repro 2 Flashcards
menstrual cycle phases?
hormones involved in mesntrual phases
which hormone triggers stroma and gland proliferation?
oestrogen
types of abnormal uterine bleeding (AUB)
causes of AUB?
cervical ectropion
pelvic inflammatory disease
endometritis
endometrial polyp
leiomyoma (fibroid)
leiomyosarcoma
adenomyosis
bleeding disorders
hyperplasia
cervical/endometrial cancer
atrophy (post-menopause)
DUB = anovulatory cycles/luteal phase defects
method of assessing endometrial hyperplasia?
indication for biopsy?
TVUS
indications for biopsy:
postmenopausal = endometrial thickness >4mm
premenopausal = >16mm
method of assessing polps or local thickening?
hysteroscopy
biopsy methods uterus
endometrial pipelle
* outpatient procedure, limited sample
dilatation and curretage
* most thorough sampling method
* can miss 5% of hyperplasias/cancers
disordered uterine bleeding (DUB)?
Ax?
abnormal uterine bleeding with no organic cause
most cases due to anovulatory cycles e.g. PCOS, hypothalamic dysfunction, thyroid disorders, hyperprolactinaemia
* commonest at either end of reproductive life
* corpus luteum does not form
rare cases due to luteal phase deficiency
* insufficient progesterone
* abnormal corpus luteum forms
anovulatory cycle pathophys
ovulation does not occur so endometrium continues to grow
glands appear cystically dilated (PCOS)
will break down irregularly i.e. oligomenorrhoea
endometritis?
Ax?
inflammatory cells in uterus
Ax
* gonorrhea + chlamydia (also TB, CMV, HSV)
* IUD
* postpartum (cause of secondary PPH)
* post-abortion
* post-curretage
* granulomatous (sarcoid, TB, foreign body)
* leiomyomata/polyps
endometritis rule?
infectious until proven otherwise (chlamdia, ghonorrhoea)
endometrial polyp s/s?
trigger?
risk?
common - usually asymptomatic but may present with bleeding
often occur during menopause
risk = almost always benign but endometrial carcinoma can present as a polyp
molar pregnancy types?
Complete mole
sperm combinies with egg which has lost its DNA
sperm then replicates forming 46 chromosome set
Only paternal DNA is present in complete mole
Partial mole
Egg fertilized by sperm which replicates itself yielding genotypes of 69, XXY (triploid)
partial moles have both paternal + maternal DNA
which mole is more dangerous?
complete mole - can develop into choriocarcinoma
myometrium Ax of AUB?
adenomyosis = endometrial glands and stroma in myometrium
* causes menorrhagia + dysmenorrhoea
leiomyoma = fibroids
leiomyoma symptoms?
growth?
risk?
menorrhagia
infetility
pain
growth is oestrogen dependent
very rarely can develop into leiomyosarcoma
what triggers ovulation?
LH surge (day 14)
when does progesterone peak?
day 21 of cycle
decidualisation?
progesterone-induced endometrial remodelling
normal menstruation
normal length of menstrual cycle?
usually lasts 4-6 days
mentrual flow peaks day 1-2
<80ml per menstruation
average 28 day cycle
between 21 to 35 days is normal
how many cases of AUB are DUB?
50%
so 50% have no organic cause
systemic disorders causing menorrhagia?
endocrine = hypothyroidism, diabetes, prolactin disorders
haemostasis = VWF, ITP, clotting dactor deficiency
liver disorders (clotting factorsO
renal disease
drugs - anticoagulants
PCOS symptoms?
complication?
oligomenorrhoea/amerneorrhoea
weight gain
facial hirsutism
facial acne
hair loss/thinning
associated with T2DM (insulin resistance), hypercholesterolaemia, hypertension, sleep apnoea
associated with increased risk of endometrial carcinoma
DUB subdivisions
Ix DUB?
diagnosis of exclusion
FBC - to assess Hb
Cervical smear (rule out cancer)
TSH
Coagulation screen
renal/liver function tests
Tranvaginal USS - endometrial thickness
hysteroscopy - fibroids and other pelvic masses
Endometrial sampling (pipelle, D+C)
Tx DUB?
Progestogens (synthetic progesterone)
Combined oral contraceptive pill
Anazol
GnRH analogues (low dose)
NSAIDs
Anti-fibrinolytics (tranexamic acid)
Capillary wall stabilisers
1st line for menorrhagia = IUS (Mirena)
infertility definition?
main causes?
Inability to conceive after 12 months regular intercourse without contraception
Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)
advice for conception?
Woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and excessive alcohol
Reduce stress
Aim for intercourse every 2-3 days
Avoid timing intercourse (i.e. timing with ovulation as can lead to increased stress and pressure on the relationship)
blood tests for infertility?
day 21 progesterone (>30 mmol/L)
TSH
anti-mullerian hormone (high levels good sign)
if oligo/amenorrhoeic:
LH (raised in PCOS), FSH, E2 levels
testosterone - SHBG, FAI
prolactin (hyperprolactinaemia can cause amenorrhoea)
PCOS blood results?
elevated LH
hyperprolactinaemia
what is the most accurate marker of ovarian reserve?
anti-mullerian hormone (high levels = good)
non-blood test Ix for infertility?
US pelvis - look for polycystic ovaries or structural abnormalities in uterus
Hysterosalpingogram - patency of fallopian tubes
Laparoscopy and dye test - tubal patency, adhesions and endometriosis
Tx anovulation?
