Obstetrics & Gynaecology Flashcards
describe genitourinary syndrome of menopause
aka atrophic vaginitis
hypoestrogenic changes leading to
- dry skin excoriation
- discomfort/burning pain
- dyspareunia
- recurrent UTIs
management
- oestrogen cream
describe umbilical cord prolapse and its management
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
describe the management of umbilical cord prolapse
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
describe premenstrual syndrome and its management
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
describe adenomyosis
endometrial tissue in myometrium
clinical features
- dysmenorrhoea (cyclical pain)
- menorrhagia
- enlarged, boggy uterus
usually women over age 30
investigations: transvaginal ultrasound / MRI
management
- tranexamic acid for menorrhagia
- GnRH agonists
- uterine artery embolisation
- hysterectomy is definitive
describe endometriosis
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
- prior to surgery: GnRH analogues
- definitive treatment is surgical
describe chronic endometritis
clinical features
- abnormal uterine bleeding
- constant, vague abdominal pain
- examination: uterine tenderness / cervical motion tenderness
> can be normal
describe pelvic inflammatory disease (PID)
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
describe Fitz-Hugh-Curtis syndrome
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
describe fibroids
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
- conservative
- medical: GnRH analogues or ulipristal acetate prior to surgery
- surgery
> hysterectomy
> myomectomy – to preserve fertility
> uterine artery embolisation
list risks of SSRIs in pregnancy
first trimester: small risk of congenital heart defects
third trimester: persistent pulmonary hypertension of the newborn
list requirements for instrumental delivery
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
list indications for forceps delivery
- fetal or maternal distress in second stage of labour
- failure to progress in second stage of labour
- control of head in breech delivery
describe contraception post-partum
- COCP: absolutely contraindicated
- progesterone-only pill: started on or after day 21 post-partum
- progestogen-only implant can be inserted at any time
- Mirena IUS / Copper IUD: used from 4 weeks post-partum
- lactational amenorrhoea
> if exclusively breastfeeding
> no periods and <=6 months post-partum
describe contraception in menopause
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
describe the clinical features of ovarian cancer
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)
- CT scan
- Cytology – pleural/ascitic fluid
- Histology – biopsy (percutaneous or laparoscopic)
FIGO staging
Management
- Surgery
- Chemotherapy
lymph node metastasis: para-aortic node
describe post-partum depression and its management
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
describe different types of physiological (functional) ovarian cysts
- 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
describe different types of benign tumours of the ovary
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
describe adverse effects of HRT
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
describe the management of anaemia in pregnancy
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
describe the management of pre-existing hypertension in pregnancy
BP >= 150mmHg systolic needs to be managed
stop ACEi/ARB if taking
start
- labetalol first-line
- nifedipine or methyldopa second-line
describe cervical cancer screening
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
describe cervical intraepithelial neoplasia and its treatment
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
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
management
- weight loss, exercise
- COCP, mirena coil
- clomifene for infertility
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
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
more common in women using COCP
ablative treatment only for troublesome symptoms
> cautery / cryotherapy / silver nitrate
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
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
list vaccinations offered in pregnancy
influenza vaccine at any point in pregnancy
16-32 weeks: pertussis
list teratogenic drugs in pregnancy and their effects
- phenytoin: Cleft lip/palate, cardiac defects, hypoplastic nails and craniofacial abnormalities (foetal hydantoin syndrome)
- sodium valproate/ carbamazepine: neural tube defects
- lithium: Ebstein’s anomaly
- warfarin: frontal bossing, cardiac defects, microcephaly, nasal hypoplasia and epiphyseal stippling
- tetracycline: discolouration of teeth
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
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
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
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
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
Which index is used to determine prognosis of breast cancer following surgery?
Nottingham Prognostic Index - uses size, grade and nodal status
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
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
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
Describe the breast screening programme in Scotland
Mammogram for 50-70 year old women every 3 years
describe smoking cessation in pregnant women
offer nicotine replacement therapy
varenicline and bupropion are contraindicated
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.
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
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.
describe the management of hyperthyroidism in pregnancy
first trimester: propylthiouracil
switch to carbimazole at beginning of second trimester
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
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
describe acute endometritis
Infection of lining of uterus, may extend to upper genital tract
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
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
list complications of abortion
- Failure to end the pregnancy
- Retained products of conception (RPOC)
- Infection (endometritis)
- Haemorrhage
Surgical abortions only
- Cervical tear
- Uterine perforation
