence of infection.

Medical management

‘Using tables to expedite the miscarriage’

Vaginal misoprostol

Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue

The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines

Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.

Should be given with antiemetics and pain relief

Surgical management

‘Undergoing a surgical procedure under local or general anaesthetic’

The two main options are vacuum aspiration (suction curettage) or surgical management in theatre

Vacuum aspiration is done under local anaesthetic as an outpatient

• Surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’

Question 16

Miscarriage general clinical features

Answer 16

The clinical features of miscarriages vary based on what category of miscarriage it is. A missed miscarriage often does not present with any symptoms while other types of miscarriages often present with signs and symptoms.

Clinical features
Vaginal bleeding

Vary from brownish light spotting to heavy bright-red blood with clots

Occurs in 20-30% of pregnant women in the first trimester, where a prospective study showed that 12% of these women then had an early miscarriage.

Lower abdominal cramping pain

Vaginal fluid discharge/tissue discharge

Loss of pregnancy symptoms (eg. No more nausea/breast tenderness)

Lower back pain

Question 17

Miscarriage referral

Answer 17

Patients should be referred based on their presenting signs and symptoms and urgency of the situation.

Immediate admission to hospital

any sign of haemodynamic instability

Immediate admission to early pregnancy assessment unit (EPAU):

Suspicion of ectopic pregnancy

Referred to EPAU or out-of-hours gynaecology unit

Symptoms that indicate an early pregnancy problem (excluding abdominal pain, pelvic tenderness, cervical motion tenderness) and is > 6 weeks pregnant or unknown gestation

Any doubt of viability of the pregnancy

If the patient presents with bleeding but no pain AND is < 6 weeks pregnant, consider expectant management.
Repeat pregnancy test after 7-10 days

Negative pregnancy test: miscarriage

Positive pregnancy test with persistent symptoms: referred to an EPAU or out-of-hours gynaecology unit

All women who have been referred to an EPAU should be followed up with the appropriate support afterwards.

All women who have experienced recurrent miscarriages should be offered a referral to a specialist gynaecologist clinic to further investigate the cause.

Question 18

Miscarriage investigations

Answer 18

Miscarriage is often suspected by its clinical presentation and confirmed by further investigation.

The most common investigation done is a transvaginal ultrasound scan (TVUS) to determine the location and viability of the pregnancy. If unable to determine the status of the fetus, a repeat scan will be done after a minimum of 7 days.

Other investigations that can be used are repeat serum beta-human chorionic gonadotropin (bhCG) levels to determine the trend of the hormone levels. bhCG levels will decrease after a miscarriage as it is produced by the placenta.

If an ectopic pregnancy as a differential diagnosis is suspected, a laparoscopy may be done.

Question 19

Contraceptives time until effective

IUD

POP

COC

Answer 19

Instant: IUD

2 days: POP

7 days: COC, injection, implant, IUS

Question 20

Cervical Cancer Screening

Answer 20

HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.

INTERPRETING RESULTS

Negative hrHPV

Individuals who are high-risk HPV (hrHPV) negative should be returned to routine recall

Positive hrHPV

All individuals who are hrHPV positive and have abnormal cytology should be referred to colposcopy.

Normal cytology but hrHPV +ve then test is repeated at 12 months

if the repeat test is now hrHPV -ve → return to normal recall

IF still hrHPV +ve AND normal cytology → repeat test 12 months later

• If hrHPV -ve at 24 months → return to normal recall*
• if hrHPV +ve at 24 months* → colposcopy

Inadequate Sample

repeat the sample within 3 months

if two consecutive inadequate samples then → colposcopy

https://cks.nice.org.uk/topics/cervical-screening/#!scenario:1

Question 21

Contraception MoAs

Answer 21

Question 22

Indications for Induction of Labour

Answer 22

Indications

Prolonged pregnancy, e.g. 1-2 weeks after the EDD

PPROM, where labour does not start

Fetal growth restriction

Diabetic mother > 38 weeks

Pre-eclampsia

Obstetric cholestasis

rhesus incompatibility

Intrauterine fetal death

Question 23

Induction of labour methods

Answer 23

Membrane sweep

Stimulate the cervix and begin the process of labour.

It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours.

A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour.

It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Vaginal prostaglandin E2 (dinoprostone) - Preferred by NICE

Involves inserting a gel, tablet (Prostin)** or **pessary (Propess) into the vagina.

The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours.

This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

Cervical ripening balloon (CRB)

Silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix.

This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

Artificial rupture of membranes (ARM) with an oxytocin infusion

Used where there are reasons NOT to use vaginal prostaglandins.

It can be used to progress the induction of labour after vaginal prostaglandins have been used.

Oral mifepristone (anti-progesterone) plus misoprostol

Induce labour where intrauterine fetal death has occurred.

Question 24

Prolonged Labour (Failure to Progress)

Answer 24

Epidemiology

More common in Primiparous women. Prolonged labour is diagnosed when cervical dilatation is of < 2cm in 4 hours during active labour

Aetiology

Progress in labour is influenced by the three P’s:

Power (uterine contractions)

Passenger (size, presentation and position of the baby)

Passage (the shape and size of the pelvis and soft tissues)

Question 25

Stages of Labour

Answer 25

First Stage (3 Phases)

Latent phase

0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.

Active phase (pushing)

3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.

Transition phase

7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Delay in the first stage of labour is considered when there is either:

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in a multiparous women

Second Stage

10cm dilatation of the cervix to delivery of the baby.

Dependent on the 3 P’s. Delay in the second stage is when the active second stage (pushing) lasts over:

2 hours in a nulliparous woman

1 hour in a multiparous woman

Third Stage

Delivery of the baby to delivery of the placenta

Delay in the third stage is defined as:

>30 minutes with active management

>60 minutes with physiological management

Question 26

Active vs. Physiological management of 3rd Stage of Labour

Answer 26

Physiological management

Uterotonic drugs (oxytocin) are not used

The cord is not clamped until the pulsations have ceased

The placenta is delivered by maternal effort

Active management

Includes prophylactic administration of oxytocin (10 units) or Syntometrine (ergometrine in combination with oxytocin)

Cord clamping and cutting

Controlled cord traction

Bladder emptying (catheterisation).

Question 27

Complication associated with induction of labour

Answer 27

Uterine hyperstimulation

Refers to prolonged and frequent uterine contractions - sometimes called tachysystole

potential consequences

intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia

uterine rupture (rare)

Management

removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started

Tocolysis with terbutaline

Question 28

Preterm Prelabour Rupture of the Membranes (PPROM)

Answer 28

Epidemiology

Amniotic sac rupture before the onset of labour and in a preterm pregnancy (< 37 weeks gestation).

Aetiology

Fetal: prematurity, infection, pulmonary hypoplasia

Maternal: chorioamnionitis

Clinical Features

Pooling of amniotic fluid

Investigations

Speculum examination

AVOID DIGITAL EXAM (infection)

Management

Prophylactic antibiotics erythromycin 250mg qds for ten days, or until labour is established if within ten days.

Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Antenatal corticosteroids (reduce risk of respiratory distress syndrome)

Question 29

Management of Failure to Progress

Answer 29

Definition: cervical dilatation < 2cm in 4 hours during active labour

Main Options

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes

Oxytocin infusion

Instrumental delivery

Caesarean section

Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

Question 30

Presentations and their management

Answer 30

Cephalic presentation

head is first

Shoulder presentation

shoulder is first

Breech presentation

Legs are first. This can be:

Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)

C-Section

Frank breech – with hips flexed and knees extended, bottom first

Footling breech – with a foot hanging through the cervix

Question 31

Indications for Forceps delivery

Answer 31

FORCEPS (mnemonic)

Fully dilated cervix (10cm)

Occipitoanterior position (Occipitoposterior position is possible with Kielland forceps and ventouse). The position of the head must be known as incorrect placement can lead to maternal and fetal trauma

Ruptured membranes

Cephalic presentation

Engaged presenting part – the fetal head must not be palpable abdominally and must be below the ischial spines

Pain relief

Sphincter (bladder) empty – will need catheterisation.

Question 32

Injuries associated with Forceps

Answer 32

Question 33

Contraindications to Ventouse

Answer 33

Prematurity (<34weeks)

Face presentation

Suspected fetal bleeding disorder such as Haemophilia

Fetal predisposition to fracture e.g. osteogenesis imperfecta

Maternal HIV or Hepatitis C.

Question 34

Indications for C-Section (standard and special)

Answer 34

Standard indications include :

failure to progress in 2nd stage

Fetal distress

Maternal exhaustion

Special indications (reasons the 2nd stage may need to be shortened) include:

maternal cardiac disease

severe PET/eclampsia

intra-partum haemorrhage

umbilical cord prolapse in 2nd stage.

Question 35

Cord Prolapse

Answer 35

Epidemiology

male fetuses predisposed

Aetiology

transverse lie (20% ) / footling breech (15%) / prematurity / abnormality / 2nd twin / multiparity / low birth weight (<2.5kg) / placenta praevia / long umbilical cord / high fetal station

Clinical Features

abdo exam: ill-fitting (one possible cause)

VE: check after rupture of artificial membrane

OVERT : cord can be palpated in vaginal canal

OCCULT: (hesrt rate changes) dropping cord

FUNIC: loops of cord - palpated through membrane

Management

OVERT:

1. oxygen 4-6L/minute
2. (see image)
3. Emergency C-section
4. Terbutaline 0.25mg subcutanesouly
5. Vaginal delivery only if delivery imminent (cervix fully dilated)
6. Ensure resus is available if needed post-delivery

OCCULT:

1. place mom in left lateral position
2. fetal herat rate normal = labour with Oxygen admin. + fetal heart rate monitored
3. fetal heart rate abnormal = C-section

FUNIC: decision between C-sec. prior to membrane rupture OR ARM (artificial membrane rupture) + prep C-section (in case cord becomes overt

Complications

death

https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology

Question 36

Shoulder Dystocia

Answer 36

Epidemiology

Macrosomia secondary to gestational diabetes. Women should be counselled of this risk.

Aetiology

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

Clinical Features

Difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head.

There may be failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head.

The turtle-neck sign is where the head is delivered but then retracts back into the vagina.

Management

Get help (anaesthetics and paediatrics)

McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.

Episiotomy

Rubins manoeuvre

Wood’s screw manoeuvre

Complications

Fetal hypoxia (and subsequent cerebral palsy)

Brachial plexus injury and Erb’s palsy (nerve roots C5 & C6)

Perineal tears

Postpartum haemorrhage

https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology

Question 37

Vasa Praevia

Answer 37

Epidemiology

RFs include: Low lying placenta, IVF pregnancy & multiparity

Aetiology

Fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os.

Two forms:

Type I – fetal vessels are exposed as a velamentous umbilical cord

Type II – fetal vessels are exposed as they travel to an accessory placental lobe

Clinical Features

Vasa praevia may be diagnosed by US during pregnancy. This is the ideal scenario, as it allows a planned C-section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally.

It may present with antepartum haemorrhage, with bleeding during the 2nd or 3rd trimester of pregnancy.

It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix.

Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.

Management

Asymptomatic women

Corticosteroids, given from 32 weeks gestation to mature the fetal lungs

Elective C-section, planned for 34 – 36 weeks gestation

Antepartum Haemorrhage

Emergency C-section is required to deliver the fetus before death occurs.

After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.

Question 38

Causes of vaginal bleeding in pregnancy

Answer 38

Question 39

Causes of vaginal bleeding

Answer 39

Question 40

Amniotic Fluid Embolism

Answer 40

Epidemiology

Amniotic fluid embolisation is a rare (2 per 100,000 deliveries) but severe condition

Aetiology

Amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above.

Risk Factors

Increasing maternal age

Induction of labour

C-Section

Multiple pregnancy

Clinical Features

Amniotic fluid embolisation usually presents around the time of labour and delivery, but can be postpartum. It can present similarly to sepsis, PE or anaphylaxis, with an acute onset of symptoms of:

Shortness of breath

Hypoxia

Hypotension

Coagulopathy

Haemorrhage

Tachycardia

Confusion

Seizures

Cardiac arrest

Management

Supportive

Medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to ICU.

The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating:

A – Airway: Secure the airway

B – Breathing: Provide oxygen for hypoxia

C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage

D – Disability: Treat seizures and consider other neurological deficits

E – Exposure

Question 41

Antepartum Haemorrhage

Answer 41

Epidemiology

Antepartum haemorrhage is defined as bleeding after 24 weeks.

Aetiology

local bleeding or problems with the placenta. Placental problems include placental abruption, placenta praevia and vasa praevi

Clinical Features

Minor APH: < 50 mls and stopped

Major APH: 50-1000 mls, NO sign of shock

Massive APH: >1000 mls OR signs of shock.

Investigations

The assessment of any APH should involve a good history, examination and initiating early management.

Basic observations: are there features of shock?

Abdominal palpation: does the uterus feel stony hard suggesting abruption?

Speculum: is the source obvious in vagina, on cervix or coming through external os?

Consider cervical assessment: is this early labour?

Do not perform vaginal examination if known placenta praevia.

Management

ABCDE approach

Fluid resuscitation

Blood products (as needed)

Escalate to multidisciplinary seniors (obstetrics, anaesthetics, midwifery, neonatal).

Mother and baby stable - discuss with a consultant, consider induction of labour

Induction of labour is by artificial rupture of membranes & syntocinon

The aim should be for a vaginal delivery if possible

The same management is considered if the mother is stable with intrauterine death (IUD)

Mother and baby unstable - discuss with consultant, emergency C-section

Anticipate post-partum haemorrhage

Question 42

Postpartum Haemorrhage (PPH)

Answer 42

Epidemiology

Pospartum haemorrhage (PPH) is defined as vaginal bleeding from delivery of baby to 24hrs postpartum. Leading cause of maternal death worldwide.

Aetiology

PPH can be classified as either primary or secondary.