1st line = clomifene
2nd line = letrozele
low dose GnRH in women resistant to clomifene
ovarian drilling in PCOS
metformin can also be used in PCOS
Tx tubal factors infertility?
tubal cannulation during HSG
laparoscopy to remove adhesions or endometriosis
IVF
Tx uterine factors infertility?
surgery to remove polyps, adhesions, structural abnrmalities
normal semen parameters
nomenclature?
Sperm conc should be >15
Motility >32
Morphology >4
Tx sperm problems infertility?
Surgical sperm retrieval - blockage of vas deferens
Surgical correction of obstruction of vas deferens
Intrauterine insemination
ICSI - injecting sperm directly into the cytoplasm of egg (useful when significant motility issues, low sperm count)
Donor insemination
ART eligibility?
Stable relationship 2y (incl same sex)
Female <40 y/o
Female BMI 18.5-30
Non-smokers
No biological child
No illegal/abusive substances (incl methadone)
Neither Partner sterilised
Duration unexplained infertility 2y
Up to 3 cycles of tx
complications of IVF?
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
ovarian hyperstimulation syndrome s/s?
Abdominal pain + bloating
vomiting + diarrhoea
Hypotension (hypovolaemia)
Ascites
Pleural effusion
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
Tx OHSS?
oral fluids
monitor urine output (hypovolaemia)
LMWH (to prevent DVT/PE)
paracentesis if req
IV colloids (albumin)
types of miscarriage
missed = foetus no longer alive but no symptoms
threatened = vaginal bleeding with closed cervical os + foetus alive
inevitable = vaginal bleeding + open cervical os
incomplete = RPOC
complete = full miscarriage with no RPOC
anembryonic pregnancy = gestational sac present but no embryo
miscarriage symptoms?
Dx?
positive UPT
bleeding primary symptom (more than cramps)
Dx = TVUS 1st line for diagnosiing miscarriage
things to look for in TVUS miscarriage?
Mean gestational sac diameter
Foetal pole and CRL
Foetal heartbeat
foetal heartbeat expected once CRL >7mm
when CRL <7mm without a heartbeat, scan repeated after at least 1 week to ensure heartbeat develops
when CRL >7mm without foetal heartbeat, scan repeated after one week before confirming non-viable pregnancy
Foetal pole expected once the mean gestational sac diameter >25mm
when >25mm but no foetal pole, scan is repeated after one week before confirming an anembryonic pregnancy
speculum exam to assess stage of miscarriage?
Is the os closed? (threatened miscarriage)
Open? (inevitable miscarriage)
Products already in vagina and os is closed? (complete miscarriage)
RPOC complications?
symptoms?
Tx?
cervical shock
* cramps
* nausea/vomiting
* collapse
* sweating
resolves if products removed from cervix
* resus with IV fluids
* uterotonics may be required
Ax miscarriage?
Embryonic abnormality - chromosomal
Immune cause - anti phospholipid syndrome (APS)
Infections - CMV, rubella, toxoplasmosis, listeria
Severe emotional upsets/stress
Iatrogenic loss (after chorionic villus sampling causing infection or uterine irritability)
Associations - heavy smoking, cocaine, alcohol misuse
Uncontrolled diabetes
signs of miscarriage on TVUS
anemebryonic pregnancy?
miscarriage = no heartbeat + foetal pole >7mm
anamebryonic = gestational sac >25mm, no foetal pole
management of miscarriage <6 weeks gestation?
Women <6 weeks presenting with bleeding can be managed expectantly (they must be in no pain and have no risk factors e.g. previous ectopic)
Expectant management = waiting for miscarriage without investigations or treatment
Ultrasound unlikely to be helpful as pregnancy too small to be seen
Repeat UPT is performed after 7-10 days
If negative, a miscrriage can be confirmed
If bleeding continues or pain occurs = referral
management of miscarriage >6 weeks gestation?
Ultrasound scan - confirm location and viability of pregnancy
Essential to exclude ectopic pregnancy!!!
3 main options for management:
* Expectant (do nothing and await spontaneous miscarriage)
1st line in women without risk
repeat UPT after 3 weeks to confirm complete miscarriage
* Medical (misoprostol)
* Surgical
manual vacuum (LA) <10 weeks gestation
electric vacuum (GA)
misoprostol?
S/E?
prostaglandin analogue (used for medical management miscarriage)
* heavier bleeding
* pain
* vomiting
* diarrhoea
important to remember surgical management miscarriage?
anti-rhesus D for rhesus neg women!!
recurrent miscarriage?
Ax?
3 consecutive 1st trim miscarriages OR
one 2nd trim miscarriage
Ax = idiopathic (older women), APS, uterine abnormalities e.g. fibroids, hereditary thrombophillias, chronic histiolytic intervillositis (NK cells in uterus), diabetes, untreated thyroid, SLE
APS?
Tx?
anti-phospholipid antibodies, hypercoagulable state
associated with thrombosis and recurrent miscarriage
Tx = LDA + LMWH
(check for past medical history of DVT)
common hereditary thrombophillias?
comps?
factor V Leiden (most common)
factor II (prothrombin)
protein S deficiency
recurrent miscarriage
Ix recurrent miscarriage?
Tx?
