Obstetrics & Gynaecology Flashcards
1
Q
describe genitourinary syndrome of menopause
A
aka atrophic vaginitis
hypoestrogenic changes leading to
- dry skin excoriation
- discomfort/burning pain
- dyspareunia
- recurrent UTIs
management
- oestrogen cream
2
Q
describe umbilical cord prolapse and its management
A
umbilical cord descends ahead of the presenting part of the fetus
50% occur at artificial rupture of the membranes
left untreated it can lead to compression of the cord / cord spasm - leads to potentially fatal fetal hypoxia
Risk factors for cord prolapse include:
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations e.g. Breech, transverse lie
clinical features
- abnormal fetal heart rate
- palpable cord vaginally
- cord is visible beyond the level of the introitus
3
Q
describe the management of umbilical cord prolapse
A
obstetric emergency
- push presenting part of the fetus back into the uterus to avoid compression
- cord past level of introitus: minimal handling, kept warm and moist to avoid vasospasm
- patient is asked to go on ‘all fours’ until emergency caesarian section
> left lateral position is alternative - tocolytics e.g. terbutaline may be used to reduce uterine contractions
- retrofilling the bladder with 500-700ml of saline to elevate the presenting part
- caesarian section is first-line method of delivery
> instrumental vaginal delivery is possible if cervix is fully dilated and head is low
4
Q
describe premenstrual syndrome and its management
A
emotional and physical symptoms experienced in the luteal phase of the menstrual cycle
clinical features
- anxiety, stress, fatigue, mood swings
- bloating
- breast pain
Management
- mild: lifestyle advice
- moderate: combined oral contraceptive pill (COCP)
- severe: SSRI
5
Q
describe adenomyosis
A
endometrial tissue in myometrium
clinical features
- dysmenorrhoea (cyclical pain)
- menorrhagia
- enlarged, boggy uterus
usually multiparous women over age 30
investigations: transvaginal ultrasound / MRI
> asymmetrical uterus, abnormal myometrial echo texture, myometrial cysts
management
- tranexamic acid for menorrhagia
- GnRH agonists
- uterine artery embolisation
- hysterectomy is definitive
6
Q
describe endometriosis
A
abnormal deposition of endometrial tissue outwith uterus
Three types
- Superficial peritoneal lesions
- Deep infiltrating lesions
- Ovarian cysts (endometriomas)
clinical features
- chronic abdominal pain/pressure
- dyspareunia
- painful/heavy periods
- infertility
- bowel/bladder dysfunction
diagnosis: laparoscopy and biopsy is gold standard
management
- symptom free: conservative
- NSAIDs
- progestogens, COCP, Mirena IUS
- GnRH analogues in secondary care
- definitive treatment is surgical
7
Q
describe chronic endometritis
A
clinical features
- abnormal uterine bleeding
- constant, vague abdominal pain
- examination: uterine tenderness / cervical motion tenderness
> can be normal
8
Q
describe pelvic inflammatory disease (PID)
A
ascending infection of female reproductive tract usually caused by Chlamydia trachomatis
> can be caused by gonorrhoea, E.coli or anaerobes
clinical features
- bilateral pelvic pain
- abnormal uterine bleeding
- vaginal discharge
- uterine, adnexal and cervical motion tenderness
diagnosis
- vulvovaginal swab
- transvaginal ultrasound: tubo-ovarian abscess
- laparoscopy
management:
- single dose of IM ceftriaxone
- doxycycline 100mg BD 14 days
- metronidazole 400mg BD 14 days
- if pelvic abscess, surgical drainage
complications: sepsis, abscess, infertility, chronic pelvic pain, ectopic pregnancy, Fitz-Hugh-Curtis syndrome
9
Q
describe Fitz-Hugh-Curtis syndrome
A
complication of pelvic inflammatory disease in which liver capsule becomes inflamed causing RUQ pain
leads to scar tissue formation and perihepatic adhesions
treatment
- eradication of responsible organism
- laparoscopy for lysis of adhesions
10
Q
describe fibroids
A
benign tumour due to proliferation of myometrial cells - leiomyoma or fibromyomas
commonest in Afro-Caribbean women
clinical features
- menorrhagia
- dysmenorrhea
- abdominal swelling
- pressure symptoms e.g. ureteric obstruction
- oestrogen-dependent: grow during pregnancy and shrink after menopause
- examination: enlarged uterus irregular in shape
diagnosis
- clinical
- ultrasound
- MRI
management
- <3cm and not distorting uterine cavity: medical management
> IUS, tranexamic acid, COCP
- surgery (GnRH analogues or ulipristal acetate prior to surgery
> hysterectomy
> myomectomy – to preserve fertility
> uterine artery embolisation
complications: red degeneration
11
Q
list risks of SSRIs in pregnancy
A
first trimester: small risk of congenital heart defects
third trimester: persistent pulmonary hypertension of the newborn
12
Q
list requirements for instrumental delivery
A
FORCEPS
- Fully dilated cervix, generally second stage of labour must be reached
- OA position preferably OP delivery with Keillands forceps and ventouse
- Ruptured membranes
- Cephalic presentation
- Engaged presenting part
> head at/below ischial spines
> head must not be palpable abdominally - Pain relief
- Sphincter (bladder) empty - usually requires catheterisation
13
Q
list indications for forceps delivery
A
- fetal or maternal distress in second stage of labour
- failure to progress in second stage of labour
- control of head in breech delivery
14
Q
describe contraception post-partum
A
women require contraception after day 21
- COCP: absolutely contraindicated until
> 3 weeks post-partum if not breastfeeding
> 6 weeks post-partum if breastfeeding - progesterone-only pill: started at any time
- progestogen-only implant can be inserted at any time
- Mirena IUS / Copper IUD: inserted within 48h of childbirth or after 4 weeks post-partum
- lactational amenorrhoea
> if exclusively breastfeeding
> no periods and <=6 months post-partum
15
Q
describe contraception in menopause
A
non-hormonal methods of contraception
- stop contraception after 1 year of amenorrhoea if aged over 50 years
- stop after 2 years if aged under 50 years
16
Q
describe the clinical features of ovarian cancer
A
clinical features
- abdominal bloating
- pelvic pain
- fatigue
- nausea
- altered bowel habit
- early satiety/loss of appetite
- urinary / pelvic symptoms
- weight loss
- abdominal/pelvic mass
- ascites
Most common is epithelial cell tumour
> Serous tumours are the most common subtype
Also germ cell tumours, ovarian stromal tumours
Risk factors: low parity, oral contraceptives, infertility, tubal ligation, early menarche and late menopause, genetics: BRCA1/2, Lynch syndrome
Risk reducing surgery: prophylactic bilateral salpingo-oopherectomy
Investigations
- pelvic ultrasound
- CA-125 tumour marker
- Calculate RMI (risk of malignancy index): CA125, menopausal status and US findings
- CT scan
- Cytology – pleural/ascitic fluid
- Histology – biopsy (percutaneous or laparoscopic)
FIGO staging
Management
- Surgery
- Chemotherapy
lymph node metastasis (most common): para-aortic node
17
Q
describe post-partum depression and its management
A
clinical features
- low self-esteem
- low mood
- anxiousness
- severe: psychotic symptoms, risk of self-harm/suicide
more common in primiparous women
Edinburgh Postnatal Depression Scale >13 suggests moderate/severe symptoms
management
- mild: reassurance and follow-up
- give antidepressants e.g. sertraline or offer CBT if
> persistent symptoms
> EPDS >13
> history of severe depression
puerperal psychosis may happen rarely
18
Q
describe different types of physiological (functional) ovarian cysts
A
- follicular cysts
> most common cause of ovarian enlargement in women of reproductive age
> due to non-rupture of dominant follicle or failure of atresia of non-dominant follicle
> usually regress after several menstrual cycles - corpus luteum cyst
> corpus luteum fails to disappear and fills with blood/fluid
> more likely to present with intraperitoneal bleeding
19
Q
describe different types of benign tumours of the ovary
A
benign germ cell tumour
- teratomas (dermoid cysts)
> include a range of tissues e.g. skin, bone, which may protrude from Rokitansky protuberance
> cause a rise in alpha-fetoprotein and hCG
benign epithelial tumours
- serous cystadenoma
> most common type, resembles most common type of ovarian cancer (serous carcinoma)
> can be bilateral
- mucinous cystadenoma
> typically large and may become massive
> if ruptures may cause pseudomyxoma peritonei - sex cord stromal tumours
> rare, can be benign or malignant - endometriomas
> lumps of endometrial tissue within ovary causing pain, disrupt ovulation
20
Q
describe HRT and its adverse effects
A
HRT is small dose of oestrogen with progestogen in women with a uterus to alleviate menopausal symptoms
side effects
- nausea
- breast tenderness
- fluid retention and weight gain
potential complications
> increased risk of breast cancer if addition of progestogen
> increased risk of endometrial cancer
> increased risk of VTE (unless transdermal HRT), increased by addition of progestogen
> increased risk of stroke