Primary PPH: is defined as vaginal bleeding that occurs from delivery of baby to 24 hrs postpartum.

Secondary PPH: is defined as vaginal bleeding from 24 hrs postpartum to 12 weeks postpartum.

Primary PPH causes include 4 T’s:

Tone (most common): reduction in uterine tone, typically the result of prolonged labour, macrosomia, twins, uterine anomalies or polyhydraminos. ‘Active’ management of the third stage reduces the risk (IM Oxytocin, Controlled cord traction (CCT) of placenta to aid delivery)

Trauma: usually due to episiotomy, extensive perineal tears or uterine rupture.

Tissue: refers to retained placenta and placenta accreta (invades .

Thrombin: refers to either pre-existing or newly developed coagulopathies. Coagulopathies may also result from significant APH or PPH!

Secondary PPH occurs due to retained products of conception and endometritis (endometrial infection).

Clinical Features

Severity

Minor: 500-1000mls

Moderate: 1000-2000mls

Severe: > 2000mls.

General Management

Anticipate those at higher risk:

Deliver on a doctor-led unit

IV access

Bloods: FBC, G&S, Crossmatch in labour

Specific Management (Primary PPH)

Uterine massage: placing one hand on lower abdomen and performing repetitive massage and squeezing movements

Bimanual compression: place one hand on the lower abdomen and one hand in the vagina. Push against the body of the uterus with the hand in the vagina, while the other hand compresses the fundus.

Uterotonic Drugs: _IV syntocino_n (oxytocin) 10 units or IV ergometrine 500 micrograms

IM carboprost (avoid in asthmatics)

the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage

Other surgical options: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

Tranexamic Acid

Massive Obstetric Haemorrhage Call (2222)

Uncontrolled haemorrhage (large volumes of blood loss) then a hysterectomy is sometimes performed as a life-saving procedure

Secondary PPH

In cases of secondary PPH, it is important to assess for infection with high vaginal and endocervical swabs.

Concurrently, an US should be completed looking for any RPOC or collections. Mothers may need antibiotics +/- surgical evacuation of retained products of conception (ERPC).

Question 43

Bleeding in early pregnancy (first trimester)

Answer 43

Epidemiology

Bleeding in early pregnancy is defined as vaginal bleeding < 24 weeks.

Aetiology

miscarriage

ectopic pregnancy

implantation bleeding

cervical ectropion

vaginitis

trauma

polyps

Clinical Features

Management

>= 6 weeks gestation

If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to EPAC.

< 6 weeks gestation

If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:

to return if bleeding continues or pain develops

to repeat a urine pregnancy test after 7–10 days and to return if it is positive

a negative pregnancy test means that the pregnancy has miscarried

Question 44

Ovulatory Disorders

Question 45

Drugs in Pregnancy

Answer 45

Eclampsia

AVOID: IV Lorazepam. USE: IV magnesium sulphate

Genito-urinary Infections (pregnancy & breastfeeding)

AVOID: Doxycycline. USE: Azithromycin

Drugs to AVOID:

NSAIDs (premature closure of DA)

ACE-I & ARBs (hypcalvaria & olgohydraminos)

Opiates (NAS - withdrawal)

Sodium Valporate (NTDs)

Lithium (Ebstein’s anomaly)

Isotretinoin (Roaccutane; miscarriage)

SSRIs - must be balanced with risks and benefits

Question 46

Indications for Anti-D

Answer 46

Indications for Anti-D

Within 72 hours of sensitising event (e.g. fetal-maternal haemorrhage)

Pregnancy < 12 weeks if ectopic, molar, therapeutic termination

Prophylactic dose at 28 weeks or at 28 and 34 weeks (no previous sensitisation)

Within 72 hours of delivery if neonate is rhesus positive based on cord blood

Intrauterine death and no fetal sample possible

Question 47

Forceps Indications

Answer 47

Mnemonic (FORCEPS)

Fully dilated cervix generally the second stage of labour must have been reached

OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure

Ruptured Membranes

Cephalic presentation

Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally

Pain relief

Sphincter (bladder) empty this will usually require catheterization

Question 48

Vaginal Candidiasis

Answer 48

Epidemiology

Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.

Aetiology

The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:

diabetes mellitus

drugs: antibiotics, steroids

pregnancy

immunosuppression: HIV

Clinical Features

‘cottage cheese’, non-offensive discharge

vulvitis: superficial dyspareunia, dysuria

itch

vulval erythema, fissuring, satellite lesions may be seen

Investigations

A high vaginal swab is NOT routinely indicated if the clinical features are consistent with candidiasis

Management

options include local or oral treatment

local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)

oral treatments include itraconazole 200mg PO bd for 1 day OR fluconazole 150mg PO stat

if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Recurrent vaginal candidiasis

BASHH define recurrent vaginal candidiasis as 4 or more episodes/year

compliance with previous treatment should be checked

confirm the diagnosis of candidiasis

high vaginal swab for microscopy and culture

consider a blood glucose test to exclude diabetes

exclude differential diagnoses such as lichen sclerosus

consider the use of an induction-maintenance regime

Induction: oral fluconazole every 3 days for 3 doses

Maintenance: oral fluconazole weekly for 6 months

Question 49

Referral Criteria for Endometrial Cancer

Answer 49

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:

Postmenopausal bleeding (more than 12 months after the last menstrual period)

NICE also recommends referral for a TVUS in women > 55 years with:

Unexplained vaginal discharge

Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Question 50

Endometrial Cancer

Answer 50

Epidemiology

Cancer of the endometrium.

Aetiology

Predominantly adenocarcinoma (80%). Oestrogen-dependent cancer. Be aware of endometrial hyperplasia (typical or atypical) - precancerous condition which involves thickening of the endometrium.

Can be treated using progestogens: IUS (mirena) or oral progestogens (medroxyprogesterone or levonorgestrel).

Main RFs related to unopposed oestrogen:

Increased age

Earlier onset of menstruation

Late menopause

Oestrogen-only HRT

No or fewer pregnancies

Obesity (adipose produces oestrogen)

_PCOS (_corpus luteum fails to secrete progesterone)

Tamoxifen (oestrogenic effects on endometrium)

Additionally: TIIDM, HNPCC/Lynch syndrome.

Protective Factors:

COCP

Mirena coil

Increased pregnancies

Cigarette smoking

Clinical Features

PMB

PCB

IMB

Unusually HMB

Abnormal vaginal discharge

Haematuria

Anaemia

Raised platelet count

Investigations

TVUS (<4mm is normal post-menopause)

Pipelle biopsy

Hysteroscopy (endometrial biopsy)

Management

Staging

Stage 1: Confined to the uterus

Stage 2: Invades the cervix

Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes

Stage 4: Invades bladder, rectum or beyond the pelvis

The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).

Other treatment options depending on the individual presentation include:

A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina

Radiotherapy

Chemotherapy

Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Question 51

Endometrial Hyperplasia management

Answer 51

Simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel IUS may be used.