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound (uterine abnormalities, fibroids)
Genetic testing of products of conception/parents
for APS = LDA + LMWH
for unexplained cases = progesterone pessary
incomplete miscarriage?
Tx?
RRPOC remain in uterus after miscarriage = risk of infection!!
Tx = medical (misoprostol) or surgical management
most common site ectopic? other sites?
risk factors?
most common site = ampulla
other sites = other fallopian tube areas, ovary, peritoneum, liver, cervix, c-section scar
risk factors
* previous ectopic
* previous PID
* surgery to fallopian tubes
* IUD
* older age
* smoking
s/s ectopic pregnancy?
Pain > bleeding
Constant lower abdominal pain in right or left iliac fossa
Missed period
Vaginal bleeding
Lower abdominal tenderness
Cervical motion tenderness (pain when moving cervix during bimanual examination)
Dizziness or syncope (collapse)
Shoulder tip pain (peritonitis)
ectopic pregnancy Ix?
FBC, BHCG (levels should not double)
TVUS gold standard for ectopic!! - blob sign, tubal ring sign
pregnancy of unknown location?
basically ectopic but not visible on USS
Tx ectopic pregnancy?
depends on presentation!
if acutely unwell (BHCG >5000, >35mm, rupture, pain, visible heartbeat)
laparoscopic salpingectomy 1st line - remember anti-D
(salpingotomy if damage to other tube)
medical management (patient well, BHCG<5000, <35mm, unruptured)
methotrexate IM to buttock
conservative management (unruptured, <35mm, no heartbeat, no pain, HCG <1500)
methotrexate ectopic S/E?
remember to advise?
vaginal bleeding, nausea + vom, abdominal pain, stomatitis (inflammation of mouth)
woman advised not to get pregnant for 3 months (teratogenic)
presentation PUL?
Dx?
Tx?
amenorrhoea + abdominal pain with no evidence of pregnancy in uterus, fallopian tube, cervix, c-section scar or abdominal cavity
Dx = HCG - repated after 48 hours
Tx = can be managed conservatively, but if persistent = methotrexate
molar pregnancy s/s?
Dx?
Tx?
Hyperemesis
Vaginal bleeding (grape-like tissue)
Hyperthyroidism (thyrotoxicosis - hCG can mimic TSH)
Early onset pre-eclampsia
Size of uterus bigger for stage of pregnancy
Rare cases - SOB (embolisation of molar tissue to lungs) or brain (seizures)
Dx = snow storm appaerance on USS
Tx = surgical
implantation bleeding?
common, occurs approx 10 days post-ovulation (once egg implanted in endometrium)
chorionic haematoma?
s/s?
Tx?
Pooling of blood between endometrium and embryo due to separation
S/s = bleeding, cramping, threatened miscarriage
Tx = usually self-limiting and resolve
cervical causes of bleeding in early pregnancy?
ectropion
Infections - chlamydia, gonococcus
Malignancy (very rare)
vaginal causes of bleeding in early pregnancy?
Tx?
Infections = trichomoniasis (strawberry vagina), bacterial vaginosis, chlamydia
Malignancy - ulcers, rare
Forgotten tampon
BV + trich = metronidazole
chlamydia = erythromycin/amxocicillin (CANNOY give doxycycline in pregnancy)
DDx pain in pregnancy?
miscarriage (bleeding > pain)
extopic (pain > bleeding)
tosion of ovarian cyst, end of 1st trimester when uterus climbs out of pelvis into abdomen
intra-abdominal bleeding from cyst rupture
UTI, appedncitis
vaginal infections, PID
when is anti-D given?
28 weeks
and after any sensitising event
hyperemesis gravidarum?
complications?
Dx?
Tx?
excessive vomiting
comps = dehydration (ketosis), electrolyte imbalance, weight loss, altered liver function (50%)
Dx = of exlcusion
Tx = fluids + electrolyte replacment
1st line antiemetic = cyclizine
2nd line = metoclopramide
steroids in protracted condition or evidence of weight loss
complication metoclopramide?
Tx?
oculogyric crisis
tx = atropine
types urinary incontinence?
risk factors?
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
risk factors = women, older, obesity, smoking, kidney disease, diabetes
overactive bladder syndrome?
Urgency (with or without urge incontinence) with frequency and nocturia
Absence of pathology that could explain these symptoms
Wet OAB = urge incontinence represent
Dry OAB = incontinence absent
mixed urinary incontinince?
urgency + stress incontinence (coughing, sneezing)
exam urinary incontinence?
palpable bladder?
External genitalia - atrophic vaginitis
Vaginal - prolapse (50% of SUI patients), malignancy, fistula
Rectal - tone, masses
Neurological - reflexes, sensory, motor
Standing or supine stress test
urinanalysis, post-redisual, bladder diary
Tx ladder OAB?
bladder drill
oxybutynin (antimuscarinic)
botox
surgery
when antimuscarinics contraindicated = mirabegron (B3 receptor agonist)
lifestyke advice urinary incontinence?
weigtht loss
stop smoking
reduce caffeine
S/E antimuscarinics e.g. oxybutynin?
Dry mouth
Constipation
Blurred vision
Somnolence
(type of anticholinergic)
clinical Ix urinary incontinence?
cystometry
post residual (abnormal >150)
urinalysis
overflow incontinence Ax?
Dx?
Tx?
Ax = obstruction of urethra (prostate), poor contractile bladder muscle
Dx = PVR
Tx = stop anticholinergics
alpha-blocker for BPH
Tx SUI?