> increased risk of ischaemic heart disease if taken more than 10 years after menopause
contraindications
- current or past breast cancer
- any oestrogen-sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
21
Q
describe the management of anaemia in pregnancy
A
first trimester cut-off: <110g/L
second/third trimester: <105g/L
post-partum: <100g/L
Management
- oral ferrous sulfate or ferrous fumarate
> continue treatment for 3 months after iron deficiency is corrected
22
Q
describe the management of pre-existing hypertension in pregnancy
A
BP >= 150mmHg systolic needs to be managed
stop ACEi/ARB if taking
start
- labetalol first-line
- nifedipine or methyldopa second-line
23
Q
describe cervical cancer screening
A
women aged 25-64, 5 year recall
high risk HPV = HPV 16, 18, 33
negative hrHPV
- return to normal recall, unless
> test of cure pathway: individuals treated for CIN1/2/3 should repeat cervical sample for test of cure 6 months after
> untreated CIN1 pathway
> follow-up for incompletely treated CGIN or other abnormalities
positive hrHPV: perform cytology
- refer for colposcopy if abnormal cytology
- if cytology is normal recall in 12 months
> if repeat test is hrHPV -ve then return to normal recall
> if repeat test is hrHPV +ve repeat again in 12 months, if positive at 24 months refer for colposcopy
if inadequate sample, repeat in 3 months
> if 2 inadequate samples - refer for colposcopy
smear should be at least 12 weeks post-partum
HIV +ve women should receive annual cervical cytology
24
Q
describe cervical intraepithelial neoplasia and its treatment
A
diagnosed at colposcopy
CIN I: mild dysplasia
CIN II: moderate dysplasia
CIN III: severe dysplasia
management
- Large loop excision of transition zone (LLETZ)
- Alternatively cryotherapy
25
describe polycystic ovarian syndrome (PCOS)
triad of anovulation, hyperandrogenism and polycystic ovaries
clinical features
- acne
- weight gain
- hirsutism
- oligomenorrhoea
- insulin resistance
- infertility
- ultrasound: polycystic ovaries, "string of pearls" appearance
lab features
- increased LH, increased LH/FSH ratio
- increased testosterone
- prolactin may be mildly raised
- decreased sex hormone binding globulin
management
- weight loss, exercise
- COCP, IUS to induce withdrawal bleeds every 3-4 months OR to prevent proliferation of endometrium
> cyclical oral progestogen can be used but does not provide contraceptive cover
- hirsutism
> facial: topical eflornithine
> widespread: COCP
> secondary care: spironolactone
- infertility: treatment initiated by secondary care specialist
- clomifene/metformin first-line
- gonadotrophins
- laparoscopic ovarian drilling
26
describe the prevention and management of preterm labour
women with cervical length <25mm or history of preterm labour
> prophylactic vaginal progesterone suppository
> prophylactic cervical cerclage (suture to hold closed)
management
- tocolysis: nifedipine
- maternal corticosteroids: <35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate: <34 weeks to protect baby's brain
- delayed cord clamping/cord milking
27
describe a cervical ectropion
aka cervical erosion, columnar epithelium that lines endocervical canal extends onto vaginal portion of cervix (ectocervix)
symptoms
- vaginal discharge
- post-coital bleeding (most common identifiable)
more common in women using COCP
ablative treatment only for troublesome symptoms
> cautery / cryotherapy / silver nitrate
28
describe bacterial vaginosis
Imbalance of normal vaginal flora with reduction in Lactobacilli and overgrowth of anaerobic bacteria e.g. Gardnerella vaginalis.
Overgrowth results in production of white malodorous discharge which is non-irritating and not associated with itch or dyspareunia
Amsel's criteria
- thin, white homogenous discharge
- microscopy of wet mount: stippled vaginal epithelial (clue) cells
- vaginal pH >4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
management
- asymptomatic: no treatment
- symptomatic: metronidazole 5-7 days
OR topical clindamycin if metronidazole not tolerated
29
describe Ebstein's anomaly
caused by use of lithium in pregnancy
posterior leaflets of tricuspid valve are displaced anteriorly towards apex of right ventricle
> creates tricuspid regurgitation (pansystolic murmur) and tricuspid stenosis (mid-diastolic murmur)
> enlargement of right atrium
30
list vaccinations offered in pregnancy
influenza vaccine at any point in pregnancy
16-32 weeks: pertussis
31
list teratogenic drugs in pregnancy and their effects
1. phenytoin: Cleft lip/palate, cardiac defects, hypoplastic nails and craniofacial abnormalities (foetal hydantoin syndrome)
2. sodium valproate/ carbamazepine: neural tube defects
3. lithium: Ebstein’s anomaly
4. warfarin: frontal bossing, cardiac defects, microcephaly, nasal hypoplasia and epiphyseal stippling
5. tetracycline: discolouration of teeth
32
Describe the anatomy of the breast
The breast consists of 15-20 lobes separated by ligaments of Cooper
Lobes contain alveoli, which contain lactocytes
Alveoli are surrounded by myoepithelial cells (contractile)
Lobes are connected by ductal system
Oxytocin stimulates myoepithelial cells to contract, pushing milk into lactiferous ducts and towards the nipple
Ducts converge at lactiferous sinus (below nipple)
Variably fibrous / fatty interlobular stroma, blood vessels, nerves
The nipple has an average of nine openings which are surrounded by the areola
Montgomery tubercles are glands which secrete a sebaceous fluid that lubricates the nipple and protects the skin
33
Describe the blood supply and lymphatic drainage of breast
Internal thoracic (medially)
Axillary (laterally)
> Lateral thoracic artery
> Pectoral branch of acromioclavicular artery
> Subscapular artery
Intercostal arteries
> Lateral perforating branches
Venous drainage - corresponding veins
Lymphatic drainage
> Axillary nodes
> Internal thoracic
34
Describe the presentation of breast cancer
Nipple/areola
> Retraction
> Eczema
> Discharge
> Lump
Skin
> Retraction
> Focal nodularity / texture change
> Rash / erosion / ulceration
> Fixation
> Dimpling
> Tethering
Oedema
Discolouration
Peau d'orange
> Aggressive inflammatory breast cancer or mastitis
Asymmetry
Pain only in 6% of breast cancers
35
List risk factors for breast cancer
Modifiable
> Smoking
> Alcohol
> Obesity
> Sedentary lifestyle
> COCP, HRT
Non-modifiable
> Age
> Family history – BRCA1/2
> Parity
> Radiation
> High risk lesion
> Early menarche / late menopause
> Nulliparity or children after 32
36
describe the assessment of breast cancer
Triple assessment - examination/history, imaging, tissue diagnosis
Imaging
> Mammogram: >40 years
> USS <40 years
> MRI
Biopsy
> FNAC - fine needle aspiration cytology
- Core needle biopsy
37
Which index is used to determine prognosis of breast cancer following surgery?
Nottingham Prognostic Index - uses size, grade and nodal status
38
Explain the management of breast cancer
Surgery (+ sentinel node biopsy)
> Wide local excision + radiotherapy
> Mastectomy (simple / skin sparing / nipple sparing)
> Reconstruction: DIEP flap, TRAM flap, TUG flap, lat dorsi flap, implants
For axilla: clearance if SNLB shows >= 3 nodes involved
+/- chemoradiotherapy
Endocrine therapy
- Tamoxifen: selective oestrogen receptor modulator used in pre-menopausal women & men
- Aromatase inhibitors e.g. letrozole, anastrozole in post-menopausal women
- Trastuzumab (Herceptin) for HER2 +ve cancers
39
List benign breast conditions
Inflammatory
> Fat necrosis (trauma): localised pain
> Periductal mastitis
> Abscess (lactational and non-lactational): acute,
Proliferative conditions
> Fibroadenoma: solid lump
> Cysts
> Fibrocystic disease: cyclical pain, may be bilateral, diffuse nodularity, may be a discrete mass
> Sclerosing adenosis
> Papilloma
40
Describe common breast cancers
Pre-invasive: high grade dysplasia
> Lobular carcinoma in situ (LCIS)
> Ductal carcinoma in situ (DCIS)
Invasive:
> Invasive ductal carcinoma (IDC)
> Invasive lobular carcinoma (LDC)
> Others
>> Malignant Phyllodes tumour
>> Tubular carcinoma
>> Mucinous carcinoma
etc
41
Describe the breast screening programme in Scotland
Mammogram for 50-70 year old women every 3 years
42
describe smoking cessation in pregnant women
offer nicotine replacement therapy
varenicline and bupropion are contraindicated
43
Describe the following breast pathologies
- Duct ectasia
- Periductal mastitis
- Mondor's disease of the breast
Mammary duct ectasia
- benign dilatation of terminal ducts of breast
- more common in post-menopausal smokers
- white, grey or green discharge
- tenderness or pain
- nipple retraction or inversion
breast lump
- microcalcifications on mammogram
- management:
> exclude breast cancer, reassurance
> troublesome symptoms: microdochectomy (if young) or total duct excision (if older)
Periductal mastitis
- common in smokers
- women present younger than in duct ectasia
- presents with recurrent periareolar/subareolar infections
-Treatment - co-amoxiclav
Mondor's disease of the breast
- localised thrombophlebitis of a breast vein.