Atypia: hysterectomy is usually advised

Question 52

Cervical Cancer

Answer 52

Epidemiology

Affects younger women (25-29) of reproductive years. Squamous (80%) and adenocarcinoma (20%).

Aetiology

Strongly associated with HPV serotypes 16, 18 & 33 (inhibit tumour suppressor genes p53 and pRb with E6 and E7 proteins respectively).

Other RFs:

Smoking

HIV (offered yearly smear)

Early first intercourse, many sexual partners

High parity

Lower socioeconomic status

COCP (>5 years)

Clinical Features

Asymptomatic

Abnormal vaginal bleeding (IMB, PCB or PMB)

Vaginal discharge

Pelvic pain

Dyspareunia (pain or discomfort with sex)

Investigations

Speculum examination

Colposcopy (urgent cancer referral) if any of the following features observed:

Ulceration

Inflammation

Bleeding

Visible tumour

Management

Stage-dependent

CIN & early-stage 1A: LLETZ or cone biopsy

Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy

Stage 2B – 4A: Chemotherapy and radiotherapy

Stage 4B: combination of surgery, radiotherapy, chemotherapy and palliative care

Advanced: Pelvic exenteration is an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life.

Metastatic/Recurrent: Bevacizumab (Avastin) is a mAb that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer. It targets VEGF-A, which is responsible for the development of new blood vessels.

Question 53

Cervical intraepithelial neoplasia (CIN)

Answer 53

Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are:

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment

CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated

CIN III: severe dysplasia, very likely to progress to cancer if untreated

CIN III is sometimes called cervical carcinoma in situ.

Question 54

Primary dysmenorrhoea

Answer 54

Epidemiology

Affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche.

Aetiology

Excessive endometrial prostaglandin production

Investigations

Clinical diagnosis.

Clinical Features

Excessive pain during the menstrual period

Pain typically starts just before or within a few hours of the period starting

Suprapubic cramping pains which may radiate to the back or down the thigh

Management

NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production

COCP are used second line

Question 55

Secondary dysmenorrhoea

Answer 55

Epidemiology

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology.

Aetiology

Endometriosis

Adenomyosis

PID

IUD (copper coil)

Fibroids

Investigations

Clinical diagnosis.

Clinical Features

Excessive pain during the menstrual period

In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period

Management

Referall to gynaecology.

Question 56

Acute causes of Pelvic Pain

Answer 56

Question 57

Chronic Pelvic Pain causes

Answer 57

Question 58

Ovarian Cancer

Answer 58

Epidemiology

Late presentation due to non-specific symptoms. 70% of patients present with advanced disease.

RFs (increased ovulation) include:

Age (peaks age 60)

BRCA1 and BRCA2 genes (consider the family history)

Increased number of ovulations

Obesity

Smoking

Recurrent use of clomifene

Early menarche

Late menopause

Nullparity (no pregnancies)

Aetiology

3 Main types

Epithelial Cell Tumours: commonest form

Dermoid Cysts (Germ Cell tumours): benign teratomas formed from germ cells. Contain various types of tissue (skin, teeth, hair, bone). Associated with ovarian torsion. May cause raised aFP and hCG.

Sex Cord-Stromal Tumours: rare tumours which can be benign or malignant. Arise from stroma (connective tissue) or sex cords (embryonic). Several types including sertoli-leydig cell tumours and granulosa cell tumours.

Metastasis: from cancer elsewhere. Krunkenberg tumour refers to metastasis in the ovary, usually from GI tract cancer. Characteristic ‘signet-ring’ appearance on histology.

Protective factors: COCP, Breastfeeding and pregnancy.

Investigations

The initial investigations in primary or secondary care are:

CA125* blood test (>35 IU/mL is significant) - non-specific test

Pelvic ultrasound

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status, US findings & CA125 level

Women under 40 years with a complex ovarian mass (solid and irregular) require tumour markers for a possible germ cell tumour:

Alpha-fetoprotein (α-FP)

Human chorionic gonadotropin (HCG)

*Can be raised in endometriosis, fibroids, adenomyosis, pelvic infection, LD or pregnancy.

Clinical Features

Non-specific features of abdo bloating, early satiety, poor appetite, pelvic pain, urinary symptoms (frequency/urgency), weight loss, abdo/pelvic mass and ascites.

NB: an ovarian mass may press on the obturator nerve and cause referred hip or groin pain (the obturator nerve passes along the inside of the pelvis, lateral to the ovaries, where an ovarian mass can compress it).

Indications for Urgent referral (2-week)

Ascites

Pelvic mass (unless clearly due to fibroids)

Abdominal mass

Management

Gynae MDT - surgery and chemotherapy

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is:

Stage 1: Confined to the ovary

Stage 2: Spread past the ovary but inside the pelvis

Stage 3: Spread past the pelvis but inside the abdomen

Stage 4: Spread outside the abdomen (distant metastasis)

Question 59

Pelvic Inflammatory Disease (PID)

Answer 59

Epidemiology

RFs include: Not using barrier contraception, Multiple sexual partners, Younger age, Existing STIs, Previous PID and IUD (copper coil).

Aetiology

Infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.

Most cases caused by one of the STIs:

Neisseria gonorrhoeae tends to produce more severe PID

Chlamydia trachomatis

Mycoplasma genitalium

Less commonly be caused by non-STIs, such as:

Gardnerella vaginalis (associated with bacterial vaginosis)

Haemophilus influenzae (a bacteria often associated with respiratory infections)

Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

Clinical Features

Pelvic or lower abdominal pain

Abnormal vaginal discharge

Abnormal bleeding (IMB or PCB)

Pain during sex (dyspareunia)

Fever

Dysuria

Examination findings may reveal:

Pelvic tenderness

Cervical motion tenderness (cervical excitation)

Inflamed cervix (cervicitis)

Purulent discharge

Patients may have a fever and other signs of sepsis.

Investigations

Testing for causative organisms and other STIs:

NAAT swabs for gonorrhoea and chlamydia

NAAT swabs for Mycoplasma genitalium if available

HIV test

Syphilis test

H_igh vaginal swab_ for BV, candidiasis and trichomoniasis.

A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.

A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.

Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.

Management

Refer to GUM specialist service for management and contact tracing.

BASSH suggest: IM Ceftriaxone (gonorrhoea coverage), Doxycycline (chlamydia and mycoplasma genitalium) and Metronidazole (anaerobes i.e. gardnerella vaginalis).

Question 60

Fitz-Hugh-Curtis syndrome

Answer 60

A complication of PID. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

Results in RUQ pain that can be referred to the right shoulder tip if there is diaphragmatic irritation.

Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Question 61

Polycystic Ovarian Syndrome (PCOS)

Answer 61

Epidemiology

Aetiology

Clinical Features

Investigations

Management

Management

Question 62

Pre-Eclampsia

Answer 62

Epidemiology

Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria. It occurs after 20 weeks gestation.

Aetiology

Spiral arteries of the placenta form abnormally (due to impaired lacunae formation), leading to a high vascular resistance in these vessels and ultimately poor placental perfusion leading to oxidative stress, systemic inflammation and imaired endothelial function.