Weight loss, smoking, reduce caffeine, avoid excessive fluid intake
Physio - pelvic floor
Pessaries
Drugs - duloxetine
surgical = vaginal tape, injections, obturator appraoch
pelvic prolapse compartments?
anterior = cystocele
middle/apical = uterine/enterocele
posterior = rectocele
classification uterovaginal prolapse?
1st degree = in vagina
2nd degree = at interoitus
3rd degree = outside vagina
4th = procidentia (entirely outside vagina)
cystocele s/s?
uterine/enterocele?
rectocele?
cystocele = bulging, pressure, “mass”, difficulty voiding, incomplete emptying, difficulty inserting tampon, pain with intercourse
uterine/enterocele = same as cystocele
rectocele = bulging, pressure, “mass”, difficulty defecating, difficulty inserting tampon, splitting vaginal wall/perineum
POP-Q?
Pelvic organ prolapse quantification system (POP-Q)
If site is above hymen - assigned negative number
If site prolapses below hymen - assigned positive number
risk factors vaginal prolapse?
Aging
Pelvic surgery e.g. prior hysterectomy
Menopause and hypoestrogenism
Loss of muscle tone
Multiple vaginal births
Obesity
Chronic constipation, coughing, heavy lifting
Uterine fibroids
Family history
Connective tissue disorders such as marfans
Tx vaginal prolapse?
conservative = avoid heavy lifting, weight loss, stop smoking, vaginal oestrogens (only if atrophic vaginitis)
pelvic floor exercises
pessaries in women unfit for surgery
surgery e.g. sacrospinous fixation, Manchester repair
prevention of ovulation?
prevention of fertilsation?
prevention of implantation?
ovulation = COCP, depo povera, implant, ring, patch. mini pill
fertilisation = IUD/IUS, POP + barrier methods
implantation = IUD (secondary action)
copper coil?
use?
S/E?
Can last up to 10 years (if inserted >40 y/o, can be kept in til menopause)
Non-hormonal (might be only reliable method for women after breast cancer)
Can be used as emergency contraception
Often makes periods heavier, longer and more painful (NSAIDs like ibuprofen can help)
IUS?
use?
S/E?
e.g. Mirena
1st line Tx for menorrhagia, endometriosis etc
S/E = irregular bleeding, 50% amenorrhoea
systemic hormones very low so hormonal side effects rarely a problem
Nexplanon?
lasts how long?
main side effect?
arm implant - most effective of all contraceptive methods
safe for most women (progesterone only)
lasts 3 years
main side effect = prolonged PV bleeding (can be controlled by COCP on top of implant)
how to take COCP
Start in first 5 days of period
Or
At any time in cycle + condoms 7 days
Take daily for 21 days followed by 7 day break (bit outdated now)
Continuous use (off licence lol)
If you have a bleed, come off it for 4 days then start again
risks of COCP?
Venous thrombosis
Arterial thrombosis
hypertension (must check BP every 3 months then annually)
increased risk breast + cervical cancer
(but protective against endometrial + ovarian cancer)
absolute contraindications COCP?
relative contraindications?
migraine with aura (sparkles are not an aura)
breast cancer
history of DVT/PE
liver disease
relative = smoking, >35, hypertension, breastfeeding
1st line Tx PCOS?
COCP
s/s COCP?
Nausea
Spots (can worsen acne in some people)
Bleeding
Breast tenderness
POP?
mechanism of action?
how to take?
main is cerelle
mechanism = inhbitis ovulation
others do not - prevent fertilisation by thickening cervical mucus
Day 1-5 of period
Or
Anytime in cycle
+ condoms 2 for days
when is implant/DMPA effective?
immediately if day 1-5 of period
if any other time - condoms for 7 days
contraindications of POP and nexplanon?
breast cancer
missed POP guidance?
Take pill at same time every day
If late taking pill, only really matters if more than 12 hours late
If >12 hours late, won’t work for 2 days
depo provera/sayana press?
mechanism?
benefit?
Side effects?
injection
suppresses ovulation
benefit = isnt affected by enzyme inducing drugs
S/E = weight gain, nausea, spots, bleeding, headaches, osteoporosis
diaphragm use?
Must leave for at least 6 hours after sex
sterilisation techniques?
vasectomy + tubal ligation
when can you not give ellaone?
instead?
when is this effective?
Can’t give ella one if been taking anything containing progesterone e.g. CHC, mini pill
instead = copper coil
Coil effective immediately if 1-5 day in cycle
If any other time, use condoms for 7 days
how long after ellaone can you begin taking POP?
5 days after
copper coil mechanism of action?
prevents fertilsation
ellaone v levonelle
ellaone= 5 days post intercourse
levonella = 3 days
normal vaginal flora?
normal ph?
lactobacillus (gram +ve rods)
other organisms = GBS, candida, strep viridans
normal pH = acidic (4-4.5)
candida infection Ax?
risk factors?
S/s?
Dx?
Tx?
Ax = most are candida albicans
risk factors = recent antibiotics, high oestrogen, diabetes, immunocomproised patients
S/s = intensely itchy, white vaginal discharge
Dx = HVS
Tx = clotrimazole cream –> oral fluconazole
(non-albicans likely to be azole resistant)
typical “spotty” appearance of candida balantitis
purulent discharge typical of gonorrhoea infection
gonorrhoea gram stain appearance?
gram -ve intracellular diplococci
where does gonorrhoea infect?
