Repro 2 Flashcards
what does the histology of a uterine fibroid look like?
shows a whorled pattern of smooth muscle bundles with well-demarcated borders.
what is the only way to definitively diagnose a uterine fibroid?
biopsy
shows a whorled pattern of smooth muscle bundles with well-demarcated borders.
what are the most common type of uterine fibroids?
intramural fibroids
what is the management of symptomatic cysts larger than five centimeters?
laparoscopic surgical removal
what is thee treatment of uterine fibroids if a woman has completed childbearing?
hysterectomy
patients with ovarian torsion will often present with sudden onset of sharp lower abdominal pain. is it unilateral or bilateral?
unilateral
are ovarian cysts mostly benign or malignant?
benign
subserosal uterine leiomyomas can easily be removed via hysteroscopy - true or false?
false. SUBMUCOSAL uterine leiomyomas can easily be removed via hysteroscopy
Carneous degeneration of a uterine fibroid occurs more commonly during pregnancy. true or false?
true
suggest an invasive radiology procedure that can be used to treat uterine fibroids
uterine artery embolization
what is endometriosis?
the presence of endometrial glands and stroma in locations other than the uterine cavity
suggest a class of drug that are given before surgery for tumour shrinkage in patients with uterine fibroids
gonadotropin-releasing hormone analogues
what are theca-lutein cysts?
they often occur as multiple ovarian cysts due to gonadotrophin stimulation and are associated with choriocarcinoma and moles
the theca folliculi comprise a layer of the ovarian follicles - they appear are the follicles become tertiary follicles.
what is the main type of cancer of the placenta?
choriocarcinoma - a malignant, trophoblastic cancer. it is also classified as a germ cell tumour and may arise in the testis or ovary.
there will be haematogenous metastases to the lungs and brain
what are the most commonly involved sites in endometriosis?
- ovares
2. pouch of douglas
what is adenomyosis?
endometriosis involving the uterine myometrium due to hyperplasia of the basalis layer of the endometrium.
what is the role of progesterone analogues in the medical treatment of endometriosis?
the progesterone analogues act by decidualization and atrophy of the endometrium
what is a dermatoid cyst?
an ovarian cyst that is described as a mature teratoma
ovarian torsion usually occurs on top of ovarian masses measuring more than how many centimetres in diameter?
5
what is the management of symptomatic cysts larger than five centimeters?
laparoscopic surgical removal
what is a chocolate cyst?
a cystic formation at the ovaries in endometriosis due to growing and shedding of the ectopic endometrium
endometriosis will decrease the risk of ovarian cancer - true or false?
fasle. endometriosis will increase the risks
what is it called when endometriosis involves the uterine myometrium?
adenomyosis
what is the diagnostic test of choice for evaluating ovarian pathology?
abdominal ultrasound
what is the most common tumour in females?
uterine leiomyomas
what typically happens to uterine fibroids after menopause?
they will typically shrink due to the decrease of oestrogen.
uterine fibroids are also known as leiomyomas and are benign smooth muscle tumours (commonest tumour overall in females). they are dependent on oestrogen for their growth and can (rarely) progress to leiomyosarcoma.
submucosal fibroids will present with abdominal vaginal bleeding and menorrhagia or menometrorrhagia.
subserosal fibroids can grow and cause pressure effects on surrounding organs, and can sometimes become parasitic fibroids that break away form the uterus and attach to other organs.
treatment is with myomectomy, uterine artery embolization or hysterectomy if childbearing is complete
what is the key characteristic of colorectal endometriosis?
cyclical rectal bleeding
Ovarian cysts measuring less than five centimeters do not usually require long-term follow up. true or false?
true
what is an endometrioid cyst?
an ovarian cyst that forms due to endometriosis
NAme 2 progesterone analogs commonly used in the treatment of endometriosis
- medroxyprogesterone
2. levonorgesterol
what is the surgical procedure of choice in patients with uterine fibroids who wish to remain fertile?
laparoscopic myomectomy
what is the mode of action of the oral contraceptive pill in the medical treatment of endometriosis?
ovarian suppression
what is an endometrioma?
a mass resulting from the entrapment of cyclic slough of endometriotic implants, through cyst formation
nearly half of those affected have chronic pelvic pain; in 70% of cases, pain occurs during menstruation, sex and infertility also occurs in up to half of women affected.
less common symptoms include urinary or bowel symptoms and 1/4 women are asymptomatic.
a negative pregnancy test in conjunction with the absence of spikes along the doppler flow graph is diagnostic for ovarian torsion - true or false?
false.
there ARE spikes along the doppler flow graph in ovarian torsion
what would an elevated estrogen level do to a uterine fibroid?
cause rapid enlargement
what is the most common complication of endometriosis?
infertility
it occurs due to adhesions and scarring.
what is the primary diagnostic modality for endometriosis?
laparoscopy
what is the mainstay of the management of the majority of ovarian cysts?
follow-up
a complication of stage IV endometriosis presents with a ground glass appearance on US and symptoms of pelvic pain, dysmenorrhoea and dyspareunia - name this complication
endometiroma
the laparoscopic visualization of lesions of powder-burned appearance in the pelvis or peritoneum is pathognomonic of which condition?
endometriosis
in the medical treatment of endometriosis, what is the action of danazol?
it is a drug that acts by inhibiting mid-cycle surges of follicular stimulating hormone and luteinizing hormone and by preventing steroidogenesis sin the corpus luteum
what si the best initial test for the diagnosis of ovarian cysts?
