Repro Flashcards
describe 4 differences between the male and female pelvis
- male pelvis has a deep greater (false) pelvis whereas the female greater pelvis is shallow.
- the male pelvic inlet is heart shaped but the female pelvic inlet is more oval shaped
- the male sub-pubic angle is narrow whereas the female sub-pubic angle is wide.
- the male obturator foramen is round but the female obturator foramen is oval.
- males have a large acetabulum but females have a small one
- females comparatively have a larger pelvic outlet than males
the piriformis muscle lies posterior to the obturator internus muscle - true or false?
true
name the 4 parts of the male urethra
- preprostatic
- prostatic
- membranous (widest part - this is where the bulbourethral gland joins the urethra
- spongy
sperm are stored in the epididymis - true or false?
true
what is the function of Sertoli cells?
- they function to form the blood-testis barrier - blood seminiferous barrier
- they also function to move the developing sperm towards the lumen.
- provision of nutrients to the sperm
- removal of wastes from developing sperm as well as the removal of excess cytoplasm following cell divisions
- support spermiation - mature spermatid is released from sertoli cells into the seminiferous tubule lumen prior to their passage to the epididymis
what are the 3 main processes which must take place for the production of new sperm
- spermatogenesis
- meiosis
- spermiogenesis
the formation of a new sperm takes around 75 days
what is the purpose of the pampiniform plexus?
temperature regulation.
arterial blood going to the testis enters a dense network of capillaries coming from the testis and epididymis before reaching the spermatic cord. the arterial blood is cooled by venous blood and helps maintain a constant testicular temperature.
suggest 3 factors which may affect spermatogenesis
- temperature - in health should be 2 degrees below body temperature
- endocrine - decreased gonadotrophins and anabolic steroids
- loss of blood-testis barrier - physical damage
- immunological reactions - auto-immune
- environment - occupation, radiation, smoking, alcohol
- medication - chemo, anti-hypertensives, anti-depressants
give some of the general effects of androgens
- deepen the voice
- increase male body hair
- increased sebaceous gland activity
- increase protein anabolism
a surge in Follicular stimulating hormone (FSH) will result in ovulation around 36 hours later. true or false?
false.
there is a surge in luteinizing hormone (LH) 36 hours before ovulation
Where is GnRH released in the body?
the hypothalamus
it will then stimulate the release of LH and FSH from the anterior pituitary
LH and FSH are released from the posterior pituitary gland along with oxytocin. true or false?
false. LH and FSH are released from the anterior pituitary
what are the respective functions of LH and FSH?
LH - maintaining the dominant follicle and induce follicular maturation and ovulation. it is also responsible for stimulating CL (corpus luteum) function
FSH - stimulation of follicular recruitment and development
where is oestradiol released? also, what is its function?
oestradiol is released from the granulosa cells.
it will support female characteristics and reproductive organs. allows for negative feedback control of LH and GnRH except for later follicular phase - positive control of LH surge, stimulates proliferative endometrium, negative control of FSH.
Where is progesterone released?
progesterone is released from the corpus leuteum to maintain secretory endometrium, negative feedback control of the HPO axis
where is the site of sperm production in the testis?
seminiferous tubules.
what is the function of the rete testis?
carries sperm from the seminiferous tubules to the efferent ducts. It is the counterpart of the rete ovarii in females.[1] Its function is to provide a site for fluid reabsorption.
what are the typical LH and FSH levels in males?
LH - 1-8
FSH - 1-11
what is the name of the female hormone that is able to elicit both negative and positive feedback control of its prohormones?
oestrogen
a low oestrogen concentration will result in negative feedback most of the month
however
a high oestrogen concentration will result in positive feedback during ovulation
what are the 4 main ligaments fo the uterus?
broad - mesovarium, mesosalpinx and mesometrium
round
suspensory
ovarian
morning sickness is worse when the mother has twins or has a molar pregnancy. true or false?
true morning sickness heavily correlates with HCG levels
a complication of morning sickness is hyperemesis gravidarum
cardiac output increases during pregnancy - true or false?
true.
this also causes the HR to rise and thus women complain of palpitations. At term, blood flow to the uterus must exceed 1L/min
it is important to note that BP will decrease in the second trimester.
what is the effect of pregnancy on the maternal urinary system?
- increase by up to 50%, GFR will increase similarly.