Dx?
Tx?
urethra, rectum thorat, eyes, endocervix (in females)
Dx = miscroscopy (endocervical NOT HVS, purulent discharge in males), culture, NAATs (more sensitivity than culture, only needs VVS)
Tx = ceftriaxone
chlamydia infects?
gram appearance?
serological groupings?
Tx?
urethra, rectum, throat, eyes, endocervix
does not gram stain!!
serovars A-C = trachoma (eye)
serovars D-K = genital
serovars L1-L3 = lymphogranuloma venereum
Tx = doxycyline (azithromycin in pregnancy)
LGV?
S/s?
chlamydia infection
painless genital lesion + regional lymphadenopathy
painful bowel movements (or painful anal sex)
bloody stools
NAATs?
how are they taken?
tests for gonorrhoea and chlamydia (more sensitive than culture)
females = VVS (can be self-taken)
males = first pass urine (i.e. not MSSU like UTI)
Trichomonas vaginalis?
transmission?
S/s?
Dx?
Tx?
protozoal parasite
STD
s/s females = itching, greenish fishy discharge
males = itching, discharge from penis
Dx = HVS for miscroscopy
Tx = oral metronidazole
(treat partners as well as notoriously difficult to diagnose)
bacterial vaginosis?
Dx?
Tx?
complications BV?
technically imbalance rathe than infection (absence of lactobacilli)
Dx = positive whiff test (fishy) + wet mount miscroscopy, will show absence of lacobasilli + prescence of clue cells (look fluffy)
Tx = metronidazole 7 days
complications = endometritis, PROM, preterm delivery
syphillis Ax?
stages?
Dx?
Tx?
treponema pallidum
4 stage illness:
stage 1 = chancre (will heal without Tx)
stage 2 = snail track mouth ulcers, generalised rash, flu-like symptoms
stage 3 (latent) = no symptoms, multiplication
stage 4 (late stage) = cardiovascular + neurovascular complications
Dx = cannot be gram stained or cultured
primary = dark field miscoscopy, PCR, IgM
seondary + tertiary = serology
Tx = IM benzylpenicillin
(if allergic = doxycyline/erythromycin 14 days)
Tx syphillis?
early syphillis
IM benzylpenicillin single dose
(if allergic = doxycycline/erythromycin 14 days)
late syphillis
IM benzylpenicillin (2 doses)
allergic = doxycycline 28 days
Dx?
Tx?
genital herpes (HSV2)
Tx = aciclovir
Tx pubic lice (pthirus pubis)
malathion lotion
abortion legal til?
management after 20 weeks?
Abortion is legal up to 24 weeks
>20 weeks = purely surgical
what has to be completed for every abortion in UK?
HSA1 form has to be completed for every abortion in the UK
2 doctors sign (clause A-E)
1 doctor signs (if emergency clauses F+G)
All abortions perfomred in UK must be reproted to CMO via HSA4
Most abortions fall under clause C (risk to physical or mental health of mother)
conscientious objection abortion?
does not apply in emergency situations
should not delay or prevent patient’s access to care
should not apply to indirect tasks associated with abortion i.e. administrative, supervision of staff
when is uterus palpable?
12 weeks
medical abortion?
timing?
Mifepristone 200mg PO 1st + prostaglandins
Misoprostol 800mcg PV/SL - 2nd (24-48 hours after taking mifepristone)
<12 weeks gestation = can self-administer
2nd dose misoprostol if >10 weeks
>12 weeks = inpatient procedure
>20 weeks = purely surgical management
early medical abortion at home?
Contents of pack:
Mifepristone 200mg
Misoprostol 800mcg (PV or SL) + additional dose 400mcg
(additional dose for those who do not experience bleeding within 4 hours, or who are over 10 weeks)
Anti-emetic, analgesia, antibiotics
Contraception (6/12 POP)
surgical abortion available until?
types?
availible up to 14 weeks in scotland
<14 weeks = electric vacuum aspiration (GA), manual vacuum aspiration (up to 10 weeks - LA)
>14 weeks = Dilation and evacuation
complications of abortion?
haemorrhage
failed/incomplete abortion
infection
uterine perforation (surgical risk only)
cervical trauma (surgical risk only) - reduced with cervical ripening (misoprostol)
prophylaxis at time of abortion to reduce complications?
antibiotics (7 days doxycycline + 2days azithroycin)
rhesus anti-D
VTE prophylaxis - LMWH if smoker, BMI, previous embolus
contraception after abortion?
Can be started at/soon after abortion
Immediately effective if started on day of abortion or within 5 days
If started after 5 days, efficacy depends on method:
2 days for POP
7 days for CHC/DMPA/SDI/LNG-IUS
IUD after abortion?
COCP/POP?
IUD can be inserted immediately after STOP/MTOP once expulsion of pregnancy confirmed
COCP/POP can be started any time after MTOP/STOP including on day of mife/miso
follow-up abortion?
No formal follow-up after surgical abortion or in-hospital abortion where passage of PoC confirmed
After EMAH = UPT performed at least 2 weeks after abortion
history STI?
query deep dyspareunia (upper genital tract infection e.g. PID, endometritis)
characteristics of vaginal discharge
query urianry/bowel symptoms
date of LMP
contraceptive use
sexual history - no. of partners in last 6 months
standard STI screen?
chlamydia, gonorrhoea, HIV, syphillis
HIV?
pathophys?