abdominal ultrasonography
oral contraceptives are first line medications used in treating endometriosis. true or false?
true.
in the medical treatment of endometriosis, what is ‘add-back therapy’
- estrogen
2. GrH analogs
what si the definitive treatment for adenomyosis?
hysterectomy
what is used as the gold standard for diagnosis of ovarian torsion?
laparoscopy
submucosal leiomyomas are a type of uterine fibroid that can break away from the uterus and receive blood supply from another abdominal organ - true/false?
false
SUBSEROSAL
what is the most common symptoms of submucosal types of uterine leiomyomas?
uterine bleeding
what is a corpus luteum cyst?
a corpus luteum cyst is an ovarian cyst that forms due to haemorrhage into a persistent corpus luteum
what is a hemorrhagic cyst?
an ovarian cyst that is due to blood vessel rupture in the cyst wall and one that grows with increased blood retention
what are most associated with recurrent pregnancy loss and infertility:
submucosal or subserosal uterine leiomyomas?
submucosal
what does post-coital bleeding and oligomenorrhea mean?
post-coital bleeding is bleeding after itnercourse
oligomenorrhea means infrequent periods and absence for 35/45-90 days.
dysmenorrhoea means painful periods and menorrhagia is heavy periods >80 ml/cycle
name 4 fertility conserving treatments for abnormal uterine bleeding
- hormonal therapy
a. combined oral contraceptive pill (COCP)
will reduce blood loss and relive pain as well as regulating the cycle
b. progestogens
provera 10mg od
reduces blood loss for only part of cycle and provides slight cycle regulation
c. gonadotropin releasing hormone
- antifibrinolytics
a. tranexamic acid
will reduce blood loss will ave no effect on the cycle regulation - NSAIDs
a. mefenamic acid (inhibits prostaglandins)
will reduce blood loss and relieve pain but has no effect on cycle regulation - intrauterine device
a. progesterone (mirena)
will reduce the bleeding but initial 3-4 months of irregular bleeding
a 41 yo mother of 2 presents to the GP with long-standing heavy menstrual bleeding which has become worse over the past year. she is otherwise well and has no significant medical history. she requests treatment to alleviate the heavy impact on her social life. pelvic examination reveals a normal sized uterus. what is the most appropriate 1st line treatment?
levonorgestrel-releasing intrauterine system (mirena)
name 7 causes of antepartum haemorrhage
- miscarriage
- ectopic pregnancy
- idiopathic
- vasa praevia - membranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie the internal os
- local lesions - vaginal or cervical
- placental abruption
- premature separation of a normally implanted placenta from the uterine wall - placenta praevia - placenta that lies wholly or partially in the lower segment of the uterus over the internal os
what is balanitis?
a skin irritation of the head of the penis that can affect men and boys
It is a yeast infection caused by candida albicans mainly
what are the main organisms that cause dermatophyte infection?
- dermatophytes
a. trichophyton rubrum
b. trichophyton mentagrophytes - Candida - candida albicans
- epidermophyton
a. epidermophyton flaccosum
A 33 y/o woman presents who was well throughout pregnancy. Has spontaneous labour at 38 weeks, which progresses well but mom has fever. The baby is born, distressed with poor APGAR score and sent to the neonatal unit. In the neonatal unit: baby resuscitated, well after 5 days, no malformations, home after 2 weeks. Placenta examined (routine if baby is sent to neonatal unit): membranes contain neutrophils, trilobed nucleus is easily deformable and allows them to move easily into tissues, phagocytose (ingest) and destroy microorganisms.
- Diagnosis?
- How does an ascending infection affect babies brains?
- Acute chorioamnionitis (acute inflammation)
neutrophils present in membranes, cord and fetal plate of placenta. It is an ascending infection in which bacteria are typically perineal or perianal flora (e.g E.coli) which ascend vagina and get into the amniotic sac.
- neutrophils produce cytokine ‘storm’ which activates some brain cells, when then get damaged by normal hypoxia of labour.
what are the screening programs in place for breast cancer?
- mammogram every 3 years
targets women who are aged between 50 and 70. there is also clinical surveillance 5 years below the age any one in the family had been diagnosed with breast cancer.
it will detect 5 cancers per 100 screened and will benefit 30% reduction in mortality
what are some prevention methods used for breast cancer?
prophylactic mastectomy
removes most but not all of breast and significantly reduces the risk in women with a family history of cancer and women with the BRCA1 mutation (down to 5%)
in a total mastectomy more tissue will be removed in comparison say to a subcutaneous mastectomy
what is the management used for breast cancer?
- surgery
a. mastectomy (radical)
b. wide local excision (breast conservation)
c. lymph node removal (if necessary) - Radio or chemo
- antihormonal - tamoxifen
- monoclonal antibodies (trastuzumab - herceptin - if the patient is HER2 positive)
discuss the clinical spread of breast cancer
- local - pectoral muscles or skin
- blood - bone, lung liver and brain
- lymphatic - axillary and internal mammary nodes
how would you investigate suspected breast cancer?
- clinical examination
a. hard lump
b. fixed mass
c. tethering to skin
d. oedema - peau d’orange sign - imaging
a. mammography
i. soft tissue opacities
ii. masses
iii. microcalcifications
these are tiny deposits of calcium and most women will have 1 or more areas of microcalcifications of various size but the majority are harmless but a small percentage may be cancerous or precancerous.
b. US
c. MRI
- FNAC
- Needle core biopsy
what is the differential diagnosis of breast cancer?