44
describe the management of breast cancer
surgery
> Wide local excision if mass <4cm + radiotherapy
> sentinel node biopsy
> mastectomy
hormone therapy
> tamoxifen (selective oestrogen receptor modulator) - pre-menopausal if ER+
> aromatase inhibitors e.g. anastrozole (post-menopausal, can cause osteoporosis)
biological therapy
> herceptin aka trastuzumab if Her2+
>> cardiac toxicity is common so echocardiogram prior to treatment
node status
- neoadjuvant FEC-D chemotherapy if node positive
- clinically palpable lymphadenopathy: axillary node clearance
45
Describe the guidelines for breast cancer referral
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
46
describe the management of hyperthyroidism in pregnancy
first trimester: propylthiouracil
switch to carbimazole at beginning of second trimester
47
describe the management of UTI in pregnant women
Pregnant women
> symptomatic: nitrofurantoin (avoid near term)
>> second-line: amoxicillin or cefalexin
- avoid trimethoprim - teratogenic
> asymptomatic bacteriuria: 7 dayas of nitrofurantoin / amoxicillin / cefalexin
breastfeeding
- trimethoprim is safe
- avoid nitrofurantoin
48
describe inflammatory breast cancer
features
- progressive
- erythema and oedema of the breast - absence of signs of infection e.g. fever, discharge or elevated WCC and CRP)
investigations: elevated CA 15-3
management
- neo-adjuvant chemotherapy first-line
- total mastectomy +/- radiotherapy
49
describe acute endometritis
Infection of lining of uterus, may extend to upper genital tract
> most common cause of puerperal pyrexia (within 14 days post-partum)
Signs and symptoms
- Persistent lower abdominal pain / tenderness
- Pain with intercourse (deep dyspareunia)
- Persistent bleeding
- Offensive vaginal discharge
- Fever
- Cervical motion tenderness
Occurs within first few days of an abortion but reporting may be delayed
Management
- broad-spectrum antibiotics e.g. co-amoxiclav PO 7 days
- analgesia
- if sepsis/systemically unwell: admit, IV antibiotics, IV fluids
- if evidence of retained tissue and infection, empty uterus ASAP
50
describe retained products of conception (RPOC)
Placental or fetal tissue left inside uterus
Usually presents with persistent pain/bleeding
Can be associated with infection
Clinical diagnosis however patients will usually have USS
Management
- expectant - watchful waiting
- medical – further dose of misoprostol may be appropriate
- surgical – evacuation of retained products of conception (ERCP)
Urgent surgical evacuation if heavy bleeding / haemodynamically unstable / infection
51
list complications of abortion
- Failure to end the pregnancy
- Retained products of conception (RPOC)
- Infection (endometritis)
- Haemorrhage
Surgical abortions only
- Cervical tear
- Uterine perforation
52
describe uterine perforation
Usually recognised and managed at time of procedure
If not, typically presents up to 48h later
Severe or persistent abdominal pain +/- bleeding, may be peritonism
Associated injury to surrounding structures e.g. bladder, bowel, blood vessels
Imaging: CT abdomen, USS
High clinical suspicion: surgical repair
53
explain medical abortions
Induced abortion: aka termination of pregnancy (TOP)
Medical abortion types
- medical termination of pregnancy (MTOP)
- early medical abortion at home (EMAH)
MiFepristone (first): 200mg orally
- Anti-progesterone: blocks pregnancy hormones
- Mechanism of action: decidual necrosis, detachment, cervical softening and dilatation, uterine sensitisation to prostaglandins
MiSoprostol (second): 800 micrograms vaginal, buccal or sublingual
- prostaglandin analogue 24-48h after
- pain medication before taking misoprostol as will cause strong cramps and heavy bleeding (with clots)
- more painful than a period for approximately a week
- lighter bleeding for 2-3 weeks
- mechanism of action: softens and dilates cervix; uterine contractions and expulsion of pregnancy
Further doses if >10 weeks
give anti-D prophylaxis if rhesus negative after 10+0 weeks
multi-level pregnancy test needed 2 weeks post mTOP
54
explain surgical abortions
Surgical termination of pregnancy (STOP)
Manual vacuum aspiration (MVA)
- Up to 13 weeks, LA/GA/conscious sedation, 7-10 mins duration
- Cervical dilation with misoprostol
- Aspiration of pregnancy with electric or manual suction
- Can have IUD/IUS fitted at the time of procedure
- Less pain and bleeding than medical abortion
Electric vacuum aspiration (EVA)
Dilatation and evacuation (D&E)
- >13 weeks, under GA, 15-20 mins duration
- Cervical preparation with osmotic dilators and misoprostol or mifepristone
- Removal of pregnancy with forceps or vacuum aspiration
Feticide recommended from 22/40 to avoid possibility of live birth
- Digoxin (intraamniotic, intrafetal, intracardiac)
- Potassium chloride (intracardiac)
55
list side effects of misoprostol
Side-effects
- Hot flushes
- Chills
- Nausea and vomiting
- Diarrhoea
- Headache, dizziness
56
list contraindications to abortion
Medical abortion
- Allergy to mifepristone or misoprostol
- Severe, uncontrolled asthma
- Inherited porphyria
- Chronic adrenal failure
- Known/suspected ectopic pregnancy
Surgical abortion
- Inability to remove the pregnancy through cervix
57
describe an ectopic pregnancy
Implantation of embryo outside uterus
> most common site of implantation: ampulla
> most high risk site for rupture: isthmus
Risk factors
- Previous ectopic pregnancy
- Contraception e.g. POP, IUD
- Damage to fallopian tubes from pelvic inflammatory disease, endometriosis, previous tubal surgery
- Pelvic surgery including C-section
Symptoms
- Non-ruptured: vaginal bleeding, spotting, abdominal pain
- Ruptured
> Pain under ribs/shoulder tip
> Severe abdominal pain
> maternal collapse / hypovolaemic shock
> Rebound tenderness
> pain opening bowels
investigations
- positive pregnancy test
- HCG tracking
- ultrasound: transabdominal or transvaginal
management
- non-emergency:
> medical: methotrexate
>> pregnancy test 3 weeks after to confirm miscarriage
> surgical: laparoscopy, salpingectomy or oopherectomy
>>indications: >35mm in size or with serum bCHG >5000IU/L or visible foetal heartbeat or pain
- emergency: resuscitate, surgery
58
List antibiotic choices for the following conditions
Genital system
> gonorrhoea
> chlamydia
> PID
> Syphilis
> Bacterial vaginosis
Gonorrhoea: IM ceftriaxone
or oral azithromycin + cefixime
Chlamydia: doxycycline / azithromycin
PID: oral ofloxacin + oral metronidazole OR IM ceftriaxone + oral doxycycline + oral metronidazole
Syphilis: benzathine benzylpenicillin
Bacterial vaginosis: metronidazole; topical clindamycin
59
describe causes of genital ulceration
painful
- HSV
> more common
> multiple painful ulcers, fever, painful inguinal lymphadenopathy
> first attack: 7 days oral vanciclovir
> recurrence: 3 days oral vanciclovir
- chancroid
> less common
> caused by haemophilus ducreyi
> painful ulcers with unilateral painful lymph node enlargement
> ulcers are typically sharply defined, ragged with undermined border
> management: PO azithromycin / IM ceftriaxone
painless
- syphilis
> more common
> single painless ulcer (chancre) is seen in the primary stage
> progresses to painless generalised lymphadenopathy, maculopapular rash and constitutional symptoms
- lymphogranuloma venereum
> less common
> caused by Chlamydia trachomatis
> small painless pustule later forms an ulcer
> progresses to painful inguinal lymphadenopathy and proctocolitis
> management: doxycycline
60
describe the management of genital warts
caused by HPV 6 and 11
solitary keratinised wart: cryotherapy
multiple non-keratinised warts: topical podophyllum (caution in pregnancy)
61
describe scabies
infestation with the mite Sarcoptes scabiei
features
- intense itching that is worse at night along
- erythematous papules and burrows in web spaces of hands, wrists and genitals
- nodules - axilla, umbilicus, groin, penis
- crusted scabies. (immunosuppressed)
treatment
- head, neck and scalp
- treat whole family
62
Describe genital herpes and its management
Features
- painful genital ulceration
- dysuria and pruritus
- systemic features: headache, fever and malaise
- tender inguinal lymphadenopathy
- urinary retention
Investigations
- nucleic acid amplification tests (NAAT) on swab
- HSV serology if recurrent genital ulceration
Management
- saline bathing
- analgesia
- topical anaesthetic agents e.g. lidocaine
- oral aciclovir
- reassure patients recurrent episodes are less severe than primary infection
63
Describe HIV and its management
Seroconversion occurs 3-12 weeks after infection
features of seroconversion
- sore throat
- lymphadenopathy
- malaise, myalgia, arthralgia
- diarrhoea
- maculopapular rash
- mouth ulcers
- rarely meningoencephalitis
other
- chronic HIV-associated nephropathy: large/normal kidneys on US (whereas CKD has bilateral small kidneys)
management
- highly active anti-retroviral therapy