- serum creatinine and urea will decrease (due to increased GFR and the dilution of increased plasma volume)
- increased urinary stasis and hydronephrosis (but this is physiological) - can lead to an increased risk of hydronephrosis.
there is no change in iron requirements by a woman in pregnancy. true or false?
false.
iron requirements increase by 1g. iron supplements should be given if the Hb drops below 110
WBC increases slights and plasma volume and RBC mass also increase.
platelet count will fall by dilution.
what happens to platelet count in pregnancy?
it will fall - due to dilution.
suggest 5 general health measures women should take before pregnancy
- improve diet - obesity affects rates of miscarriage and still-birth. may be challenging when measuring fundal height (monitoring fetal growth). venous thromboembolic events are also more common in obese patients.
- optimise BMI
- reduce alcohol consumption - associated with foetal abnormalities and learning disability
- smoking cessation
- folic acid - 400 mcg daily
- age - teenagers (lack of support, smoke more, antenatal care may suffer), >40 (more prone to having medical conditions or develop complications such as gestational diabetes and hypertension
- parity
- occupation
- substance misuse - heroin, methadone etc can be addictive for the baby (withdrawal)
what is phenylketonuria?
inborn error of metabolism causing inability to metabolise phenylalanine. this can cause mental development impairment.
women with PKU need to restart low phenylalanine diet to prevent high levels reaching the developing foetus.
what is the most common thyroid disease in pregnancy?
hypothyroidism.
treatment is thyroxine. demand for thyroxine will increase during pregnancy, therefore, doses need to be increased. normal thyroxine levels are needed for foetal brain development.
a 22-year-old woman with type II diabetes presents to your clinic as her, and her partner wishes to have a baby. she is on an oral hypoglycemic.
what risks do you want to inform her of?
should you discontinue her medication?
risks of TIIDM in pregnancy :
- pre-eclampsia
- still-birth
- macrosomic infants (smaller babies)
yes, discontinue her medication - switch her to insulin.
what is the main concern for women with epilepsy when having a child?
effect of anti-epileptic medication on the baby.
sodium valproate is an extremely teratogenic drug
during pregnancy, the examination at 20 weeks, suggest 8 things that the women will be checked for.
- detect evolving hypertension
- urinalysis
- diabetes
- UTI
- abdominal palpation
- assess symphyseal fundal height
- estimate the size of baby
- estimate the liquor volume
- determine the foetal presentation
- listen to the foetal heart
what are 4 important infection screens a mother will receive?
- HIV - maternal treatment and careful planning reduces vertical transmission
- syphilis - easily treated with penicillin
- Hepatitis B - if infected can provide passive and active immunisation for the baby
- Rubella - antibodies indicating immunity due to prior infection or immunisation. rubella can result in mental handicap in the child, blindness, deafness and heart defects.
- MSSU - urinary tract infections
all women will receive the top 4 - with their consent
what are the consequences of syphilis infection in pregnancy?
- growth restriction
- hepato-splenomegaly
- anaemia
- thrombocytopaenia
- skin rashes
what is the treatment for iron deficiency anaemia in pregnant women?
Iron tablets
this is actually very common. blood counts are taken at around 28/40 weeks gestation. additional iron is required to make extra maternal RBCs as normal adaptation of pregnancy and needed by the developing fetus and placenta.
what are the antibodies present in Rhesus disease?
anti-D antibodies are present in Rhesus disease. Women who are rheesus negative are given Anti D IgG prophylactically and after potentially sensitising events.
if a rhesus negative woman is carrying a rhesus positive baby she will develop anti-D antibodies if the fetal RBC enter the maternal circulation. it may result in a miscarriage or ectopic pregnancy etc. antibodies will tend to develop during the first pregnancy.
in subsequent pregnancies, the maternal antibodies will cross the placenta and cause the destruction of the fetal red blood cells cause fetal anaemia. screening can allow identification of women at risk (Rheesus negative women) and give them passive immunity to destroy all fetal RBC in maternal circulation before the maternal immune system has opportunity to be activated and produce its own antibodies.
suggest 3 things that will be checked at a woman’s first baby scan (on the US)
- viability of pregnancy
- multiple pregnancies
- abnormalities incompatible with life.
- Down’s syndrome screening
trisomy of which chromosome causes Down’s syndrome?
trisomy 21.
the incidence of Down’s increases with advancing age and family history
at how many weeks is first-trimester screening carried out?