- benign breast tumours
- fibroadenomas
- tubular adenoma
- lactating adenoma
- intraductal papillomas
- connective tissue tumour
- phyllodes tumour (can also be malignant) - fibrocystic change
- fat necrosis
- duct ectasia
In the UK National Breast Screening Programme, what are the age of women targeted for screening?
50-70
these women must also be registered with a GP.
offered a mammography every 3 years with clinical surveillance 5 years before pathology of diagnosis in family member.
what is the causative agent in erythrasma?
- Corynebacterium spp
a. Corynebacterium minutissimum
what are labial adhesion’s?
labial minora become fused and this typically affects adolescents
presentation - midline adhesion and is sometimes asymptomatic with retention of urine and vaginal secretions
managements - improved hygiene, lubrication and topical estrogen and surgical separation
complications include vulvovaginitis and UTIs
what are the two histological types of cervical cancer?
adenocarcinoma and squamous cell carcinoma (90%)
what is the management of cervical cancer?
- excision biopsy
- hysterectomy - exploration of the pelvic and para-aortic space with removal f the following structures:
- uetrus
- cervix
- upper vagina
- parametria
- pelvic nodes - chemotherapy - cisplatin
- radiotherapy - external beam and caesium insertion
what is the prevention scheme in place fro cervical cancer?
HPV quadrivalent immunization - 6,11, 16 and 18
name 4 presentations of cervical cancer
- asymptomatic
- intermenstrual bleeding
- post-menstrual bleeding
- discharge
- pain
- cervical abnormalities - bleeding on examination or a hard craggy surface
- post-coital bleeding
what are the age of woman offered a cervical screen for cancer?
25-65. once every 3 years until 50 then once every 5 years. this is followed by liquid based cytology.
LBC - microscopic histological assessment of cells scraped from the transformation zone looking for dyskariosis and evidence of cervical intraepithelial neoplasia (CIN)
- increased size
- nuclear: cytoplasmic ratio
- variation in size, shape or outline and coarse irregular chromatin
- nucleoli
if high grad then refer for colposcopy if low grade then repeat in 6 months if normal repeat in 3 years as normal
what are the risk factors for developing cervical cancer?
Middle age (45 - 55 y/o peak) Multiple partners Early age at 1st intercourse Older age of partner Prolonged oral contraceptive (OC) use Previous STDs Smoking Immunodeficiency
what kind of cells are found in the endocervical canal?
mucous columnar epithelium
the vaginal cervix is lined with squamous epithelium
the transitional zone is the area between them - the squamo-columnar junction - this area is predisposed to malignant change
if CIN is asymptomatic then dont treat, pubertal or in pregnancy. if taking hormonal contraception then consider switching
what is the main complication of CIN II and CIN III?
invasive squamous carcinoma of the cervix
smears collect cervical cells for microscopy for dyskaryosis. women with borderline or mild changes are tested for high-risk HPV and if positive, referred for colposcopy regardless of HPV status.
HIV positive women should have annual smears
what are the risk factors for CIN?
Middle age (45 - 55 y/o peak) Multiple partners Early age at 1st intercourse Older age of partner Prolonged oral contraceptive (OC) use Previous STDs Smoking Immunodeficiency
what is lichen sclerosus?
a skin disease of unknown cause, commonly appearing as whitish patches on the genitals (but also affecting the rest of the body)
aka balanitis xerotica obliterans (BXO)
it is associated with lichen planus - chronic recurrent inflammatory disorder of the skin/mucous membranes
A 62 y/o nulliparous lady presents to the GP with 3 episodes of vaginal bleeding. She is menopausal, obese and diabetic. Her smears were up to date until 60 years of age (the limit for the national screening programme at that time). She was referred to the hospital by the GP. What is the most probable diagnosis?
Endometrial cancer - affects older people past menopause
) A 79 y/o woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had 2 children both via caesarean section, has a normal smear history and is currently sexually active. On examination the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management
Pelvic ultrasonogrpahy - TVUS
a 32 year old woman who misses her epriod is 8 weeks pregnant and has a small amount of bleeding per vagina. investigations show a raised b hcg and US shows a thickening lining of the endometrial cavity and expanded tube on 1 side.
- most likely diagnosis?
- management?
- ectopic pregnancy
- consider using methotrexate. if she isnt game then do an operative removal of fallopian tube and tissue sent to pathology. may be haemorrhage or rupture due to an improper decidual layer
A 22 y/o is referred to the gynaecology clinic with cyclical pain and dyspareunia. The consultant is concerned that she has endometriosis. What is the best investigation to confirm her diagnosis?
: Diagnostic laparoscopy
A 35 y/o P0 presents with 2ndary dysmenorrhoea (painful periods), dyspareunia (painful sex), pain when sitting down and dyschezia (painful passing of stools). She has been trying to get pregnant for 2 year. diagnosis?
endometriosis
At laparoscopy a 21 y/o woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic sidewall. The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries freed. Which of the following medications would be appropriate to help treat her endometriosis
Triptorelin (GnRH)
what is impetigo caused by?
A highly infectious bacterial infection that involves the superficial skin, presenting with yellowish-golden crusts on the face, arms or legs.
caused by staph aureus and strep pyogenes
what is the best treatment for impetigo?
- flucloxacillin and mupirocin or fusidic acid
it can be complicated with cellulitis but usually will resolve within 3 weeks
what are some of the risk factors for impetigo?