> 2 nucleoside reverse transcriptase inhibitor (NRTI) e.g. tenofovir and emtricitabine + one other agent
> integrase inhibitors
> protease inhibitors
> non-nucleoside reverse transcriptase inhibitor
- if CD4 count <200 give co-trimoxazole as prophylaxis against pneumocystis jiroveci pneumonia
> often normal CXR with desaturation on exertion
64
Describe HIV testing
Combined HIV antibody/antigen tests (HIV p24 antigen and HIV antibody)
> turn positive approx 4 weeks post-exposure
> repeat test to confirm diagnosis before starting treatment
if initial negative result when testing an asymptomatic patient, offer a repeat test at 12 weeks
65
explain PrEP and PEP
PEP: post-exposure prophylaxis
> taken up to 72h after unprotected intercourse
> 28 days duration
> final HIV testing at 8 weeks
PrEP: used by people more at risk of getting HIV
> daily or event-based dosing
66
describe thrush
usually infection of vagina with Candida albicans
symptoms
- itching
- pain
- thick white "cottage cheese" discharge
- dyspareunia
signs
- swelling
- fissures
- discharge
- vulvovaginitis
diagnosis
- history and macroscopic appearance
- pH <5
- microscopy
management
- uncomplicated:
> first-line: fluconazole oral single-dose 150mg stat (avoid if pregnant/breastfeeding)
> if oral therapy contraindicated: clotrimazole 500mg pessary (prolonged i.e. 7 days in pregnancy)
> if vulval symptoms, topical imidazole in addition to above
- complicated if severe/immunocompromised/diabetic
- recurrent vaginal candidiasis: >=4 episodes per year
> induction-maintenance regime
>> induction: oral fluconazole every 3 days for 3 doses
>> maintenance: oral fluconazole weekly for 6 months
67
Describe the features of Trichomonas vaginalis
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite causing an STI
Features
- vaginal discharge: malodorous, yellow/green, frothy
- superficial dyspareunia
- vulvovaginitis
- dysuria
- in men is usually asymptomatic but may cause urethritis
Investigation
> microscopy of wet mount: motile trophozoites
- strawberry cervix
- pH > 4.5
Management
- oral metronidazole for 5-7 days
68
how long does it take to exclude pregnancy following unprotected sex
3 weeks or 21 days
69
list side effects associated with hormonal contraception
- irregular and/or prolonged bleeding
- breast tenderness / enlargement / pain
- bloating / weight gain
- headache
- mood swings
- reduced sex drive
- acne
- nausea
- greasy skin/hair
- increased body and facial hair
- vaginal dryness
- increased vaginal discharge
- chloasma (skin pigmentation)
many are likely to be temporary
> if persists: switch pills/method
> if chloasma: stop COCP
70
describe rules for missed COCP
One missed pill
- No condoms needed
- No EC needed
- Take the last missed pill and continue taking the rest of the pack
Two or more missed pills
- Condoms for 7 days
- Ask where in the packet
- Week 1: EC needed if unprotected sex during pill-free interval or week 1
- Week 2: no EC needed, carry on taking the pill as usual
- Week 3: no EC needed, start next packet of pills without a break
71
describe urge incontinence / overactive bladder
overactive bladder / urge incontinence
features
- urge
- frequency
- nocturia
- +/- no infection
causes
- idiopathic
- neurological / UMN conditions
- psychological
- bladder irritation e.g. UTI/stones
- BPH in men
management
- conservative: bladder retraining, pelvic floor exercises
- pharmacological:
> antimuscarinics first-line: Oxybutinin, solifenacin, tolterodine
> beta 3 agonists: mirabegron
- invasive
> botulin toxin A into bladder wall
> percutaneous / sacral nerve stimulation (PTNS)
- surgical
> augmentation cystoplasty
> urinary diversion
72
describe stress incontinence
stress incontinence: weak pelvic floor
features
- leaking small amounts when coughing / laughing / jumping / sneezing
causes
- childbirth
- chronic cough
- constipation
- obesity
management
- non-pharmacological: caffeine reduction, pelvic floor exercises
- pharmacological: duloxetine (SNRI)
- invasive: intramural bulking agents
surgery
- mid-urethral sling
- colposuspension
73
describe different types of prolapse and associated risk factors
Uterine prolapse
- Uterus descends into vagina
Vault prolapse
- In women who have had a hysterectomy and no longer have a uterus
- Top of vagina (vault) descends into vagina
Cystocoele
- Defect in anterior vaginal wall
- Bladder prolapses backwards into vagina
- Prolapse of urethra is possible (urethrocoele)
Rectocoele
- Defect in posterior vaginal wall
- Rectum prolapses forward into vagina
Risk factors
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopausal status
- Chronic increase in intra-abdominal pressure
> Occupational / recreational e.g. weightlifting
> Chronic cough
> Constipation
> Obesity
74
describe the clinical presentation and classification of prolapse
Symptoms
- Feeling of "something coming down" in vagina
- Worse on straining or bearing down
- Dragging or heavy sensation in pelvis
- Urinary symptoms: incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms: constipation, incontinence and urgency
- Sexual dysfunction: pain, altered sensation and reduced enjoyment
- Lump on digitation
Pelvic Organ Prolapse Quantification (POP-Q) Stages
- Stage 0 – no prolapse
- Stage 1 – lowest part is more than 1cm above introitus
- Stage 2 – lowest part is within 1cm of introitus (above or below)
- Stage 3 – lowest part is more than 1cm below introitus
- Stage 4 – full descent with eversion of the vagina
Prolapse extending beyond the introitus: uterine procidentia
75
describe the examination and management of prolapse
Examination: Sim's speculum, dorsal or left lateral position
Management of prolapse
- Do nothing if asymptomatic
- Conservative (non-surgical)
> Physiotherapy (pelvic floor exercises)
> Lifestyle changes: improve constipation, do not lift heavy weights, weight loss
> Vaginal oestrogen cream to improve dry tissue
- Vaginal prolapse pessaries – support prolapse
Surgery
- Vaginal (non-mesh)
> Reconstructive e.g. pelvic floor repair
> Obliterative: colpocleisis
- Abdominal (mesh)
> Open
> Laparoscopic +/- robotically
Complications of surgery
- Dyspareunia
- Worsening bladder – bowel symptoms
- Chronic pain – neuropathy
- Mesh complication s
- Failure
- Recurrence especially with vaginal non-mesh
76
list problems with vaginal pessaries
Problems
- Discharge / bleeding
- Pain
- Sexual function
- Erosion / fistula
- Expulsion / retention
- Repeated appointments v self-management
77
describe cervical cancer
caused by high risk subtypes of HPV: 16, 18
Squamous cell carcinoma is the most common
Risk factors: smoking, early first episode of sexual intercourse, COCP, multiple sexual partners, immunosuppression
Clinical features
- Asymptomatic
- Unscheduled vaginal bleeding: intermenstrual bleeding, post-coital bleeding, post-menopausal bleeding
- Sero-sanguinous offensive vaginal discharge
- Back ache
- Obstructive renal failure
- Supraclavicular node
- Systemic symptoms
Investigations
- Examination: abdominal, inguinal, speculum, bimanual and PR
- Colposcopy
- MRI – local staging
- PET-CT: metastatic disease
FIGO staging
Management
- CIN and early stage 1A: LLETZ or cone biopsy to preserve fertility
> gold standard: hysterectomy +/- lymph node clearance
- stage IA2: radical trachelectomy to preserve fertility
> gold standard: hysterectomy + lymph node clearance
- Stage 1B-2A: radical hysterectomy + lymphadenectomy
- later stages: chemoradiotherapy, palliative
78
describe a Krukenberg tumour
Metastasis in the ovary usually from GI tract cancer
Characteristic signet ring cells on histology
79
describe vulval cancer
Most are squamous cell carcinoma, can be malignant melanomas
Risk factors: smoking, HPV, chronic skin conditions e.g. lichen sclerosus
Clinical presentation
- Vulval lump
- Ulceration
- Pain
- Bleeding
- Itching
- Lymphadenopathy in groin
- Irregular mass
- Fungating lesion
Investigations
- Biopsy + sentinel node biopsy
- Staging imaging e.g. CT AP
FIGO staging
Depth of invasion is an important prognostic factor
Management
- Wide local excision
- Groin lymph node dissection
- Chemotherapy
- Radiotherapy
80
describe vulval intraepithelial neoplasia
Premalignant condition affecting squamous epithelium of skin that can precede vulval cancer
Clinical presentation
- Asymptomatic
- Pruritus
- Pain
- Ulceration
- Leukoplakia
- Lump/ "wart"
Investigations: biopsy
Management
- Observation
- Wide local excision
- Imiquimod cream
- Laser ablation
81
describe endometrial cancer
Presentation
- Post-menopausal bleeding, post-coital bleeding, intermenstrual bleeding
- Altered menstrual pattern
- Abnormal vaginal discharge
- Haematuria
- Anaemia
- Thrombocytosis
Adenocarcinoma of endometrium is most common
Risk factors: obesity, T2DM, unopposed oestrogen exposure, tamoxifen, nulliparity, late menopause, genetics: HNPCC aka Lynch syndrome (more common than ovarian)