10-14 weeks gestation.
it will use maternal factors such as:
- serum B-HCG
- pregnancy-associated plasma protein A (PAPP-A)
- fetal nuchal translucency (NT)
other tests include:
- chorionic villi sampling
- amniocentesis
- non-invasive prenatal testing (testing maternal blood for fetal cell DNA)
- alpha feto-protein
what is the purpose of the second-trimester scan?
detecting fetal abnormalities
- 50% with T21 will have a normal detailed USS
- 17% with T18 will have a normal USS
- 9% with T13 will have a normal USS
is the Egg a haploid or diploid cell?
haploid.
progesterone, testosterone and oestrogen are all steroid type hormones. true or false?
true.
where do LH and FSH act?
they both act on the ovaries.
LH and FSH will initiate the growth of new follicles, beginning a new ovarian cycle
the ovaries will then go on to produce steroid hormones - oestrogen and progesterone
oestrogen has positive feedback during days 12-14 but will have negative feedback during most of the cycle.
when in the month roughly does ovulation occur?
ovulation tends to occur mid-month - around day 14.
the corpus luteum is formed after this.
when is the endometrial wall thickest?
the endometrial wall is thickest at day 28 - towards the end of the month but grows from day 5.
at what week of pregnancy is a fetal heartbeat able to be detected?
week 6
once a fetal pole is identified, a crown-rump length (CRL) measurement is made from one end of the embryo to the other.
the length of the embryo closely correlates with the gestational age of the pregnancy and allows an estimated due date (EDD) to be decided upon.
anencephaly is what type of disorder?
neural tube defect.
it results when the vault of the skull fails to develop. the brain is unprotected and becomes worn away - not compatible with life.
what may we look for on the first trimester US scan?
- gestational age
- diagnose miscarriage
- multiple pregnancies (2 fetal poles will indicate twins)
- exclusion of other abnormalities - hydatidiform, ectopic pregnancies (pregnancy outwith the uterus), anencephaly
- evaluation of maternal ovaries
what is the overall incidence of trisomy 21?
1 in 700
what is the simplest screening method for Down’s syndrome?
maternal age
incidences of chromosomal abnormalities increases with maternal age.
when is the CUB (combined US and biochemical) screen test carried out and what does it test for?
between 11 and 14 weeks.
if a patient books after this 14 weeks they can still receive a screening in the form a blood test for 4 serum markers between weeks 15 and 20:
- AFP
- total HCG
- unconjugated oestriol
- inhibin
if the patient has levels indicating a high risk then it will necessitate an invasive test to be performed such as an amniocentesis
suggest 3 measurements which could be taken from a mother that would aid in the diagnosis of a fetal chromosomal abnormality
- HCG
- PAPP-A
- nuchal translucency - crown-rump length (CRL)
- AFP is used to screen for neural tube defects
( a serum AFP of >2 MoM - multiples of median - is considered abnormal. an AFP test is offered to all women.
what is the aim of a second-trimester scan?
identify fetal structural abnormalities
what is the function of the third-trimester scan?
ensuring fetal well-being
in the 3rd trimester scan, there is no routine US as there is no evidence of any benefit. scans are indicated if the baby feels small or large for their dates. standard measurements involve the head, abdomen and femur.
what conditions are tested for in the neonatal blood spot test?
- sickle cell
- PKU
- hypothyroidism
- cystic fibrosis
in Tay Sachs disease, what is deficient?
Tay Sachs is a lysosomal storage disease in which hexosaminidase A deficiency results in the build-up of lipid GM gangliosides
there is progressive neurological deterioration and is fatal by 3-5 years old.
name the 4 different kinds of cells present in the testis
- interstitial (Leydig cells)
- Sertoli cells - support the sperm-producing cells and produce inhibin
- germ cells - produce sperm
- seminiferous tubules (containing sustentacular cells and spermatids
where are LH and FSH released from in the body?
they are released by the anterior pituitary
what are the respective functions of LH and FSH?
- LH will act on Leydig cells (interstitial cells ). this will go on to aid in the formation of androgens necessary for secondary sex characteristics (testosterone)
- FSH will act on the spermatogonia in the seminiferous tubules of the testes leading to spermatogenesis. FSH will act on the Sertoli cells
what does oligozoospermia mean and how does this differ from azoospermia?
a low concentration of sperm is oligozoospermia.
azoospermia means no sperm
each cycle of spermatogenesis will lead to the maturation of how many sperm cells?
4
In embryology, during which weeks does gastrulation, neurulation and somite formation take place?
during weeks 3.
what are the 3 embryological renal structures that from the genitourinary system?