Clinical Features

Triad of HT, Proteinuria and Oedema

Investigations

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with:

Blood pressure

Symptoms

Urine dipstick for proteinuria

Diagnosis of Pre-eclampsia involves:

BP 140/90 PLUS any of:

Proteinuria (1+ or more on urine dipstick)

Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)

Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Management

Prophylaxis: Aspirin from 12 weeks until birth in women with a single high risk factor or two or more moderate risk factors.

Medical management of pre-eclampsia is with:

Labetolol is first-line as an antihypertensive

Nifedipine (modified-release) is commonly used second-line

Methyldopa is used third-line (needs to be stopped within two days of birth)

IV hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Following delivery:

Enalapril (first-line)

Nifedipine or amlodipine (first-line in black African or Caribbean patients)

Labetolol or atenolol (third-line)

Eclampsia

Eclampsia refers to the seizures associated with pre-eclampsia.

IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

HELLP Syndrome

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:

Haemolysis

Elevated Liver enzymes

Low Platelets

Question 63

Pre-Eclampsia Risk Factors

Answer 63

High-risk factors:

Pre-existing hypertension

Previous hypertension in pregnancy

Existing autoimmune conditions (e.g. systemic lupus erythematosus)

Diabetes

Chronic kidney disease

Moderate-risk factors:

Older than 40

BMI > 35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

These risk factors are used to determine which women are offered aspirin as prophylaxis against pre-eclampsia. Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Question 64

Gestational Hypertension

Answer 64

Epidemiology

Hypertension occurring after 20 weeks gestation, without proteinuria.

Clinical Features

systolic > 140 mmHg or diastolic > 90 mmHg

or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Investigations

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with:

BP

Symptoms

Urine dipstick for proteinuria

Management

Prophylaxis: women who have either 1 high RF or 2 or more moderate RFs for developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.

Medical management of pre-eclampsia is with:

Labetolol is first-line as an antihypertensive

Nifedipine (modified-release) is commonly used second-line

Methyldopa is used third-line (needs to be stopped within two days of birth)

IV hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Following delivery:

Enalapril (first-line)

Nifedipine or amlodipine (first-line in black African or Caribbean patients)

Labetolol or atenolol (third-line)

Question 65

Venous Thromboembolism (VTE) in Pregnancy

Answer 65

Epidemiology

Significant cause of death in obstetrics.

Aetiology

_{RFs for VTE in pregnancy:}

_Smoking

_{Parity ≥ 3}

_{Age > 35 years}

_{BMI > 30}

_{Reduced mobility}

_{Multiple pregnancy}

_{Pre-eclampsia}

_{Gross varicose veins}

_Immobility

_{Family history of VTE}

_{Thrombophilia}

_{IVF pregnancy}

Clinical Features

_{<strong>DVT</strong>}

_{<u>Unilateral</u> calf/leg swelling (>3 cm difference between calves)}

_{Dilated superficial veins}

_{Tenderness to the calf (particularly over the deep veins)}

_Oedema

_{Colour changes to the leg}

_{<strong>PE</strong>}

_SOB

_{Cough with or without <u>haemoptysis</u>}

_{Pleuritic chest pain}

_Hypoxia

_{Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)}

_{Raised RR}

_{Low-grade fever}

_{Haemodynamic instability causing hypotension}

Investigations

Doppler US for DVT - repeat US at day 3 & 7 in patients with negative US but high index of suspicion

Chest X-ray and ECG for suspected PE.

_{<strong>NB: Patients with a suspected DVT and PE should have a Doppler ultrasound initially, and if a DVT is present, they <u>DO NOT</u> require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.</strong>}

Definitive diagnosis

CTPA with contrast - increased risk of maternal breast cancer.

V/Q Scan - deficit in perfusion will be observed. Increased risk of childhood cancer.

Management

Prophylaxis with LMWH (enoxaparin, dalteparin and tinzaparin)

28 weeks if there are three RFs

First trimester if there are four or more of these RFs

LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis.

Contraindications to LMWH

Intermittent pneumatic compression

Anti-embolic compression stockings

Massive PE and Haemodynamic compromise

Unfractionated heparin

Thrombolysis

Surgical embolectomy

Question 66

Atrophic Vaginitis

Answer 66

Epidemiology

Frequently seen in post-menopausal women. Peak incidence 50-60 years.

Aetiology

Caused by reduction in levels of oestrogen. The vaginal mucosa becomes drier, thinner and more easily broken, which can lead to epithelial irritation and inflammation.

Clinical Features

Vaginal dryness

Local irritation (pruritus, pressure and burning)

Painful intercourse

Vaginal bleeding (PCB or haematuria)

Urinary symptoms - increased frequency, recurrent UTIs, incontinence (stress and urge)

Vaginal discharge (white or yellow)

Investigations

Pelvic examination with bimanual and speculum.

TVUS - >4mm is considered abnormal in post-menopausal women in which case pipelle biopsy is indicated.

Management

1st Line: Topical oestrogens - creams, rings and pessaries (take 3 weeks to have any effect). Considered safe long-term.

Systemic HRT - side-effects/risks will need to be discussed. Topical oestrogens may be required alongside as HRT can cause vaginal dryness.

Other options include topical lubricants and moisturisers.

Question 67

Gestational Diabetes

Answer 67

Epidemiology

Gestational diabetes refers to diabetes triggered by pregnancy.

Aetiology

Reduced insulin sensitivity during pregnancy, resolves following birth.

Clinical Features

Large for dates fetus and macrosomia (risk of shoulder dystocia). Increased risk of T2DM following pregnancy.

Polyhydramnios (increased amniotic fluid)

Glucose on urine dipstick

Investigations

Individuals with RFs* should be screened with an Oral Glucose Tolerance Test (OGTT) at 24-48 weeks gestation.

*Includes

Previous gestational diabetes

Previous macrosomic baby (≥ 4.5kg)

BMI > 30

Ethnic origin (black Caribbean, Middle Eastern and South Asian)

FHx of diabetes (first-degree relative)

Normal results are:

Fasting: < 5.6 mmol/l

At 2 hours: < 7.8 mmol/l

Remember as 5-6-7-8.

Management

Fasting glucose < 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

Fasting glucose >7 mmol/l: start insulin ± metformin

Fasting glucose > 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.

Blood sugar level targets

Fasting: 5.3 mmol/l

1 hour post-meal: 7.8 mmol/l

2 hours post-meal: 6.4 mmol/l

Avoiding levels of 4 mmol/l or below

Question 68

Management of Pre-existing Diabetes in Pregnancy

Answer 68

Before becoming pregnant, women with existing diabetes should aim for good glucose control.

They should take 5mg folic acid from preconception until 12 weeks gestation.

Women with existing TI & TIIDM should aim for the same target insulin levels as with gestational diabetes*. Women with TIIDM are managed using metformin and insulin, and other oral diabetic medications should be stopped.

Blood sugar level targets*

Fasting: 5.3 mmol/l

1 hour post-meal: 7.8 mmol/l

2 hours post-meal: 6.4 mmol/l

Avoiding levels of 4 mmol/l or below

Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.

NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth upto 40 + 6).

A sliding-scale insulin regime is considered during labour for women with T1DM. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. Also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes.

Question 69

Menopause

Answer 69

Epidemiology

Average age of 51 years, although this can vary significantly.

Aetiology

Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation.

Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:

Oestrogen and progesterone levels are low

LH and FSH levels are high, in response to an absence of negative feedback from oestrogen due to decline in ovarian follicles.

_{<strong>Risks</strong>}

_{Cardiovascular disease and stroke}

_Osteoporosis

_{Pelvic organ prolapse}

_{Urinary incontinence}

Clinical Features

A lack of oestrogen in the perimenopausal period leads to symptoms of:

Hot flushes

Emotional lability or low mood

Premenstrual syndrome

Irregular periods

Joint pains

Heavier or lighter periods

Vaginal dryness and atrophy

Reduced libido

Investigations

Clinical Diagnosis alone ​(no Ix required): A diagnosis of perimenopause and menopause can be made in women >45 years with:

Typical symptoms

Ammenorhoea for 12m and not using hormonal contraception

Symptoms alone if no uterus

FSH blood test:

Women aged >45 with atypical symptoms

Women <40 years with suspected Premature Ovarian Insufficiency (POI)

Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Management

Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include:

No treatment

Hormone replacement therapy (HRT)

Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)

Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors

Cognitive behavioural therapy (CBT)

SSRI antidepressants, such as fluoxetine or citalopram

Testosterone can be used to treat reduced libido (usually as a gel or cream)

Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)

Vaginal moisturisers, such as Sylk, Replens and YES

Lifestyle Measures

Hot flushes and night sweats — regular exercise, weight loss (if applicable), wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol). See the CKS topics on Obesity, Smoking cessation, and Alcohol - problem drinking for more information.

Sleep disturbances — avoiding exercise late in the day and maintaining a regular bedtime. See the CKS topic on Insomnia for more information.

Low mood and anxiety — adequate sleep, regular physical activity, and relaxation exercises.

Cognitive symptoms — exercise and good sleep hygiene.

Question 70

Menopause contraception

Answer 70

Women need to use effective contraception for:

<50 years: t_wo years after LMP_

>50 years: one year after LMP

Good contraceptive options (UKMEC 1; no restrictions) for women approaching the menopause are:

Barrier methods

Mirena or copper coil

POP

Progesterone (Nexplanon) implant

Progesterone depot injection (<45 years; over this age is associated with osteoporosis and weight gain)

Sterilisation

Question 71

UTIs in Pregnancy

Answer 71

Epidemiology

Aetiology

Clinical Features

Investigations

Management

Question 72

Obstetric Cholestasis

Answer 72

Epidemiology

Obstetric cholestasis is a relatively common complication of pregnancy, occurring in around 1% of pregnant women. It usually develops later in pregnancy (i.e. Third trimester - after 28 weeks), and is thought to be the result of increased oestrogen and progesterone levels.

Aetiology

In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis).

Obstetric cholestasis is associated with an increased risk of stillbirth.

Clinical Features

Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.

Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:

Fatigue

Dark urine

Pale, greasy stools

Jaundice

Investigations

Obstetric cholestasis will cause:

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT

Raised bile acids

TOM TIP: It is normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.

Management

1st Line: Ursodeoxycholic acid

Symptoms of itching can be managed with:

Emollients (i.e. calamine lotion) to soothe the skin

Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)

Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged

Planned delivery after 37 weeks may be considered, particularly when the LFTs and bile acids are severely deranged

Question 73

Acute Fatty Liver of Pregnancy

Answer 73

Epidemiology

Rare condition that occurs in the third trimester of pregnancy.

Aetiology

Rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. There is a high risk of liver failure and mortality, for both the mother and fetus.

Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency resulting in impaired fatty acid metabolism.

Autosomal recessive.

Clinical Features

The presentation is with vague symptoms associated with hepatitis :

General malaise and fatigue

Nausea and vomiting

Jaundice

Abdominal pain

Anorexia (lack of appetite)

Ascites

Investigations

LFTs will reveal raised ALT and AST.

TOM TIP: In your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.

Management

Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.

Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Question 74

UTI in Pregnancy

Answer 74

Epidemiology

Pregnant women are at higher risk of developing lower urinary tract infections and pyelonephritis.

Aetiology

Commonest causes are E.Coli & Klebsiella pneumoniae (gram-negative anaerobic rod). Risk of pre-term delivery.

Clinical Features

Lower urinary tract infections present with:

Dysuria (pain, stinging or burning when passing urine)

Suprapubic pain or discomfort

Increased frequency of urination

Urgency

Incontinence

Haematuria

Pyelonephritis presents with:

Fever (more prominent than in lower urinary tract infections)

Loin, suprapubic or back pain (this may be bilateral or unilateral)

Looking and feeling generally unwell

Vomiting

Loss of appetite

Haematuria

Renal angle tenderness on examination

Investigations

Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S).

Management

Urinary tract infection in pregnancy requires 7 days of antibiotics.

The antibiotic options are:

Nitrofurantoin (avoid in the third trimester)

Amoxicillin (only after sensitivities are known)

Cefalexin

_{<strong>Nitrofurantoin needs to be avoided in the third trimester</strong> as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).}

_{<strong>Trimethoprim needs to be avoided in the first trimester </strong>as it is works as a folate antagonist. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.}

Question 75

Bacterial Vaginosis

Answer 75

Epidemiology

Half of women with BV are asymptomatic.

Aetiology

Overgrowth of bacteria in the vagina, specifically anaerobic bacteria. Reduced numbers of lactobacilli, leads to more alkaline environment. Organisms:

Gardnerella vaginalis (most common)

Mycoplasma hominis

Prevotella species

RFs.

Multiple sexual partners (although it is not sexually transmitted)

Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)

Recent antibiotics

Smoking

Copper coil

Clinical Features

Fishy-smelling watery grey or white vaginal discharge.

Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.

Investigation

A speculum examination can be performed to confirm the typical discharge, complete a high vaginal swab and exclude other causes of symptoms.

Management

Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.

Metronidazole* is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.

*Avoidance of alcohol is necessary - causes a disulfiram-like reaction (n/v, flushing, shock)

Question 76

Candidiasis

Answer 76

Epidemiology

Usually after a course of antibiotics.

Aetiology

Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. Commonest is Candida albicans.

Clinical Features

Thick, white discharge that does not typically smell

Vulval and vaginal itching, irritation or discomfort

Investigation

Often treatment for candidiasis is started empirically, based on the presentation.

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between BV and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

A charcoal swab with microscopy can confirm the diagnosis.

Management

Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:

Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator

Antifungal pessary (i.e. clotrimazole)

Oral antifungal tablets (i.e. fluconazole)

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.

Question 77

Chlamydia

Answer 77

Epidemiology

Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.

Aetiology

Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others.

Being young, sexually active and having multiple partners increase the risk of catching the infection. A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on.