FIGO staging
Investigations
- transvaginal ultrasound: endometrial thickness >4mm if not on HRT, >5mm if on HRT
- pipelle biopsy
- hysteroscopy with endometrial biopsy
Management
- Surgery: total abdominal hysterectomy with bilateral salpingo-oophorectomy
> also recommended for atypical endometrial hyperplasia
- Chemotherapy, radiotherapy
- Progesterone to slow progression or if too elderly/frail for surgery
82
describe pre-eclampsia
pregnancy-induced hypertension (>20 weeks) + proteinuria (>0.3g/24h) + oedema
- pregnancy-induced hypertension is hypertension >20 weeks
> hypertension >160 mmHg is a medical emergency in pregnancy
risk factors: pre-existing hypertension, diabetes, chronic kidney disease, autoimmune conditions e.g. SLE, nulliparity, maternal age >40
symptoms
- headache
- visual disturbance or blurriness
- nausea and vomiting
- RUQ or epigastric pain
- oedema
- reduced urine output
- hyperreflexia
diagnosis
- BP >140/90 PLUS any of
> proteinuria
> organ dysfunction (e.g. raised creatinine or liver enzymes)
> placental dysfunction (e.g. FGR, oligohydramnios)
- low placental growth factor (PlGF)
- scoring systems (fullPIERS or PREP-S)
management
- prophylaxis: aspirin 150mg from 12 weeks until birth if risk factors
- anti-hypertensives: oral labetalol first-line
> or nifedipine MR
> IV hydralazine in severe pre-eclampsia or eclampsia
- IV magnesium sulphate if birth is planned within 24h, during labour and in the 24h afterwards
> monitor urine output and respiratory rate due to risk of toxicity if renal function deteriorates, loss of deep tendon reflexes and respiratory depression
> IV calcium gluconate: reversal agent
- fluid restriction
- delivery within 24-48h if mild/moderate hypertension >37 weeks
83
describe eclampsia
pre-eclampsia + generalised tonic-clonic seizures
management
- IV magnesium sulfate until 24h after delivery or last seizure
> reversal agent is calcium gluconate
84
describe HELLP syndrome
haemolysis with elevated liver enzymes and low platelets
complication of severe pre-eclampsia
85
describe the choice of menopausal HRT
general principles
- cyclical/sequential: still having periods, causes bleeds
- continuous: no periods, will not cause bleeds
- oestrogen + progesterone: uterus
- oestrogen only: no uterus
management:
Vaginal sex only: vaginal oestrogen lubricants and moisturisers
Uterus intact
- LMP <1y
> oral sequential combined oestrogen and progesterone
>> e.g. oestradiol with norethisterone
> patch sequential combined oestrogen and progesterone
> transdermal/oral oestrogen + IUS/oral progesterone
> oestradiol valerate & dienogest COC: if low risk and contraception needed
- LMP >1y
> oral continuous combined oestrogen and progesterone
>> e.g. oestradiol with norethisterone
> patch continuous combined oestrogen and progesterone
> transdermal/oral oestrogen and IUS/oral progesterone
> tibolone
Post-hysterectomy
- transdermal or oral oestrogen
>> e.g. oestradiol
- tibolone
86
describe the management of
- post-menopausal osteoporosis
- vasomotor symptoms in someone that can't take HRT
- menopausal atrophic vaginitis
- vaginal dryness
post-menopausal osteoporosis
- alendronic acid or risedronate sodium
vasomotor symptoms if can't take HRT
- SSRI e.g. fluoxetine, citalopram OR venlafaxine OR clonidine
menopausal atrophic vaginitis
- topical vaginal oestrogen (pessary or ring)
vaginal dryness
- vaginal lubricant or moisturiser
87
describe emergency contraception
IUD (copper coil)
- gold standard
- within 5 days of last UPSI or within 5 days of last ovulation
> earliest day of ovulation is shortest cycle length - 14
Levonelle (levonorgestrel)
- UPSI <3 days
- if vomiting within 3h, repeat dose
- if weight >70kg or BMI>26, double dose
- can be used more than once in a cycle
- can resume contraception immediately
EllaOne (ulipristal acetate)
- UPSI <5 days
- contraindicated in asthma
- can be used more than once in a cycle
- wait 5 days before resuming contraception
oral contraception not suitable if gastric sleeve/bypass/duodenal switch
88
describe oral hormonal contraception
COCP
- inhibits ovulation
- effective after 7 days
> if switching from IUD to COCP no additional contraception needed if removed day 1-5 of cycle
- increases breast/cervical cancer risk, decreases ovarian/endometrial cancer risk
- increased VTE risk
- e.g. Microgynon 30 aka ethinylestradiol with levonorgestrel
POP
- thickens mucus
- effective after 2 days
- irregular bleeding
- e.g. Cerazette (desogestrel)
> the injection, implant and IUS take 7 days to be effective
89
describe pre-term labour and its management
regular uterine contractions accompanied by effacement (shortened cervix) and dilatation of the cervix after 20 weeks and before 37 weeks
Risk factors
- Previous preterm labour (strongest predictor) or preterm rupture of membranes <34 weeks
- Previous LLETZ >1cm or multiple
- Previous full dilatation caesarean
- Previous cerclage
- Uterine anomaly e.g. bicornuate / didelphis
If at risk offer cervical length surveillance and if short cervix offer treatment (<25mm)
> Cervical cerclage (suture)
> Progesterone pessaries
Prevention of neonatal complications
- maternal corticosteroids
> IM betamethasone or dexamethasone given in divided doses over 24h if <34 weeks' gestation
> Reduced incidence of RDS, intraventricular cerebral haemorrhage and neonatal death
- Magnesium sulphate
> Neuroprotective for baby
90
describe miscarriage
spontaneous termination of pregnancy before 24 weeks
clinical presentation
- in the presence of a positive pregnancy test
- vaginal bleeding – brown spotting to heavy +/- tissue
- pelvic discomfort or pain
- or asymptomatic
investigations
- ultrasound
> mean gestational sac diameter>=25mm without fetal pole
> crown-rump length >=7mm without a fetal heartbeat
> repeat scan after one week to confirm
management
- expectant management
- medical: misoprostol
> mifepristone + misoprostol if missed miscarriage
- surgical: electrical or manual vacuum aspiration (+ cervical priming with misoprostol)
91
describe a molar pregnancy
Premalignant: risk of malignant conversion
- Partial hydatidiform mole
> Triploid: 2 sperm, 1 egg
> May be an embryo present
> Most present as failed pregnancy
- Complete hydatidiform mole
> Diploid – 2 sperm, empty ovum
Malignant
- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic tumour
- Very sensitive to chemotherapy
Clinical features (many due to increased production of hCG)
- PV bleeding
- Enlarged uterus
- Hyperemesis gravidarum
- Hyperthyroidism (hCG can mimic TSH
Investigations
- Ultrasound: snowstorm appearance
- Histology
Management
- evacuation of the uterus to remove mole
- if metastasis may require systemic chemotherapy
92
describe hyperemesis gravidarum
normal nausea and vomiting in pregnancy peaks around 8-12 weeks gestation and resolves by 16-20 weeks (although can persist throughout pregnancy)
hyperemesis gravidarum requires protracted nausea and vomiting plus
- > 5% weight loss compared with before pregnancy
- dehydration
- electrolyte imbalance
severity scoring: pregnancy-unique quantification of emesis (PUQE)
management
- antiemetics
> prochlorperazine (stemetil)
> cyclizine
> ondansetron
> metoclopramide (no longer than 5 days due to extrapyramidal side effect risk)
- ranitidine or omeprazole can be used if acid reflux is a problem
complications
- Wernicke's encephalopathy
- VTE
93
describe gestational diabetes and its complications in pregnancy and the neonate
gestational diabetes is diabetes triggered by pregnancy as it is a state of increasing insulin resistance
risk factors: previous gestational diabetes, previous macrosomic baby (>4.5kg), BMI>30, ethnic origin, family history of diabetes
Investigations
- oral glucose tolerance test
> ASAP if previous gestational diabetes, repeated at 24-28 weeks if first one normal
> 24-28 weeks to women with risk factors
diagnosis
- fasting glucose >=5.6mmol/l
- 2-hour glucose >=7.8mmol/l
Complications
- maternal
> pre-eclampsia
> polyhydramnios
- neonatal
> Foetal macrosomia (risk of shoulder dystocia)
> Neonatal hypoglycaemia
> Birth trauma
management
- fasting glucose <7mmol/l: trial of diet and exercise 1-2 weeks
- metformin
- insulin if fasting glucose >=7mmol/l
94
describe stillbirth
birth of a dead fetus after 24 weeks gestation
Causes
- unexplained
- pre-eclampsia
- placental abruption
- vasa praevia
- cord prolapse
- obstetric cholestasis
- infections
- genetic abnormalities
Presentation
- Bleeding
- Abdominal pain
- Reduced fetal movements
- Asymptomatic – unexpected finding at ultrasound
management
- rhesus-d negative women require anti-D prophylaxis
- expectant management or induction of labour
- dopamine agonists e.g. cabergoline to suppress lactation
95
describe a breech presentation
presenting part of the fetus (the lowest part) is the legs and bottom
Types of Breech