- children
- skin abrasions
- minor trauma
- eczema
- atopic dermatitis
- chicken pox
suggest 3 presentations of impetigo
- vesicular golden lesions
- erythema
3, pain - itchy
- fever - although very uncommon
what is medium chain acyl-coA dehydrogenase deficiency (MCADD)
a condition where babies cannot break down fat to make enough energy for the body.
it is an autosomal recessive condition typically
management is with prevention of a metabolic crisis - avoiding fasting and monitor frequency of the child’s meals.
in an emergency give glucose polymers such as dextrose.
it untreated it can lead to the life threatening stage with a mortality of 1/4.
how long do maternity blues usually last for?
A transient condition that mothers may experience shortly after childbirth in which they display mild anxiety & depressive symptoms for a few days.
Risk factors: 1st delivery (50%)
Presentation:
Tearfulness
Anxiety
Aetiology:
Multifactorial
Radical changes in mother’s hormone levels (withdrawal symptoms)
Sleep deprivation
Physical, mental and emotional exhaustion
Prognosis:
Self-limiting (1 - 3 days)
what is primary prevention of cervical cancer in the UK?
quadrivariant immunization
6, 11, 16 and 18
when should you refer a couple on who have had a history of infertility?
- usually after 1 year of trying
- usually are aged between 35 and 45
little can be offered if >45:
- period irregularity
- past medical history
- testicular oroblems
- abnormal tests
- HIV
- hep B
- anxiety
- pelvic ultrasound - can identify PCOS and PCO)
physical examination
further investigations
semen analysis (repeat)
hysterosalpingo-contrast sonography (HyCoSy) test - assess fallopian tube patency and
laparoscopy
1st line management for PCOS
diet and lifestyle modifications to lose weight. if BMI was normal then you can try metformin and then clomiphene citrate to induce ovulation
how do you diagnose tubal block?
hysterosalpingo-contrast sonography (HyCoSy), laparoscopy and US
it will cause infertility and can be caused by inflammation, STDs (chlamydia) and endometriosis
treat tubal block with IVF, tubal surgery but risk of ectopic pregnancy
what are some causes of obstructive and non-obstructive sub-fertility in males?
OBSTRUCTIVE
CF
congenital bilateral absence of vans deference
testicular maldescent
vasectomy
NON-OBSTRUCTIVE
previous chemo or radiotherapy
occupation
sertolli cells will be only ones present
what questions would you want to ask in a history for a male experiencing infertility?
- occupation
- PMH
- drug history
- previous mumps
- surgeyr in inguinal area
- STDs
- ejaculatory dysfunction
- epididymitis
- retrograde ejaculation
what is the best medical treatment for subfertility?
clomiphene citrate
what is the definition of primary infertility?
someone who has never had a child who is infertile
what is the definition of infertility?
inability to conceive after 1 year of regular unprotected sex
how do you diagnose PCOS?
check for hyperandrogenism
check for anovulation or irregular periods
check for polycystic ovaries
2/3 is enough for diagnosis
what is the first line management for PCOS?
diet and lifestyle modifications to lose weight
if the patient has a normal BMI then prescribe clomiphene citrate
is breast cancer a risk in PCOS?
no
but endometrial cancer and hyperplasia is
what is cystocele?
this is prolapse of the upper vaginal wall and the bladder
what is urethrocele?
urethrocele is the prolapse of the lower anterior vaginal wall and the urethra
what is uterovaginal prolapse?
prolapse of the uterus, cervix and upper vagina
what is enterocele?
apical prolapse of the upper posterior wall and loops of small bowel
what is rectocele?
this is the prolapse of the lower posterior wall and rectum
what is a threatened miscarriage?
bleeding and abdominal pain can occur but the pregnancy continues. there is a closed cervical os and doesnt always indicate morbidity
what is an inevitable miscarriage
occurs when the symptoms of pregnancy loss occur but the products of conception are still inside the uterus for the time being
there is an open cervical os with bleeding
what is an incomplete miscarriage?
this occurs when there are retained products of conception and often requires treatment. there is an open cervix with bleeding
what is a complete miscarriage?
passed all products of conception POC) the cervical os is closed and bleeding has stopped - should ideally have confirmed the POC or should have had a scan previously that confirmed an intrauterine pregnancy
what is a missed miscarriage? (early fetal demise)
the gestational sac seen on US but is empty and the fetal pole is seen in the gestational sac but there is no fetal heart
) A 50 y/o woman has irregular periods and suffering from mood swings and night sweats. She is perimenopausal and wishing to commence on HRT to help her symptoms. What lack of hormone is it that causes the menopausal symptoms
Oestrogen
There is evidence that HRT prevents coronary heart disease (CHD) t/f
false
thrombophilia screen is always prior to starting HRT (not routine) due to its risks t/f?
false
A 54 y/o woman comes to your clinic complaining of hot flushes and night sweats that are unbearable. Her last menstrual period was 14 months ago. She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms
Elleste solo
types:
- Oestrogen (only if no uterus)
a. Elleste solo - Oestrogen + progestogen (if uterus present)
a. Elleste duet
b. Evorel
14 days E / 14 days E + P
Get a withdrawal bleed
Use if still some ovary function (e.g perimenopause)
28 days E + P
Use if > 1 year after menopause or > 54 y/o
28 days E + Mirena (levornestregel) IUD
Any age
what is puerperal psychosis?
occurs in the first 4 weeks postpartum and presents with 3 main symptoms
- hallucinations
- irrational ideas
- negativity towards their child
Management:
- referral to the psychiatric team and admission to mother and baby unit for supervision
what is tay-sachs disease?
lysosomal storage disease in which there is a progressive deterioration as of 6 months
it has autosomal recessive transmission
a 31 year old presents with severe right sided upper abdominal pain at 34 weeks gestation. she reported normal fetal movements up until now. she has no vaginal bleeding but pain is getting worse. abdomen is tense and tender. high blood pressure was recorded at her midwife visit. urine dipstick is normal. what is the most likely diagnosis?