Clinical Features

The majority of cases of chlamydia in women are asymptomatic.

Consider chlamydia in women that are sexually active and present with:

Abnormal vaginal discharge

Pelvic pain

Abnormal vaginal bleeding (IMB or PCB)

Painful sex (dyspareunia)

Painful urination (dysuria)

Consider chlamydia in men that are sexually active and present with:

Urethral discharge or discomfort

Painful urination (dysuria)

Epididymo-orchitis

Reactive arthritis

It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.

Examination Findings

Pelvic or abdominal tenderness

Cervical motion tenderness (cervical excitation)

Inflamed cervix (cervicitis)

Purulent discharge

Investigation

Nucleic acid amplification (NAAT) swabs are used to diagnose chlamydia. This can involve a:

Vulvovaginal swab

Endocervical swab

First-catch urine sample (in women or men)

Urethral swab in men

Rectal swab (after anal sex)

Pharyngeal swab (after oral sex)

Management

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.

Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:

Azithromycin 1g stat then 500mg once a day for 2 days

_{Erythromycin 500mg four times daily for 7 days}

_{Erythromycin 500mg twice daily for 14 days}

_{Amoxicillin 500mg three times daily for 7 days}

_{<strong>Other factors to consider are:</strong>}

_{<u>Abstain from sex for seven days</u> of treatment of all partners to reduce the risk of re-infection}

_{<u>Refer all patients to genitourinary medicine (GUM)</u> for contact tracing and notification of sexual partners}

_{Test for and treat any other STIs}

_{Provide advice about ways to prevent future infection}

_{Consider safeguarding issues and sexual abuse in children and young people}

Question 78

Gonnorhea

Answer 78

Epidemiology

Being young, sexually active and having multiple partners increases the risk of infection with gonorrhoea. Having other STIs, such as chlamydia or HIV, also increases the risk. There is a high level of antibiotic resistance to gonorrhoea.

Aetiology

Neisseria gonorrhoeae is a Gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.

Clinical Features

Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site.

Female genital infections can present with:

Odourless purulent discharge, possibly green or yellow

Dysuria

Pelvic pain

Male genital infections can present with:

Odourless purulent discharge, possibly green or yellow

Dysuria

Testicular pain or swelling (epididymo-orchitis)

Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.

Investigation

NAAT is use to detect the RNA or DNA of gonorrhoea.

Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample.

Rectal and pharyngeal swab are recommended in all MSM, and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.

Charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

Management

_{Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known.}

For uncomplicated gonococcal infections:

A single dose of IM ceftriaxone 1g if the sensitivities are NOT known

A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

_{All patients should have a follow up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:}

_{72 hours after treatment for culture}

_{7 days after treatment for RNA NATT}

_{14 days after treatment for DNA NATT}

_{<strong>Other factors to consider are:</strong>}

_{Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection}

_{Test for and treat any other sexually transmitted infections}

_{Provide advice about ways to prevent future infection}

_{Consider safeguarding issues and sexual abuse in children and young people}

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

Question 79

Mycoplasma Genitalium

Answer 79

Epidemiology

STI

Aetiology

Bacteria that causes non-gonococcal urethritis

Clinical Features

Most cases are asymptomatic. Similar presentation to Chlamydia. Key feature is urethritis. Other features:

Epididymitis

Cervicitis

Endometritis

Pelvic inflammatory disease

Reactive arthritis

Preterm delivery in pregnancy

Tubal infertility

Investigation

NAAT

First urine sample in the morning for men

Vaginal swabs (can be self-taken) for women

The guideline recommends checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient.

Management

BASHH guidelines (2018) recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:

Doxycycline 100mg twice daily for 7 days then;

Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

Moxifloxacin is used as an alternative or in complicated infections.

Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Question 80

Trichomoniasis

Answer 80

Epidemiology

STI

Aetiology

Parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella. Lives in the urethra of men and women and the vagina of women.

Trichomonas can increase the risk of:

Contracting HIV by damaging the vaginal mucosa

BV

Cervical cancer

PID

Preterm delivery

Clinical Features

Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:

Vaginal discharge

Itching

Dysuria (painful urination)

Dyspareunia (painful sex)

Balanitis (inflammation to the glans penis)

The typical description of the vaginal discharge is offensive frothy and yellow-green, although this can vary significantly. It may have a fishy smell.

Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.

Testing the vaginal pH will reveal a raised ph (above 4.5), similar to BV.

Investigation

The diagnosis can be confirmed with a standard charcoal swab with microscopy.

Women: Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.

Men:Urethral swab or first-catch urine

Management

Patients should be referred to a GUM specialist service for diagnosis, treatment and contact tracing.

Treatment is with metronidazole.

Question 81

Genital Herpes

Answer 81

Epidemiology

Common

Aetiology

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

HSV-1; cold sores

HSV-2; genital herpes - STI via oro-genital sex

Clinical Features

Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated.

The symptoms of an initial infection with genital herpes usually appear within two weeks. The initial episode is often the most severe, and recurrent episodes are milder.

Signs and symptoms include:

Ulcers or blistering lesions affecting the genital area

Neuropathic type pain (tingling, burning or shooting)

Flu-like symptoms (e.g. fatigue and headaches)

Dysuria (painful urination)

Inguinal lymphadenopathy

Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

Investigation

Clinical diagnosis

Viral PCR

Management

Referral to GUM

Aciclovir

Additional measures, including to manage the symptoms include:

Paracetamol

Topical lidocaine 2% gel (e.g. Instillagel)

Cleaning with warm salt water

Topical vaseline

Additional oral fluids

Wear loose clothing

Avoid intercourse with symptoms

Question 82

HIV

Answer 82

Epidemiology

Aetiology

RNA retrovirus. HIV-1 is the most common type, and HIV-2 is rare outside West Africa. The virus enters and destroys the CD4 T-helper cells of the immune system.

An initial seroconversion flu-like illness occurs within a few weeks of infection.

The infection is then asymptomatic until the condition progresses to immunodeficiency. Immunodeficient patients develop AIDS-defining illnesses and opportunistic infections. This progression occurs potentially years after the initial infection.

Transmission

_{Unprotected anal, vaginal or oral sexual activity}

_{Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)}

_{Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye}

Clinical Features

An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Immunodeficient patients develop AIDS-defining illnesses and opportunistic infections. This progression occurs potentially years after the initial infection.

Investigation

Antibody testing is the typical screening test for HIV. May be negative for the first 3 months due to seroconversion. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.

p24 antigen testing, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.

PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.

Management

Monitoring

CD4 Count

_{The CD4 count is the number of CD4 cells in the blood. These are the cells destroyed by the virus. The <u>lower the count, the higher the risk of opportunistic infection</u>:}

_{500-1200 cells/mm3 is the normal range}

_{<200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections}

Viral Load (VL)

_{Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.}

Antiretroviral therapy (ART)

Two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent.