- complete breech: legs are fully flexed at the hips and knees
- incomplete breech: one leg flexed at the hip and extended at the knee
- extended breech: aka frank breech, with both legs flexed at the hip and extended at the knee
- footling breech: foot presenting through cervix with the leg extended
management
- <36 weeks: often turn spontaneously, no intervention
- External cephalic version (ECV)
> 37 weeks in multiparous women
> 36 weeks in nulliparous women
> can attempt if amniotic sac has not ruptured
- choice between vaginal and caesarean delivery
96
describe placenta accreta
refers to when the placenta implants deeper, through and past the endometrium
types
- superficial placenta accreta: placenta implants in surface of myometrium but not beyond
- placenta increta: placenta attaches deeply into myometrium
- placenta percreta: placenta invades past myometrium and perimetrium, potentially reaching other organs e.g. bladder (may present with frank haematuria)
risk factors: previous placenta accreta, previous endometrial curettage procedures, previous caesarean, multigravida, low-lying placenta or placenta praevia
presentation
- antepartum haemorrhage
investigations
- antenatal ultrasound
- MRI to assess invasion
management
- planned delivery between 35-36+6 weeks
- caesarean section + hysterectomy / uterus preserving surgery / expectant management
97
describe placental abruption
separation of placental from wall of uterus can lead to retroplacental haemorrhage
risk factors: previous placental abruption, pre-eclampsia, trauma, multiple pregnancy, polyhydramnios, cocaine or amphetamine use
presentation
- sudden onset severe abdominal pain that is continuous
- vaginal bleeding (antepartum haemorrhage)
- shock (hypotension and tachycardia)
- abnormalities on CTG indicating fetal distress
- hard woody uterus on palptation: Couvelaire uterus
concealed abruption: closed cervical os means bleeding remains within uterine cavity (opposite of revealed abruption)
clinical diagnosis
management
- fetus alive and <36 weeks
> fetal distress: immediate caesarean
> no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
- fetus alive and >36 weeks
> fetal distress: immediate caesarean
> no fetal distress: deliver vaginally
- fetus dead: induce vaginal delivery
98
describe vasa praevia
condition where fetal vessels are within the chorioamniotic membranes and travel across the internal cervical os
exposed vessels are prone to bleeding particularly when membranes are ruptured during labour and at birth
risk factors: low lying placenta, IVF pregnancy, multiple pregnancy
diagnosis: ultrasound ideally or during labour
management
- asymptomatic women: steroids, elective caesarean section 34-36 weeks
- antepartum haemorrhage: emergency caesarean section
99
describe placenta praevia
Low lying placenta: placenta within 20mm of internal cervical os
> if low lying placenta at 20 weeks, re-scan at 32 weeks
Placenta praevia: placenta covers the internal cervical os
risk factors: previous caesarean sections, previous placenta praevia, IVF, uterine abnormalities
Clinical presentation
- Painless bleeding
- Non-engaged presenting part
- Soft uterus
- shock in proportion to visible loss
investigations: transvaginal ultrasound to determine distance between edge of placenta and internal os
> do not perform digital vaginal examination
management
- delivery via Caesarean section
- do not examine with hands if previa due to risk of bleeding
Risks
- antepartum haemorrhage
- emergency caesarean section / hysterectomy
Management
- planned caesarean section between 36-37 weeks gestation
- earlier emergency delivery may be required if haemorrhage occurs
100
describe polymorphic eruption of pregnancy
clinical features
- starts in third trimester
- begins on abdomen
- associated with stretch marks
- Urticarial papules (raised itchy lumps)
- Wheals (raised itchy areas of skin)
- Plaques (larger inflamed areas of skin)
condition will get better towards the end of pregnancy and after delivery
Management
- Topical emollients and steroids
- Oral antihistamines
- Oral steroids if severe
101
describe atopic eruption of pregnancy
eczema that flares up during pregnancy
presents in the first and second trimester of pregnancy
condition will get better after delivery
Management
- Topical emollients and steroids
- Phototherapy with UVB or oral steroids in severe cases
102
describe melasma
aka mask of pregnancy
increased pigmentation to patches of the skin on the face
usually symmetrical and flat, affecting sun-exposed areas
Management:
- Avoiding sun exposure and using suncream
- Makeup (camouflage)
103
describe pyogenic granuloma
aka lobular capillary haemangioma
benign, rapidly growing tumour of capillaries
> rapidly growing discrete lump with a red or dark appearance
> up to 1-2 cm in size
> occur on fingers, or on the upper chest, back, neck or head
> may cause profuse bleeding and ulceration if injured
usually resolve without treatment after delivery
104
describe pemphigoid gestationis
rare autoimmune skin condition that occurs in pregnancy
occurs in second or third trimester
clinical features
- itchy red papular or blistering rash around the umbilicus
- spreads to other parts of the body
- over several weeks, large fluid-filled blisters form
management
- rash resolves without treatment after delivery
- topical emollients and steroids
- oral steroids or immunosuppressants if severe
risks to baby:
- fetal growth restriction
- preterm delivery
- blistering rash after delivery
105
list complications of pre-eclampsia
maternal
- intracranial hemorrhage
- placental abruption and DIC
- eclampsia
- HELLP syndrome
- renal failure
- pulmonary oedema
fetal
- FGR, oligohydramnios, hypoxia
106
describe Bartholin's abscess and cyst
Abscess
- Acute infection of the Bartholin gland by bacteria
- Very painful
Management
> antibiotics
> marsupialisation
Cyst
- Chronic painless swelling after previous acute infection
107
describe lichen sclerosus et atrophicus
Autoimmune condition mainly affecting post-menopausal women
clinical features
- itchy white spots found on vulva
- pruritus vulvae
- excoriation - pain, dyspareunia
signs
- whitening of vulval skin
- loss of labial and clitoral contours
- narrowing of entry to vagina
> in men: uncircumcised man with tight white ring around tip of foreskin and phimosis
diagnosis: clinical or biopsy
management
- strong topical steroids e.g. clobetasol propionate
- topical tacrolimus if steroid resistant
108
describe cervical polyps
irregular red growths on cervix
clinical features
- asymptomatic
- post-coital bleeding or post-menopausal bleeding
Clinical diagnosis
Management only if symptomatic: avulsion in GOPD
109
describe nabothian cysts
fluid-filled cysts often seen on the surface of the cervix
usually asymptomatic
appearance: smooth rounded bumps near os (2mm-30mm), whitish or yellow appearance
management - reassurance
110
describe female genital mutilation
surgically changing the genitals of a female for non-medical reasons
types
- type 1: removal of part or all of clitoris
- type 2: removal of part or all of clitoris and labia minora +/- labia majora
- type 3: narrowing or closing the vaginal orificie (infibulation)
- type 4: all other unnecessary procedures to female genitalia
immediate complications
- pain, bleeding, swelling, infection
- urinary retention
- urethral damage and incontinence
long-term complications
- vaginal, pelvic anad urinary tract infections
- dysmenorrhoea
- sexual dysfunction and dyspareunia
- infertility and pregnancy-related complications
- psychological issues
management
- prevention and reporting all under 18 cases to police
- de-infibulation in cases of type 3 FGM
111
describe Asherman's syndrome
adhesions form within the uterus, following damage to the uterus
usually following pregnancy-related dilatation and curettage procedure, uterine surgery or severe pelvic infection
presentation
- secondary amenorrhoea
- significantly lighter periods
- dysmenorrhoea
diagnosis: hysteroscopy, hysterosalpingography, sonohysterography or MRI scan
management: dissection of adhesions during hysteroscopy
112
describe endometrial polyps
Symptoms:
- post-menopausal bleeding
- intermenstrual bleeding,
- heavy menstrual periods
Diagnosis: transvaginal ultrasound, hysteroscopy and histology
Management
- Hysteroscopy and polypectomy
113
describe hydrosalpinx
fluid blockage in fallopian tubes
Symptoms
- Usually none after acute infective phase
- Pelvic pain
- Subfertility/infertility
Diagnosis: transvaginal ultrasound, laparoscopy, hysterosalpingogram
Treatment
- Symptom free: conservative
- Pelvic pain – bilateral salpingectomy
- Infertility – IVF
114
describe vulvodynia
Sensation of vulval burning and soreness due to hypersensitivity of vulval nerve fibres
Management
- Low dose tricyclic antidepressants
- Lubricants
- Vulval care advice
115
describe ovarian hyperstimulation syndrome