- placental abruption
- cholecystitis
- preterm labour
- urinary infection
placental abruption
name 4 problems that occur as a result of problems in pregnancy
1 Malformations
2 Neonatal hypoglycaemia
3 Huge babies that obstruct labour
4 Intrauterine death (probable sudden metabolic / hypoxic problems)
name 3 major complications of preterm birth
a. RDS (Respiratory distress syndrome)
b. Apnoea
c. Air leak i.e. pneumothorax
there are 3 main types of apnoea - obstructive (treated with CPAP), central (baby forgets to breathe - treated with caffeine and mixed.
Do you think all babies with RDS should be ventilated and given surfactants?
yes
if a baby is born <32 weeks then on day 5 post partum a head USS is done routinely
the head USS may show an intraventricular haemorrhage
what are complications of an Intraventricular haemorrhage?
- morbidity and mortality
- neurological complications
- seizures
- developmental delay
- cerebral palsy - other complications
- 10-15% will have hydrocephalus that may not appear for 2-4 weeks
what is the most common organisms to infect neonates?
- group B strep
treated with penicillin and gentamycin
the second most common is e. coli
27 year old is undergoing spontaneous labour at term +7 days.
She has slow progress to second stage i.e. slow progress to being fully dilated.
She then undergoes emergency caesarean section after failed forceps delivery with OP position (= occiput posterior fetal position = when the back of baby’s head is against the mother’s back)
She is well post-op except for low grade pyrexia.
She is breast feeding and the community midwife phones 10 days post natal due to continuous dribbling incontinence.
- Why is she suffering from incontinence?
- What are the renal and obstetric implications of pregnancy?
- During pregnancy progesterone is produced to maintain the decidua. Progesterone also acts as a muscle relaxant – it relaxes the ureter and bladder.
This could also be due to obstruction of the ureter by the baby.
- The kidney increases normally by about 1cm during pregnancy
• Urinary tract dilation occurs leading to physiological hydronephrosis during pregnancy and up to 6 weeks postpartum
o Dilatation is more pronounced on the right
• A pelvic kidney (either congenital or transplant) may lead to obstruction of labour
what is the course of the ureter?
• As the ureter enters the pelvis it passes over the pelvic brim, crossing the bifurcation of the common iliac vessels
• The ureter runs retroperitoneally on the lateral pelvic wall
• At the level of the ischial spine it turns forward and medially (related to the posterior border of the ovary)
• Crossed by the uterine artery (remember because water (ureter) under the bridge)
o It passes about 2 cm lateral to the cervix and in front of the lateral border of the vagina
Then enters into the back of the bladder
what is an episiotomy?
• An episiotomy is a planned incision on the perineum and posterior vaginal wall during the second stage of labour
Why is an episiotomy performed on the posterior of the perineum and vagina?
• This is where it relieves the most tension of the mid-line and therefore is the best for preserving the anal sphincter and other perineal muscles
Why would an episiotomy be required
• An episiotomy allows for more room in a normal birth or forceps delivery. it prevents tearing which is harder to fix/heal and the placement is uncontrollable
. An episiotomy can tear further
what is a leiomyomata?
aka a fibroid
arise from the myometrium and composed mainly of smooth muscle. often asymptomatic but may present with
- dysmenorrhoea or menorrhagia and pressure symptoms such as frequency or urgency. in some cases can cause a DVT due to pressure on the iliac vessels and there is also pressure on the perineum simulating a feeling of need to evacuate the bowels
what is the management of fibroids?
• Symptom relief Hormonal vs intervention Myomectomy +/- GnRH analogue as adjunct Hysterectomy Uterine Artery Embolisation Coagulation using cautery laser
what does dysmenorrheoa mean?
painful periods
dysparunia means painful sex
35 year old PO
Secondary dysmenorrhoea and dysparunia. she has pain when sits down and when bowels open
She has been trying to get pregnant for two years
- What might be wrong?
- What is endometriosis?
- What are the are sites of endometriosis?
- what is the presentation of endometriosis?
- Endometriosis
- Endometriosis is the presence of endometrial-like tissue outside the uterine cavity
- rare sites include lungs, brain, muscles, eyes
- symptoms
- internal bleeding
- Degenerated blood and tissue shedding
- Inflammation of the surrounding areas, pain and possible formation of scar tissue
on examination of a patient with endometriosis what are typical findings?
- adnexal masses and tenderness
- nodules in the posterior vaginal fornix or uterosacral ligament
- fixed retroverted uterus
- rectovaginal nodules
a transvaginal US (TVUS) will show cysts with ground glass apearances
26 year-old who missed a period. She has taken a pregnancy test which came back positive. She then experienced vaginal bleeding 7 weeks after period.
- What’s happened?
- What is a miscarriage/threat of miscarriage?
- what investigation would you do?
- Seven weeks is still in the first trimester → this is likely to be a miscarriage or a threat of miscarriage
- Pregnancy is failing/has failed and mother is no longer carrying the baby
- USS
What is a miscarriage/threat of miscarriage?