Additional Management

^{<u>Prophylactic co-trimoxazole (Septrin)</u> is given to patients with a <u>CD4 &lt;200/mm3</u> to protect against pneumocystis jirovecii pneumonia (PCP).}

^{HIV infection increases the risk of developing CVD. Patients with HIV have close monitoring of cardiovascular RFs and blood lipids. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease.}

^{Yearly <u>cervical smears</u> are required for women with HIV. HIV predisposes to developing human papillomavirus (HPV) infection and cervical cancer, so female patients need close monitoring to ensure early detection of these complications.}

^{Vaccinations should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.}

Question 83

Syphilis

Answer 83

Epidemiology

STI

Aetiology

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body.

The incubation period between the initial infection and symptoms is 21 days on average.

Transmission

^{Oral, vaginal or anal sex involving direct contact with an infected area}

^{Vertical transmission from mother to baby during pregnancy}

^IVDU

^{Blood transfusions and other transplants (although this is rare due to screening of blood products)}

Clinical Features

Primary syphilis

_{<u>A painless genital ulcer</u> (chancre). This tends to <u>resolve over 3 – 8 weeks</u>.}

_{<u>Local lymphadenopathy</u>}

Secondary syphilis

_{Typically <u>starts after the chancre has healed</u>, with symptoms of:}

_{<u>Maculopapular rash</u>}

_{<u>Condylomata lata</u> (grey <u>wart-like lesions around the genitals and anus</u>)}

_{<u>Low-grade fever</u>}

_{<u>Lymphadenopathy</u>}

_{Alopecia (localised hair loss)}

_{Oral lesions}

Tertiary syphilis

_{Can present with several symptoms depending on the affected organs. Key features to be aware of are:}

_{<u>Gummatous lesions</u> (gummas are granulomatous lesions that can affect the <u>skin, organs and bones</u>)}

_{<u>Aortic aneurysms</u>}

_{<u>Neurosyphilis</u>}

Neurosyphilis

_{Can occur at any stage if the infection reaches the CNS, and present with symptoms of:}

_Headache

_{Altered behaviour}

_Dementia

_{<u>Tabes dorsalis</u> (demyelination affecting the spinal cord posterior columns)}

_{<u>Ocular syphilis*</u> (affecting the eyes)}

_Paralysis

_{Sensory impairment}

_{*Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that <u>accommodates when focusing on a near object but does not react to light</u>. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.}

Investigation

_{<strong>Antibody testing </strong>for antibodies to the <strong><em>T. pallidum</em></strong> bacteria can be used as a screening test for syphilis.}

_{Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing.}

Samples from sites of infection can be tested to confirm the presence of T. pallidum with:

Dark field microscopy

Polymerase chain reaction (PCR)

Management

_{All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:}

_{Full screening for other STIs}

_{Advice about avoiding sexual activity until treated}

_{Contact tracing}

_{Prevention of future infections}

A single deep IM dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.

Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. Ceftriaxone, amoxicillin and doxycycline are alternatives.

Question 84

Swabs used in STIs

Answer 84

There are two types of swabs involved in sexual health testing:

Charcoal swabs

Nucleic acid amplification test (NAAT) swabs

Charcoal swabs

Allow for microscopy, culture and sensitivities.

_{Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.}

_{Microscopy involves gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours.}

Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS). Charcoal swabs can confirm:

BV

Candidiasis

Gonorrhoeae (specifically endocervical swab)

Trichomonas vaginalis (specifically a swab from the posterior fornix)

Other bacteria, such as group B streptococcus (GBS)

Nucleic acid amplification tests (NAAT)

Check directly for the DNA or RNA of the organism.

NAAT testing is used to test specifically for chlamydia and gonorrhoea.

_{They are not useful for other pelvic infections (except where specifically testing for Mycoplasma genitalium). In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample. The order of preference is endocervical, vulvovaginal, and then urine. In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab. It is worth noting that the NAAT swabs will specify on the packet whether the swabs are for endocervical, vulvovaginal or urethral use. A specific kit is used for first-catch urine NATT testing.}

_{Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat. Consider these swabs where anal or oral sex has occurred.}

Where gonorrhoea is suspected or demonstrated on a NAAT test, an endocervical charcoal swab is required for microscopy, culture and sensitivities.

Question 85

Disseminated Gonococcal Infection

Answer 85

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:

Various non-specific skin lesions

Polyarthralgia (joint aches and pains)

Migratory polyarthritis (arthritis that moves between joints)

Tenosynovitis

Systemic symptoms such as fever and fatigue

Question 86

Drugs during Breastfeeding

Question 87

Genital Herpes in Pregnancy

Answer 87

Epidemiology

Risk of neonatal herpes simplex infection contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality.

After an initial infection with genital herpes, the woman will develop antibodies to the virus. During pregnancy, these antibodies can cross the placenta into the fetus. This gives the fetus passive immunity to the virus, and protects the baby during labour and delivery.

Management

Pregnancy depends on whether it is the first episode of genital herpes (primary infection) or recurrent genital herpes.

Primary genital herpes contracted <28 weeks gestation

_{<u>Aciclovir followed by regular prophylactic aciclovir</u> starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery.}

_{Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection).}

_{<u>Caesarean section</u> is recommended when symptoms are present.}

Primary genital herpes contracted >28 weeks gestation

_{<u>Aciclovir</u> followed immediately by regular prophylactic aciclovir.}

_{<u>Caesarean section</u> is recommended in all cases to reduce the risk of neonatal infection.}

Recurrent genital herpes in pregnancy (known to have genital herpes before the pregnancy)

_{Carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery.}

_{Regular <u>prophylactic aciclovir</u> is considered <u>from 36 weeks gestation</u> to reduce the risk of symptoms at the time of delivery.}

Question 88

HIV in Pregnancy

Answer 88

Preventing Transmission During Birth

Viral load will determine the mode of delivery:

<50 copies/ml:__Normal vaginal delivery is recommended

>50 copies copies/ml & all women with > 400 copies/ml: C-Section

Unknown viral load or there are >10000 copies/ml: IV zidovudine given during C-section

Prophylaxis treatment may be given to the baby, depending on the mothers viral load:

Low-risk babies (<50 copies/ml): zidovudine for four weeks

High-risk babies (>50 copies/ml): zidovudine, lamivudine and nevirapine for four weeks

Breast Feeding

HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable.

Breastfeeding is NOT recommended for mothers with HIV.

However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.

Post-Exposure Prophylaxis (PEP)

Can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP.

PEP involves a combination of ART therapy. The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days.

HIV tests are done immediately and also a minimum of 3 months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.

Question 89

Human Papilloma Virus (HPV)

Answer 89

Epidemilology

6 & 11: causes genital warts

16 & 18: linked to a variety of cancers, most notably cervical cancer

Aetiology

Clinical Features

Investigations

Management

Question 90

Primary Amenorrhoea

Answer 90

Epidemiology

Defined as not starting menstruation:

By 13 years when there is no other evidence of pubertal development

By 15 years of age where there are other signs of puberty, such as breast bud development

Aetiology

Clinical Features

Investigations

Management

Question 91

Secondary Amenorrhoea

Answer 91

Epidemiology

Aetiology

Clinical Features

Investigations

Management