associated with hCG use to mature follicles during ovarian stimulation leading to increased VEGF
clinical features
- abdominal pain and bloating
- nausea and vomiting
- diarrhoea
- oedema, ascites, hypovolaemia
- thrombosis
- renal and liver dysfunction
- ARDS
- peritonitis
raised renin level is an indicator of severity
prevention: monitoring of serum oestrogen and ultrasound monitoring of follicles
management: supportive
- oral fluids
- monitoring of urine output
- LMWEH
- paracentesis
- IV colloids
116
describe premature ovarian insufficiency
menopause <40 years of age
characterised by hypergonadotrophic hypogonadism
> raised LH and FSH, low oestradiol
> further sample should be taken after 4-6 weeks for diagnosis
causes:
- idiopathic
- iatrogenic: chemo/radiotherapy, surgery
- autoimmune
- genetic
- infections
presentations
- irregular menstrual periods
- secondary amenorrhoea
- hot flushes, night sweats, vaginal dryness
management: combined HRT until typical age of menopause e.g. 51
117
describe the causes of post-partum haemorrhage (PPH)
Major obstetric haemorrhage: blood loss >1000ml
4 Ts:
- Tone: atonic uterus cannot tamponade placental bed e.g. placenta praevia, multiple pregnancy, obesity
> most common cause
- Tissue: placenta remaining inside uterus
- Trauma: C-section, episiotomy
- Thrombin: pre-eclampsia, placental abruption
- Primary: within 24h of delivery
- Secondary: 24h - 12 weeks postnatally
> usually associated with infection (endometritis) +/- retained tissue
> treat infection and consider removal of tissue
118
list causes of antepartum haemorrhage
- Placenta praevia
- Vasa praevia
- Abruption
- Uterine rupture
119
describe additional considerations in maternal cardiac arrest
Left lateral position usually to prevent aortocaval compression if more than 20 weeks
Displace uterus if person is flat to do CPR
Call obstetric team, resuscitation team, neonatal team
If no response to CPR after 4 minutes proceed to delivery / perimortem caesarean section (if >=20 week size)
Aim for delivery by 5 minutes
additional causes of cardiac arrest: eclampsia and pre-eclampsia, usually from intracranial haemorrhage secondary to uncontrolled hypertension
120
describe shoulder dystocia
obstetric emergency
anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered
turtle-neck sign: head is delivered but then retracts bak into vagina
management
- McRoberts: hyperflex legs, apply suprapubic pressure
- episiotomy to allow internal manoeuvres
> Wood's screw manoeuvre
- last resorst: symphisiotomy, Zavanelli manoeuvre
complications: fetal hypoxia (and subsequent cerebral palsy), brachial plexus injury and Erb's palsy, perineal tears and post-partum haemorrhage
121
describe an amniotic fluid embolism
rare but severe condition where the amniotic fluid passes into the mother’s blood, usually around labour and delivery
presentation
- shortness of breath
- hypoxia, hypotension
- coagulopathy
- haemorrhage
- tachycardia
- confusion
- seizures
- cardiac arrest
management: supportive
> ICU transfer
122
describe the management of post-partum haemorrhage (PPH)
Management
- Resuscitation: fluids, blood
- Arresting bleeding
> Mechanical
>> rubbing up the fundus
catheterisation
>> bimanual uterine compression
> Medical
>> IV oxytocin (Syntocinon)
>> IV/IM ergometrine: uterotonic - contraindicated in hypertension)
>> IM carboprost: intramyometrial - contraindicated in asthma
>> Misoprostol sublingual / rectal
- Surgical
> Intrauterine balloon tamponade
> B-Lynch suture for tamponade
> Bilateral uterine or internal iliac artery ligation
> Hysterectomy
123
explain the following terms
- threatened miscarriage
- inevitable miscarriage
- incomplete miscarriage
- complete miscarriage
- missed miscarriage
threatened miscarriage: painless bleeding with continuing intrauterine pregnancy <24 weeks, closed cervical os
inevitable miscarriage: heavy bleeding with clots and pain; cervical os is open
incomplete miscarriage: not all products of conception have been expelled; pain and vaginal bleeding; cervical os is open
complete miscarriage: all pregnancy tissue expelled, uterus empty
delayed/missed/early embryonic demise: foetus dying in utero <20 weeks without symptoms of expulsion; cervical os closed
124
describe mastitis
inflammation of breast tissue associated with breastfeeding
features
- painful, tender, red hot breast
- fever and general malaise
management
- first-line: continue breastfeeding, analgesia, warm compresses
- treat if systemically unwell, nipple fissure, if symptoms do not improve after 12-24h of effective milk removal or if culture indicates infection
- first-line antibiotic: flucloxacillin 10-14 days
complication: breast abscess requiring incision and drainage
125
describe 12 week screening for Down's syndrome
nuchal translucency, beta-hCG and PAPP-A
126
describe the causes and initial investigations for infertility
causes: male factor, unexplained, ovulation failure, tubal damage, other causes
investigations (after 1 year of regular sexual intercourse)
- semen analysis
- serum progesterone 7 days prior to expected next period, usually day 21 if 28 day cycle
> if <16nmol/l, repeat and then consider specialist referral
counselling points:
> folic acid 3 months before conception until 12 weeks (0.4mg unless high risk or BMI>30, then 5mg)
> aim for BMI 20-25
> regular intercourse
> smoking/drinking advice
127
describe intrahepatic cholestasis of pregnancy
features
- pruritus (worse in palms, soles and abdomen)
- clinically detectable jaundice in 20% of patients
- raised bilirubin in >90% of cases
management
- induction of labour at 37-38 weeks due to risk of stillbirth
- ursodeoxycholic acid
- vitamin K supplementation
can recur in subsequent pregnancies
128
state the most common cause of pruritus vulvae
contact dermatitis
e.g. new condom usage
129
describe Paget's disease of the nipple
eczematoid change of the nipple associated with underlying breast malignancy
differs from eczema of the nipple as it involves nipple primarily and later spreads to areola (opposite in eczema)
diagnosis: punch biopsy, mammography and US breast
management depends on underlying lesion
130
describe chorioamnionitis
ascending bacterial infection of the amniotic fluid/membranes/placenta
clinical features
- fever
- uterine tenderness
- foul-smelling discharge
- baseline fetal tachycardia
associated with prolonged premature rupture of membranes
management
- IV antibiotics
- prompt delivery of foetus
131
state the only contraceptive with a proven associated with weight gain
depo provera - medroxyprogesterone acetate
> given every 12 weeks
132
describe induction of labour and its complications
Bishop score should be assessed prior to induction
- score <=6: cervix not favourable for induction, requires cervical ripening methods
> vaginal prostaglandins or oral misoprostol
> osmotic cervical dilator if high risk of hyperstimulation or previous caesarean
- score >6 cervix favourable for induction
> amniotomy and IV oxytocin infusion
methods
- membrane sweep (adjunct to induction)
- osmotic cervical dilator e.g. cervical ripening balloon
- vaginal prostaglandin E2 (dinoprostone)
- oral prostaglandin E1 (misoprostol)
- amniotomy (artificial rupture of membranes)
- maternal oxytocin infusion
complications
- uterine hyperstimulation ak tachysystole
> prolonged and frequent uterine contractions
> management: remove vaginal prostaglandins, stop oxytocin infusion, consider tocolysis
133
describe reduced fetal movements
fetal movements should be established by 24 weeks
> if not, refer to maternal fetal medicine unit
can represent fetal distress
risk of stillbirth and fetal growth restriction
risk factors: posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, fetal size
investigations
- >28 weeks: handheld Doppler to confirm heartbeat
>> if no heartbeat detected, immediate ultrasound
>> heartbeat present: CTG at least 20 mins
>> if concern remains despite normal CTG offer ultrasound within 24h
134
state the treatment of group B streptococcus during labour
IV benzylpenicillin sodium 3g once-off then 1.2g every 4h
135
describe the indications for giving anti-D immunoglobulin
all rhesus negative women: routine antenatal anti-D prophylaxis
- one dose at 28 weeks and another at 34 weeks
antenatal bleeding if mother is rhesus negative:
- one dose of anti-D immunoglobulin followed by Kleihauer test
- anti-D should be given within 72h
Kleihauer test determines proportion of fetal RBCs in maternal circulation to assess if additional anti-D is necessary
indications
- delivery of Rh+ infant
- termination of pregnancy
- miscarriage if gestation >12w
- ectopic pregnancy if managed surgically
- external cephalic version
- antepartum haemorrhage
- amniocentesis, chorionic villus sampling, fetal blood sampling
- abdominal trauma
136
how is irregular/heavy bleeding from the implant managed?