- Pregnancy is failing/has failed and mother is no longer carrying the baby
investigation is with an USS
there is no foetus but the membranes and decidua are still present → confirms miscarriage.
what is the cause of a miscarriage?
There is often NO OBVIOUS CAUSE but can be due to:
- Chromosomal abnormalities
- Infection
- Maternal issues
- Ill-health
- Trauma
- Hormonal problems
32 year old who has missed her period. She is 8 weeks pregnant when she has a small amount of vaginal bleeding.
Her β-hCG is raised and USS shows a thickened endometrial cavity with an expanded fallopian tube on one side.
- What’s happened?
- Where can ectopic pregnancies occur?
- What is the treatment for an ectopic pregnancy in the fallopian tube?
- Ectopic pregnancy in the fallopian tube
- The most common site is the fallopian tube but they can also occur in the abdomen and cervix
- Methotrexate – if detected early enough in the pregnancy, methotrexate can be used to stop the foetus from growing and ending the pregnancy
Surgical removal of the fallopian tube.
25 year old woman with a history of irregular periods and PCO (poly-cystic ovaries) on USS attends infertility clinic with two years of primary infertility. Her BMI is 40. Semen analysis is normal.
What is primary infertility
Primary infertility occurs in a couple where neither of them has ever had a pregnancy before.
(Secondary infertility is when either the male or female in a couple has had a pregnancy before)
How do you define infertility
NICE guidelines state that a couple who have not conceived after 12 months of trying should be referred to an infertility clinic.
What do you mean by irregular periods?
An irregular period is a period which varies in cycle length; length of the period or how heavy it is.
- How do you diagnose PCOS?
2. What is the first line of management
- For a diagnosis of PCOS you must have two out of three of the following:
a. Irregular/no periods
b. Androgen excess
- Clinical signs: hirsutism, acne, weight gain
- Biochemical sign: ↑ testosterone
c. Poly-cystic ovaries on an USS
- >12 follicles
OR
- >100cm3 ovary - Lifestyle changes – mainly weight loss but also eating healthier, stopping smoking, etc.
(no medical intervention i.e. ovulation induction is normally given until a BMI of ≤ 30 is achieved)
2nd and 3rd line management is ovulation induction
o 2nd = Clomifene treatment
o 3rd = FSH treatments
- What investigations would you do to confirm tubal block?
- What are the implications
- What are the causes?
- what are the treatments available?
- a. HSG (hysterosalpingogram) = x-ray with contrast
b. Laparoscopy = gives a direct view (often used when there is a pelvic inflammatory/STI history)
c. HyCoSy (Hystero salpingo contrast sonography) – contrast scan
2. As both tubes are block the main implication is that fertilisation can’t occur as the sperm and eggs can’t meet.
- a. surgery
b. previous infections
c. ciliary function - a. IVF
b. tubal surgery
- only suitable if small bonds
- tubal surgery has very small role as it is costly and there is a chance of an ectopic pregnancy
which of the following statements about IVF are false?
- IVF stimulates the ovaries to get as many eggs as possible 2. This is done via FSH injection given subcutaneously via metred dose pen.
- The eggs are fertilised in a lab after egg collection (sperm can be directly injected into the egg if there is not enough sperm/sperm motility)
they are all true
Once the FSH injections have been started the woman needs to be monitored closely – this involves an USS every 2-3 days. It can take 2-3 weeks to be ready for egg collection.
- What is azoospermia?
2. What are the causes?
- Azoospermia = two ejaculations containing no sperm.
- two samples must be taken in case the first sample was not done correctly/mishandled
- patients need to abstain for a minimum of three days before giving a sample
2. Pre-testicular and Testicular causes can be grouped together as Non-Obstructive Azoospermia (NOA). a. pre-testicular - Chronic illnesses - Tumours - Some medications - Kallmann’s (anosmia is another sign) b. Testicular - Congenital (Kleinfelder’s XXY) - Acquired • Trauma • Infection • Surgery • Radio/Chemotherapy • Mumps c. OA (Obstructive Azoospermia) or Post-testicular (Problems of the outflow tract) • Epididymitis • Surgery on Vas Deferens • Absent Vas Deferens (CF) • STI & UTI → prostatitis • Retrograde ejaculation
FSH will act on sperm cells to produce sperm and LH will act on the leydig cells to produce testosterone
- what are important questions to ask a male who is experiencing azoospermia?
- What investigations would you do?
- What treatments are available?
1. o Previous fertility o Medical history (E.g. cancer → chemotherapy/radiotherapy) o Surgical history o Occupational history Some dyes can affect fertility o Sexual history o Previous investigations and treatments
2. o FSH level o LH level o Testosterone level o Karyotype To rule out CF or Kleinfelder’s XXY
- • For obstructive = surgical sperm retrieval
• If higher centres is the issue i.e. NOA = gonadotrophin (FSH & LH) therapy
on a histology sample, what findings will indicate HPV infection?
Halo around nucleus
SIGNS OF low grade DYSKARIOSIS:
- Larger & longer nucleus
- coarsening of chromatin pattern
- an irregular nuclear outline
because low grade dyskariosis patient repeat cervical smear in 6 months. Once she has had three negative smears 6 months apart then return back to a cervical smear every three years (routine recall).
what is the protocol for high grade dyskariosis?
Refer to colposcopy. Then LLETZ = Large Loop Excision of the Transformation Zone (same as LEEP = Loop Electrosurgical Excision Procedure) → this can often be done during colposcopy.
what is dyskariosis?