- pronephros
- mesonephros
- metanephros
(the cloaca will divide to form the rectum and anteriorly the urogenital sinus)
in males, what embryological structure does the urinary bladder form from?
the urogenital sinus
the caudal end of the urogenital sinus will form the urethra and prostate. in males, the mesonephric duct is responsible for the production of the sex organs while the paramesonephric duct degenerates but…
in females, the mesonephric duct will degenerate and the paramesonephric duct will form the fallopian tube, uterus and cervical part of the vagina. the urogenital sinus will form the bladder and the lower part of the vagina.
what protein is responsible for transforming the indifferent gonads into Sertoli cells?
testis-determining factor (TDF) is the protein and it is encoded by the SRY (sex determining region Y). expression of SRY will form the Sertoli cells.
The Sertoli cells will then secrete MIS (Mullerian-inhibiting substance). MIS promotes the formation of the Leydig cells. after the secretion of MIS then the paramesonephric duct will degenerate.
Leydig cells are responsible for producing testosterone. remember that the Leydig cells are not formed from the epithelium
name 3 complications of undescended testes
- infertility
- malignant transformation (germ cell tumour)
- testicular torsion
management of undescended testes is with an orchiopexy.
what is the effect of pregnancy on the renal system?
- dramatic dilation of the urinary collecting system
- increased renal plasma flow
- GFR increases and creatinine clearance will increase
- protein excretion is increased and microscopic haematuria may be present
- 80% of women develop oedema and glycosuria is common
- urate increases with an increasing gestation
- . urea and creatinine levels will decrease
pregnancy will increase a woman’s platelet count - true or false?
false - platelet count will decrease
WCC, on the other hand, will increase.
when taking an Obs and Gynae history - what are 4 things that you should not forget to inquire about?
- LMP
- Cycle
- contraception/sexually active
- last smear test
suggest 4 common conditions to look out for when taking an Obs and Gynae history
- menorrhagia
- prolapse
- pelvic pain
- early pregnancy bleeding
suggest 4 things we are looking for when performing a vaginal exam
- position
- size
- mobility
of the uterus
- adnexal masses
- tenderness
- cervical excitation
what is the most common kind of contraception?
the combined oral contraceptive pill (COCP)
what are the different methods of using the progesterone only pill?
- pill
- injectable
- implant
all methods of contraception should be 100% reversible - true or false?
true. they should also be 100% effective however no options are actually 100%. the best bet is a vasectomy followed by an implant.
what is the safest type of contraception?
vasectomy followed by an implant
condoms are generally good protection against STIs. Name 2 viruses that condoms don’t protect against
- HSV
2. HPV
what are the two main hormone components of the oral contraceptive pill?
- ethinyloestradiol (EE)
- synthetic progesterone (progestogen)
the COCP is usually taken for 21 days and then there is a pill free week
what is the mode of action of the combined oral contraceptive pill
- it will prevent ovulation by removing the surge of FSH and LH.
2, it will prevent implantation by providing an inadequate endometrium
- it inhibits sperm penetration of the cervical mucus by altering the quality and character of the mucus
suggest a risk associated with using the COCP (combined oral contr…)
- it increases the risks of developing a VTE
- increase in risk of ischaemic stroke
- breast cancer risk
- cervical cancer
suggest some benefits of using the COCP (combined oral contra…)
- reduction in functional ovarian cysts
- 50% reduction in ovarian and endometrial cancer
- improvement in acne
- reduction in benign breast disease, RA, colon cancer
- reduction in osteoporosis
suggest 4 factors aside from the COCP for increased risk of developing a serious VTE
- major surgery and immobility
- thrombophilias
- family history of VTE in those who are aged 45 and younger
- BMI over 30
- underlying vascular disease
- post-natally within 21 days
when using the progesterone only pill (POP) how many days off should you take?
none. there are no pill-free days with the progesterone only pill.
the maximum effect of POP is 48 hours after ingestion.
what is the mode of action of the depot contraception method?
the depot - depot medroxyprogesterone acetate (Depo-Provera) will act by preventing ovulation and altering cervical mucus making it hostile to sperm. it prevents implantation by rendering the endometrium unsuitable.
it is very useful for those who are forgetful - given as an IM injection once every 12 weeks and doesn’t contain oestrogen
what are some of the side effects of using the depot as contraception?