CD4 level to aim for?
RNA retrovirus
attacks helper T cells
CD4 >500
HIV symptoms?
onset 2-4 weeks after infection
S/s = fever, rash (maculopapular), myalgia, pharyngitis, headache/aseptic meningitis
then latent stage
then late stage - AIDS = oppurtunistic infections and cancers
most important oppurtunistic infection HIV?
organism?
CD4 threshold?
S/s?
Dx?
Tx?
Prophylaxis?
pneumocystis pneumonia (PCP)
Ax = pneumocystis jiroveci (fungus)
CD4 <200
S/s = dry cough, SOB, insidious onset
Dx = CXR may be normal, BAL + PCR
Tx = high dose co-trimoxazole
prophylaxis when CD4 <200 = low dose co-trimox
cerebral toxoplasmosis Ax?
CD4 threshold?
S/s?
Dx?
Tx?
toxoplasma gondii
CD4 <150
S/s: cerebral abscesses, chorioretinitis, headache, fever, focal neurology, seizures, raised ICP
Dx = MRI (cerebral abscesses)
Tx = co-trimoxaxole?
CMV CD4?
complications?
symptoms?
screening?
CD4 <150
causes retinitis, colitis + oesophagitis
S/s = vision loss, floaters, abdominal pain, diarrhoea, PR bleeding
opthalmic screening for all individuals CD4 <50
HIV-induced neurocognitive imapirment?
Dx?
reduced short term memory + motor dysfucntion
Dx = MRI (enlarged ventricles + deep sulci i.e. atrophy)
progressive multifocal leukoencephalopathy (PML) Ax?
CD4?
S/s?
organism = JC virus
CD4 <100
S/s = rapid!!, focal neurology, confusion, personality change
skin infections HIV?
herpes zoster = mutlidermatomal, recurrent
herpes simplex = extensive ulceration, tumour-like, aciclovir resistant
HPV = extensive + resistant to Tx
AIDS oppurtunistic infections?
PCP
Tuberculosis
cerebral toxoplasmosis
CMV
progressive multifocal leukoencephalopathy
HIV associated wasting?
Ax?
Slim’s disease
Ax = chronic immune activation, anorexia, malabsoprtion/diarrhoea (CMV)
AIDS-related cancers?
Kaposi’s sarcoma
non-Hodgkin’s lymphoma (Burkitts)
cervical cancer
Kaposi’s sarcoma Ax?
S/s?
Tx?
organism = human herpes virus 8 (HHV8)
S/s = cutaneous lesions, mucosal lesions, visceral lesions
Tx = anti-retrovirals, liquid nitrogen, systemic chemo
Burkitt’s lymphoma Ax?
Type of cancer?
S/s?
Tx?
Ax = EBV
non-Hodgkins lymphoma (AIDS-related)
S/s = B symptoms (weight loss, night sweats, fever), bone marrow involvement, CNS involvement
Tx = antiretrovirals
non-AIDS symptomatic HIV?
Mucosal candidiasis
Seborrhoeic dermatitis
Diarrhoea
Fatigue
Worsening psoriasis
Lymphadenopathy
Parotitis
Neuroligcal presentations = polyneurpathy, monenuritis multiplex, aseptic meningitis
Haematological = leukolymphopenias, thrombocytopenia
transmission HIV?
sexual contact
injected drugs
infected blood products
mother to child
high prevelance areas HIV?
Sub-saharan africa
Caribbean
Thailand
Lab markers HIV?
Viral RNA is first marker to become positive
Second is p24 protein
Antibody can take 3 months to become detectable in blood
types antiretroviral drugs?
HAART?
Reverse transcriptase inhibitors
Integrase inhibitors
Protease inhibitors
Entry inhibitors
HAART example = Atripla
prognosis HIV?
life expectancy with treatment essentially normal
HAART toxicity?
GI side-effects (protease inhibitors) = transaminitis, fulminant hepatitis
Skin = rash, hypersensitivity, SJS
CNS = mood, psychosis
Renal toxicity = proximal renal tubulopathies, nephrolithiasis
Bone = osteomalacia
CVS - increased MI risk
Haematology - anaemia
post-exposure prophylaxis HIV?
within 72 hours
antiretroviral Tx for 4 weeks e.g. tenofevir
prevention of mother to child transmission HIV?
HAART during pregnancy
c-section if detected viral load
2-4 weeks antiretroviral for neonate
exclusive formula feeding
Dx?
Ix?
Tx?
Extopic pregnancy
Ix = TVUS gold standard, FBC, G+S
Tx = laparoscopic salpingectomy
Dx?
on USS, see cyst
likely ovarian torsion
ovarian torsion Ax?
premenopausal vs postmenopausal
Tx ovarian torsion?
Ax = dermoid cyst (any cyst >5cm really)
premenopausal = likely benign
postmenopausal = likely malignant
Tx = deterosion, oophrectomy
rebound + guarding
Rovsing’s positive
Dx = appendicitis
Dx?
Ix?
Ax?
Tx?
classic presentation cyst rupture
Ix = FBC, CRP, G+S, USS
Ax = can be spontaneous, or after sex/trauma
Tx = conservative, stop bleeding, resus
Dx?
Ix?
Ax?