In terms of cervical screening dyskariosis is the name given to an abnormal smear
histology is staged:
CIN 1 = lower 1/3 changes
CIN 2 = lower 23 changes
CIN 3 = all affected
What is dysplasia?
In terms of cervical screening dysplasia is the name given to an abnormal excision
what is the staging for microinvasive squamous carcinoma?
Stage 1Ai. = <3mm deep, 7mm width
- not visible to the naked eye & asymptomatic BUT often picked up on cervical screening
- negligible risk of nodal spread and recurrence in only 1%
Stage 1Aii. = <5mm deep, 7mm width
- usually presents as abnormal cytology
- 8% risk of nodal spread
- generally treated by loop excision biopsy
How common is cervical cancer?
Among the ten most common cancers in women. Most common cause of cancer death in some countries.
When is the peak incidence for cervical cancer?
Peak incidence of cervical cancer is 40-50 years
What are the different morphology of cervical cancer?
Polypoid
ulcerated
infiltrative.
What are the common sites of metastases of cervical cancer?
Local spread: to bladder, ureters, rectum, vagina, pelvic tissues.
Via the lymphatics: to pelvic nodes
Haematogenous spread: to liver, lungs, bone
What are the common histological types of cervical cancer?
90% = squamous cell carcinoma 10% = adenocarcinoma
What are the symptoms of cervical cancer?
- Painless intermittent vaginal bleeding (often post-coital),
- discharge
- pain (late symptom)
How is cervical cancer staged?
Staged via FIGO staging:
A. 0 – in situ (CIN 3)
- 100% 5 year survival
B. 1Ai. Microinvasive (<3mm x 7mm)
o 1Aii. (<5mm x 7mm)
o 1B – confined to the cervix
C. 2 – outwith the cervix/upper 1/3 vagina
- 50-70% 5 year survival
D. 3 – pelvic wall/lower 1/3 vagina
- 30% 5 year survival
E. 4 – bladder, rectum or distant metastases
- <20% 5 year survival
what are Garrod’s pads?
Idiopathic, genetic, or acquired through repetitive trauma. Assosciated with dupuytren’s, peyronie’s and lederhosen disease.
- how long is a full term?
- what is the management for nuchal cord?
- what is protocol for a baby with a low APGAR score?
- suggest some reasons why a baby might go to a neonatal unit
- 37 weeks
- Nuchal cord i.e. the cord wrapping around the baby’s neck is very common. Normally the midwife can just unhook the cord. Issues arise when the cord is too tight.
- send to neonatology unit
4. o Congenital abnormalities e.g. Down’s syndroms → cardiac anomaly Spina bifida o Cord problems Hypoxia o Placental problems Abruption = haemorrhage under the placenta; detached before baby is born. Bleeding can be trapped behind the placenta (retro placental haematoma); bleeding into membranes; vaginal bleeding (before baby is born) = anti-partum haemorrhage Placenta Previa o Prematurity o Obstetric issues related to the labour E.g. prolonged labour o IVDU mother
what is whartons jelly and what is its job?
Wharton’s jelly is what surrounds the vessels in the umbilical cord – it protects these vessels.
what are the layers of the amniotic sac?
The amniotic sac is made up of two layers/sides:
o Amnion = foetal side
o Chorion = outer surface
describe the maternal side of the placenta.
The maternal side of the placenta is lobulated. Sometimes parts of this surface are left behind
What complications can occur involving the umbilical cord?
o Too long The longer the cord the more effort the baby’s heart has to put in to get blood o Over twisted o Knots True knots o Coiled around neck
what are the main 3 most worrying pathological problems in the body of a diabetic mother
o Microvascular disease = small vessels
Retinopathy, neuropathy
- Microvacular problems can be associated with difficulties in getting pregnant
o Macrovascular disease (depends on length of disease)
o Hypoglycaemic episodes
what is likely to happen to insulin requirment in pregnancy and why?
o Insulin requirement increase in pregnancy
Because the mother is more metabolically active → two humans to sustain
Also a lot of pregnancy hormones have anti-insulin effects
what are the main complications with Stillbirth?
o Depression
o Has to deliver dead baby
o Has to go through labour known the baby will be dead
As it is later in the pregnancy, may offer caesarean section
o Will still experience all the normal risks of complications as a live birth
what is a diabetic baby called with broad shoulders?
diabetic cherub
does glucose cross the placenta?
yes
Glucose is a small molecule so it goes easily through the placental barrier
o Also it is allowed through because all cells need it so the baby does require some
Baby’s insulin levels also increase in response to the increased glucose levels the baby cannot reduce its glucose level to normal because there is a continuous supply of vast amounts of glucose from the mother. the baby’s pancreas cant produce enough insulin to combat this much glucose
what is the issue with a baby having too much glucose and insulin?
The insulin is driving the glucose into cells (muscles and fat) so the high levels causes all of the glucose into them causing the baby to be huge. Long term high insulin and high glucose – massive growth.
Susceptibility to intrauterine death (not known why)
what are the complications of pregnancy caused by diabetes?
o Malformations
Occur early in pregnancy
o Huge babies that obstruct labour
o Intrauterine death (probably sudden metabolic and hypoxic problems)
o Neonatal hypoglycaemia
Once born the baby is producing high insulin but is no longer receiving all of its mother’s glucose
Should be corrected within a day and then baby is ok
Need good glucose control before conception (to prevent malformations) and then all the way through (to prevent metabolic complications)
- what does a neutrophil look like and what does it do?
- Mother’s neutrophils are normal, baby’s are raised. Neither have fevers.