co-prescription of COCP
137
describe menorrhagia and its management
not requiring contraception
- mefenamic acid
- tranexamic acid
requiring contraception
- IUS first-line
> IUS contraindicated in uterine distortion due to fibroids
- COCP
- long-acting progestogens
norethisterone can be used short-term to rapidly stop heavy menstrual bleeding
138
describe the management of exposure to chickenpox in pregnancy
<20 weeks gestation
- unsure of immunity: urgent varicella antibodies
- no immunity: consider oral aciclovir with caution 7-14 days post-exposure
> immune: no intervention
>=20 weeks gestation
- asymptomatic
> unsure of immunity: urgent varicella antibodies
> no immunity: oral aciclovir 7-14 days post-exposure
> immune: no intervention
- symptomatic: oral aciclovir within 24h of rash appearing
139
state cut-offs for iron supplementation
non-pregnant women: 115 g/L
first trimester: 110 g/L
second and third trimester: 105 g/L
post-partum: 100 g/L
140
describe the classification of perineal tears and their management
first degree
- superficial damage with no muscle involvement
- do not require repair
second degree
- injury to perineal muscle but not involving anal sphincter
- require suture on the ward by suitably experienced midwife or clinician
third degree
- injury to perineum involving the anal sphincter complex
- require repair in theatre by suitably trained clinician
fourth degree
- injury to perineum involving anal sphincter complex and rectal mucosa
- require repair in theatre by suitably trained clinician
141
describe fetal hydrops
clinical features
- polyhydramnios
- ascites
- fetal skin oedema
causes
- parvovirus B19
- genetic disorders
- complication in twin pregnancy
- congenital structural anomalies
management
- fetal transfusion
142
list risk factors for neural tube defects in pregnancy
- previous child with NTD
- diabetes mellitus
- women on antiepileptic
- obese (body mass index >30)
- HIV +ve taking co-trimoxazole
- sickle cell
143
list the categories for C-sections
Category 1
- immediate threat to life of mother or baby
- e.g. uterine rupture, cord prolapse, fetal hypoxia
- delivery should occur within 30 mins
Category 2
- maternal or fetal compromise which is not immediately life-threatening
- delivery should occur within 75 mins
Category 3
- delivery is required but mother and baby are stable
Category 4
- elective caesarean
144
list causes of reduced variability on CTG
- foetus is asleep (most common if <40 mins)
>40 mins
- maternal drugs e.g. benzodiazepines, opioids, methyldopa
- foetal acidosis (usually due to hypoxia)
- prematurity <28 weeks
- foetal tachycardia >140bpm
- congenital heart abnormalities
145
list causes of baseline bradycardia and tachycardia on CTG
baseline bradycardia: <100 bpm
- increased foetal vagal tone
- maternal beta-blocker use
baseline tachycardia: >160 bpm
- maternal pyrexia
- chorioamnionitis
- hypoxia
- prematurity
146
describe early and late decelerations on CTG
deceleration: drop in >=15 bpm for >=15 seconds
early deceleration: commences with the onset of a contraction and returns to normal on completion of contraction
> innocuous feature, indicates head compression
late deceleration: lags the onset of a contraction and does not return to baseline
> fetal distress e.g. asphyxia or placental insufficiency
147
list features associated with Edward's syndrome on CUBS
- reduced AFP
- reduced oestriol
- reduced hCG
-normal inhibin A
148
describe an imperforate hymen
imperforate hymen blocks passage of menses without affecting development of secondary characteristics e.g. pubic hair or breast development
can cause buildup of menstrual blood in vagina - haematocolpos - leading to pelvic pain and bloating
clinical features
- primary amenorrhoea
- regular painful cycles
149
describe normal findings on obstetric obstetric examination
normal fundal height growth after 24 weeks: 1cm / week
fundus should be palpable at umbilicus from 20 weeks and xiphisternum from 36 weeks
head may be free on palpation until 37 weeks in nulliparous women; in multiparous women head engages just before labour starts
breech presentation is common before 34 weeks
150
describe preterm pre-labour rupture of membranes (PPROM)
diagnosis
- sterile speculum examination
> identify pooling of amniotic fluid in posterior vaginal vault
- avoid digital examination due to risk of infection
- no pooling of fluid: test fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1
- fetal fibronectin: high level associated with early labour
- ultrasound to show oligohydramnios
management
- admission with regular observations to exclude chorioamnionitis
- oral erythromycin 10 days
- antenatal corticosteroids to reduce risk of respiratory distress syndrome
- consider delivery at 34 weeks gestation
complications
- fetal: prematurity, infection, pulmonary hypoplasia
- maternal: chorioamnionitis
151
describe chorionic villous sampling and amniocentesis
chorionic villous sampling (CVS)
- performed between week 11 and 13
- diagnostic
- higher risk of miscarriage
amniocentesis
- performed >=15 weeks
- diagnostic
- lower risk of miscarriage
152
what VTE prophylaxis should be given to pregnant women with history of thrombus
LMWH throughout pregnancy until 6 weeks post-partum
153
describe regular contraceptive use after emergency contraception
ulipristal acetate
- wait 5 days before starting hormonal contraception
levonorgestrel
- start right away
154
describe fibroadenomas and their management
management
-
- surgical excision if >3cm
155
list conditions which are screened for in pregnancy
- HIV
- syphilis
- Hepatitis B
> if present, take tenofovir
156
describe the second stage of labour
from full dilation to delivery of fetus
passive second stage: second stage without pushing
active second stage: active maternal pushing
less painful than first as pushing masks pain
lasts approximately one hour
> if longer than one hour consider ventouse extraction, forceps delivery or caesarean section
episiotomy may be necessary following crowning
associated with transient fetal bradycardia
157
describe rules for patch change including delayed patch change
change patches weekly with 1 week break after 3 patches
can be delayed up to 48h without need for additional contraception
delayed >48h
- barrier protection for 7 days
- emergency contraception if sexual activity in last 10 days
158
describe ovarian torsion
clinical features
- sudden onset unilateral lower abdominal pain
- onset may coincide with exercise / strenuous activity
- nausea and vomiting
investigations
- whirlpool sign on US
- examination: tender adnexal mass
management
- surgery
159
describe a vesicovaginal fistula
risk factors
- prolonged labour
- poor obstetric care
clinical features
- continuous dribbling incontinence
160
state conditions which are routinely screened for antenatally
haematology
- anaemia
- blood group, rhesus status and anti-red cell antibodies
infections
- hepatitis B
- HIV
- syphilis
- bacteriuria
anomalies
- Down's syndrome
- fetal anomalies
- neural tube defects
risk factors for pre-eclampsia
161
describe false labour
aka braxton hicks
occurs in the last 4 weeks of pregnancy
presentation
- contractions felt in lower abdomen
- irregular and mild
- progressive cervical changes are absent
162
describe contraception for women over age 50
COCP and depo-provera an be continued to 50 years
if on COCP: switch to non-hormonal or progestogen-only method
if on depo-provera: switch to non-hormonal method and stop after 2 years of amenorrhoea or switch to progestogen-only method
implant, POP and IUS can be continued beyond 50 years
163
164
describe the hepatitis B vaccine schedule in babies born at risk of developing hepatitis B
Hepatitis B vaccine and 0.5 millilitres of HBIG within 12h of birth
further hepatitis vaccine at 1-2 months
further vaccine at 6 months
165
describe the management of HIV in pregnancy
vaginal delivery is recommended if viral load <50 copies/ml at 36 weeks
166
describe the first stage of labour
latent first stage: 0-3cm cervical dilatation
active first stage: 4-10cm cervical dilatation
167
explain missed pill rules for POP
'Traditional' POPs: Micronor, Noriday, Nogeston, Femulen
- <3 hours late: no action required, continue as normal
- >3 hours late
- take the missed pill as soon as possible
- If more than one pill has been missed just take one pill
- take next pill at the usual time, which may mean taking two pills in one day
- continue with rest of pack
- extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Cerazette (desogestrel)
- <12 hours late: no action required, continue as normal
- >12 hours late
> action as above
168
state the calculation for estimated date of delivery (EDD)
Naegele's rule
date of LMP + 1 year and 7 days - 3 months
169