Tx?
Dx = PID
Ix = FBC, CRP, LFT (Fitz-Hugh Curtis), genital swabs
Ax = chlamydia, gonorrhoea, IUD, anaerobes
Tx = 14 days metronidazole + doxycycline, remove IUD
complications PID?
infertility
chronic pelvic pain
ectopic pregnancy
management acute PV bleed?
tranexamic acid + resus
bartholin’s abscess Tx?
conservative
broad spectrum antibiotics
incision + drainage
vaginismus?
Body’s automatic reaction to vaginal penetration - whenever penetration is attempted, vaginal muscles tighten on their own
menopause?
no periods >12 months
premature ovarian insufficiency?
early menopause?
POI = <40 y/o
early menopause = 40-44
symptoms menopause
Mood swings
Night sweats
Hot flushes
Weight gain
Dry skin/hair
Aches and pains
Insomnia
Depression
Brain fog
Loss of sex drive
Dx early menopause/atypical menopause?
FSH levels 2 x 6 weeks apart = indicated in women >45 with atypical symptoms, women 40-45 with menopausal symptoms
FSH, E2, TFT, glucose, prolactin, FAI = in women <40
check chromosomes and exclude autoimmune disorders in women <35
Tx menopause?
HRT
lifestyle = phytooestrogens, regular exercise, no smoking, limit alcohol + caffeine
environmental = cool ambient temperature, intelligent fabrics, cooling scarf
non-hormonal Tx = black kohosh, sage, SSRIs/SNRIs
benefits HRT?
risks?
contraindications?
benefits = symptom relief, reduces risk of osteoporosis + cardiovascular disease
risks = breast cancer, VTE, increased CVD>60 y/o
contraindications = history of breast cancer, coronary heart disease, TIA/stroke, unexplained vaginal bleeding, liver disease
HRT principles
POI Tx?
early menopause Tx?
POI <40
HRT til average age of menopause ~51
CHC continuously could be considered as alternative?
Continue with contraception
Early menopause 40-44
HRT til average age of menopause ~51
indications for transdermal HRT?
benefits?
Individual preference
Poor symptom control with oral HRT
Increased VTE risk
High blood pressure
benefits = no associated risk of VTE, better for symptom control, less CVD risks
side effects of COCP/HRT
perimenopausal contraception?
Age <40 = continue contraception
Age 40-49 - contraception can be stopped:
2 years after last NATURAL period OR 2 years after 2 results of FSH > 30 IU/I taken 6 weeks apart
Age >50 contraception can be stopped:
1 year after last natural period OR 1 year after 1 result of FSH >30 IU/I
Age >55 contraception can be stopped even if still having periods
vulvo-vaginal atrophy?
Tx?
complication of menopause
Tx = vaginal oestrogen (can be used in addition to HRT)
how long must wait to test for chlamydia?
14 days following exposure (incubation period)
Tx gonorrhoea?
1st line = ceftriaxone 1g IM
2nd line = cefixime 400mg oral plus azithromycin 2g (only if IM injection is contra-indicated or refused by patient)
complications gonorrhoea?
lower genital tract = bartholinitis, tysonitis, periurethral abscess, rectal abscess, epididymitis, urethral stricture
upper genital tract = endometritis, PID, hydrosalpinx, infertility, ectopic pregnancy, prostatitis
Behcet’s disease symptoms?
genital ulcers
mouth ulcers
red painful eyes + blurred vision
acne-like spots
headaches
painful swollen joints
primary syphillis incubation period?
approx a month until chancre appears
symptoms secondary syphillis?
Skin (macular, follicular or pustular rash on palms + soles)
Lesions of mucous membranes - SNAIL TRACK
Generalised lymphadenopathy
Fever, sore throat, malaise
Anterior uveitis
Cranial nerve lesions
Condylomata lata (most highly infectious lesion in syphilis, exudes a serum teeming with treponemes)
Dx?
Tx?
HPV
Tx = podophyllotoxin, imiquimod, cryotherapy
Meigs syndrome?
Tx?
Triad
Benign ovarian tumour (most common is ovarian fibroma)
+ Ascites
+ Pleural effusion
Tx = resolves after removal of tumour
red flag symptoms ovarian cancer?
new onset IBS >50
Bloating
Early satiety
Reduced appetite
Ix ovarian masses?
MRI in young women
Ca125 (>30), AFP, LDH, HCG
ovarian masses with low RMI = MRI (esp in young women)
high RMI = CT
RMI score?
Ca125 x USS x menopausal status
<30 = low
30-200 = intermediate
>200 = ¾ chance
smear test recall?
smear test screening age?
24-65
every 5 years
HPV vaccine?
6, 11, 16 + 18
epithelium ectocervix?
endocervix?
transformation zone?
ecto = stratified squamous epithelium
endo = columnar epithelium
TZ = mix of columnar and squamous
cervicitis?
Ax?
Dx?
complication?
inflammation of cervix
Ax - chlamydia, herpes
Dx = lymphocytes in cervix
coplication = can lead to infertility
what increases risk of cervical cancer x3?
smoking!
whats this?
Koilocytes = epithelial cells that have been infected by HPV
whats this?
squamous cell carcinoma - keratin swirls
time line HPV infection
HPV infection –> high grade CIN = 6 months - 3 years
High grade CIN → invasive cancer = 5-20 years
CIN3?
carcinoma in situ
CIN?
occurs where?