What does this suggest?
o Neutophils have a trilobed nucleus which allows them to pass through small spaces e.g. through capillary walls
o Neutrophils phagocytose (ingest) and destroy micro-organisms.
- o Raised neutrophils suggest a bacterial infection
a cytokine storm is when there are lots of neutrophils together spread throughout the body and it causes a cytokine storm
- what are the most common presentations of a ascending infection in pregnancy
- what are the complications?
- o Mother has fever and raised neutrophils in blood
o Mother asymptomatic → ill baby when born
o Intrauterine death
2. o Very variable Prior to birth - Growth restriction - IUD Neonate - Baby ill when born but recovers Later life - Cerebral palsy
what are the complications of pregnancy in a cytokine storm?
o Normal labour causes hypoxic shock because the uterus is squeezing the baby out (squeezes blood vessels)
If there is a cytokine storm this can overwhelm the baby
o Biggest consequence of cytokine storm is cerebral palsy – neutrophils activate some brain cells which then get overwhelmed by the normal hypoxia of labour
Ascending infection is the commonest cause of cytokine storm.
why do we prescribe mothers methodone?
o Produces similar effects to heroin
o Reduce withdrawal symptoms
o Difference in their pharmacology – methadone had a much longer half-life and therefore slows down withdrawal
Need to take it less often
what are the withdrawal symptoms?
o Cravings
o Anxious
o Strange behaviour
babies should be transferred to neonatal unit as they will be born addicts and will withdraw soon after birth. if mum is addicted to heroin then withdrawal will be in a day but if mum takes methadone then it will take a few weeks before the baby withdraws
dont discharge until the baby withdraws
can opiates cross the placenta?
yep
what is the main risk of a baby born to an IVDU mother?
The baby is effectively quitting drugs cold turkey → can cause epileptic fits → baby could die.
- what are the different types of shock?
- why does hr increase in shock?
- what part of the brain does the carotid body connect to?
- What nerves are used to tell the heart about the low BP?
- What effect do these nerve have?
o
1. o Cardiogenic (normal or raised atrial pressure) o Septic – vasodilation (red and warm) (low atrial pressure because low venous return due to vasodilation) o Hypovolaemic (low atrial pressure because low venous return
- Low partial pressure of oxygen (caused by low BP) will be detected in the baroreceptors of the carotid body (found at the bifurcation of the common carotids) and the aortic arch.
- The brainstem – this is where respiration is controlled from as well as all basic, involuntary actions.
- Sympathetic and Parasympathetic nerves
- Tells to increase HR (sympathetic)
o Also might feel stressed causing adrenaline and noradrenaline to be produced – controlled by sympathetic nervous system (this would happen anyway due to sympathetic activation)
Adrenaline and noradrenaline increase contractility and increase heart rate
- This is to maintain CO to compensate for low BP and keep blood i.e. oxygen going to the brain (only survives three minutes without oxygen) and lungs (to keep oxygen coming in)
- what is an ectopic pregnancy?
- what is the most common anatomical site?
- Why is a fallopian tube ectopic pregnancy not viable?
- An ectopic pregnancy = a pregnancy in the wrong anatomical site
- The most common site of an ectopic pregnancy is in the fallopian tube.
- Lack of proper decidual layer and small size of tube predisposes to haemorrhage and rupture. If it presents early woman may not even know she is pregnant.
- what is a molar pregnancy?
- what causes it?
- what are the consequences of a molar pregnancy?
- what is the treatment for a molar pregnancy?
- A molar pregnancy is an overgrowth of trophoblast cells
- Complete mole is usually caused by two sperms fertilising an ovum which has previously lost its 23 chromosomes
This is a problem because in the testis, dad has inactivated several genes by adding methyl groups to stretches of DNA; this switches these genes off and promotes trophoblast growth → large aggressive placenta and a tiny baby. - Molar pregnancy is a form of pre-cancer – if it persists it can (rarely) give rise to an invasive tumour called choriocarcinoma.
4.o If Beta-hCG returns to normal then there is no need for further treatment
o If Beta-hCG stays high (persistent disease) → cure with methotrexate
- what is a fibroid?
2. do all fibroid become malignant?
- A fibroid is a benign growth of the uterus = leiomyoma (smooth muscle tumour)
- no
what are the causes of right heart failure
o Commonest cause is left heart failure
Commonest cause of left heart failure is atheroma of the coronary arteries; next most common is hypertension
o Lung disease is the second most common cause of right heart failure
When lung disease causes right heart failure = cor pulmonale
E.g. COPD (any chronic lung disease)
what is the most common symptom of LHF - left heart failure?
SOB
what are the causes of bilateral leg swelling?
LOW ALBUMIN e.g. due to renal failure
o If you have proteinuria and you have albumin in your urine you lose oncotic pressure and water is retained
Starts in feet/legs because of gravity (in person who still walks around
what are the causes of low albumin?
o Renal failure o Liver disease Do LFTs o Malnutrition IVDU Coeliac Homeless Anorexia Some gut diseases lose albumin into the lumen of the gut o Compression of the vena cava Mass Baby
what is CA125?
CA 125 is a tumour marker → particularly for ovarian cancer
what are the most common sites of ovarian cancer metastases?
bone, liver, lung and brain
what are the options for perimenopause?
o Information
o Life-style/herbal intervention e.g. red clover
o Hormone replacement therapy
what are the risks of using hormone replacement therapy in premature menopause?
o There aren’t any
In premature menopause just replacing what should be there