Dx?
S/s?
Pre-invasive stage of cervical cancer - dysplasia of squamous cells
Occurs at transformation zone
Not visible to naked eye - detectable by cervical screening
s/s = asymptomatic
histology CIN?
Delay in maturation/differentiation - immature basal cells occupying large proportion of epithelium
Nuclear abnormalities = hyperchromasia (nucleus super dark), increased nucleocytoplasmic ratio (i.e. massive nucleus), pleomorphism (lots of variation in nuclear size and shape)
Excess mitotic activity i.e. above basal layers
Koilocytosis (indicating HPV infection) often present
CIN 1 vs 2 vs 3?
when is it classed as carcinoma?
CIN1 = basal ⅓ of epithelium occupied by abnormal cells
CIN2 = abnormal cells extend to middle ⅓
CIN3 = abnormal cells occupy full thickness of epithelium
Even a single cell breaking through basement membrane makes it carcinoma
cervical squamous cell carcinoma Ax?
S/s?
develops from pre-existing CIN
S/s
* post-coital/PMB/IMB
* pelvic pain
* haematuria/UTIs
* acute renal failure
spread squamous cell carcinoma?
is this SCC well-differentiated or poorly differentiated?
well-differentiated = keratin swirls
Cervical glandular intraepithelial neoplasia (CGIN)?
pre-invasive phase of endocervical adenocarcinoma
endocarvical adenocarcinoma?
precursor?
Epidemiology?
less common than SCC
precursor = CGIN
epidemiology = higher socioeconomic class, later onset sexual activity, smoking, HPV 18
HPV driven diseases - other than CIN/SCC?
Vulvar intraepithelial neoplasia (VIN)
Vaginal intraepithelial neoplasia (VaIN)
Anal intraepithelial neoplasia (AIN)
Types of Vulvar intraepithelial neoplasia (VIN)?
2 types
VIN of usual type - precursor of SCC (HPV-driven)
Differentiated VIN (dVIN) - precursor of vulval SCC but not associated with HPV
* higher risk of malignancy than HPV-driven!!
* often background inflammatory skin disease like lichen sclerosus
vulvar invasive squamous carcinoma epidemiology?
S/s?
Ax?
most important prognostic factor?
Tx?
elderly women
s/s = ulcer
can arise from normal epihtelium or VIN
most important prognostic factor = spread to inguinal nodes
Tx = radical vulvectomy +/- inguinal lymphadenopathy
vulvar paget’s disease s/s?
features?
Tx?
s/s = crusting rash (sharp demarcation), itchy, painful
tumour cells contain mucin - rarely cancerous
Tx = excision
is ca125 specific to ovarian cancer?
absolutely not - can be raised in ovulation, pregnancy, endometriosis, fibroids, SLE, sarcoidosis, cirrhosis, pericarditis, pancreatitis
when to suspect primary ovarian mass?
if Ca125:CEA >25
AFP raised in?
HCG?
LDH?
Alpha foeto-protein - raised in yolk sac tumour
HCG - raised in choriocarcinoma
LDH - raised in dysgerminoma
malignant features ovarian mass?
multiloculated
solid areas
bilateral
acites
metastasis
endometriosis presentation?
examination?
Severe dysmenorrhoea/premenstrual pain
Dyspareunia (painful intercourse)
Associated with sub-fertility
Acute abdomen if ruptures
examination = tender
Tx borderline ovarian tumours?
young women = unilateral oophrectomy/cystectomy
postmenopausal = pelvic clearance
ovarian cancer Tx?
type of chemo?
1a cancer = surgery only
early stage = surgery followed by adjuvant chemo
advanced = neoadjuvant chemo followed by surgery
chemo = cisplatin + paclitaxel
signet ring histology ovary?
Krukenberg tumour = metastasis from stomach
Ca125:CEA <25
complex atypical endometrial hyperplasia?
precursor to endometrial carcinoma
endometrial carcinoma epidemiology?
types?
peak 50-60 years
if <40, consider underlying condition e.g. PCOS or Lynch syndrome
2 types
* endometroid carcinoma = precursor is atypical hyperplasia
* serous carcinoma = precursor is serous intraepithelial carcinoma
endometrial cancer presents with?
type 1 tumours?
type 2?
post-menopausal bleeding
Type 1 tumours (80%) = endometrioid + mucinous
* releated to oestrogen
* precursor = atypical hyperplasia
* associated with Lynch syndrome
Type 2 tumours = serous and clear cell
* not associated with ostrogen
* affect elderly women
* precursor = serous endometrial intraepithelial carcinoma
* TP53 mutation
* much more aggressive than type 1 tumours
risk factors endometrial cancer?
obesity
PCOS
Lynch syndrome
staging endometrial cancer?
Tx?
1a = <50% of myometrium
1b = >50% myometrium (completely within myometrium)
2 = extends to cervix
3a = serosa of uterus or adnexae
3b = invades vagina
3c = para-aortic lymph nodes
4 = bladder/bowel + distant metastases
Tx = hysterectomy + chemo/radiotherapy
grading endometrial carcinoma?
Grade 1 = <5% solid growth
Grade 2 = 6-50% solid growth
Grade 3 = >50% solid growth
most common uterine sarcoma?
s/s?
leiomyosarcoma
s/s = abnormal vaginal bleeding, palpable pelvic mass, pelvic pain