- delay in return to fertility
- reversible reduction in bone density
3 problematic bleeding - weight gain
the marina contraception acts by thinning the endometrium - true or false?
true
it is composed of copper which creates a toxic environment for fertilisation
what is the most effective option for emergency contraception?
CU-IUD (copper intra-uterine device )
it can be used up to 72 hours of unprotected sex
levonorgestrel and newer options are available that cover up to 120 hours. it is less effective however than ongoing contraception.
what is a vasectomy?
a vasectomy is the permanent division of the vans deferens under local anaesthetic.
there is no evidence of a reduction in testosterone and semen will remain the same colour and volume. there is no evidence that vasectomy predisposes to testicular cancer or prosthatic cancer
males that are about to receive a vasectomy should be informed of which 3 things?
- low failure rate in terms of post-procedural pregancies
2. there is less risk associated with the procedure than sterilisation carried out by laparoscopy and laparotomy
at what stage does a termination of pregnancy need to be referred to England?
after 20 weeks.
however, remember that the earlier the procedure, the less the complications.
what are the 3 main types of emergency contraception?
- ellaone (ulipristal cetate) should be given within 120h of unprotected sex. efficacy is not reduced by obesity but levonorgestrel may be)
- levonelle
- IUD - copper coil
suggest 2 forms of non-hormonal contraception
- condoms
- IUD
- diaphragms
- caps - diaphragm stretching from pubic bone to posterior fornix (fit over the cervix)
suggest 4 types of hormonal contraception
- OCP
- contraceptive patch (transdermal)
- vaginal ring
- injection (depot)
suggest 4 risks of using an intrauterine contraceptive device (IUCD)
- they may be expelled
- associated with pelvic inflammatory disease
- risk of ectopic pregnancy
- can cause dysmenorrhoea and menorrhoea
what are 4 contraindications for using an IUCD (intrauterine contra….)
- active pelvic infection/STD
- pregnancy
- allergy to copper
- Wilson’s disease
- heavy painful periods
- gynae malignancy
IUCD will tend to last around 5 years.
can a woman use an IUCD (intrauterine contrac…)if she is pregnant
yes. but do warn the patient about spotting +/- heavy bleeding for the first few weeks following insertion.
what should you discuss with the patient before offering emergency contraception? suggest 6 things
- history of LMP
- normal cycle
- number of hours since unprotected sex
- contraindications to later COCP
- check BP
- explain teratogenicity has not been proven
- discuss future contraception
- offer an infection screen to cover HIV
- offer a follow up in 3-6 weeks if coil is inserted
how long does the patient have to use levonorgestrel after having unprotected sex?
72h
suggest 4 reasons for not using combined hormonal contraception
- venous disease - current or past VTE or giving sclerosing treatment for varicose veins
- arterial disease - avoid if valvular or congenital heart disease
- liver disease- hepatitis, cirrhosis etc
- cancer - breast cancer
- previous pregnancy complications -pruritis, obstetric cholestasis, chorea
- hepatic enzymatic drugs - avoid if taking rifampicin or rifabutin
a migraine with stroke is an absolute contraindication for combined oral contraceptive pill use - true or false?
true
suggest 4 short-term side effects of combined hormonal therapy use
OESTROGENIC
- breast tenderness
- nausea
- cyclical weight gain
- bloating
PROGESTOGENIC 1. mood swings 2. PMT 3. vaginal dryness 4. sustained weight gain decreased libido
HEADACHE
BREAKTHROUGH BLEEDING
suggest 4 risks of using combined hormonal contraception
- VTE risk is doubled
- ischaemic stroke
- breast and cervical cancer
- mood changes
suggest 4 benefits to using combined hormonal therapy
- improvement in acne
- decreased menorrhagia
decreased ovarian, endometrial and bowel cancer
4, decreased menopausal symptoms
what is the method of action of progesterone-only contraceptives?
- thicken cervical mucus
- reduce receptivity of the endometrium to implantation
- inhibit ovulation
they also have advantages of reducing pelvic infection and are used where oestrogen-containing contraceptives are contraindicated.
suggest 4 reasons to avoid a progesterone-only contraception method
- current breast cancer
- trophoblastic disease
- liver disease
- new symptoms or diagnosis of migraine with aura/IHD/stroke
- avoid if SLE with antiphospholipid antibodies
- undiagnosed vaginal bleeding should be investigated before starting
name 4 side effects of using the progesterone only pill
- higher failure rate than COCP
- menstrual irregularities
- increased risk of ectopic pregnancy
- functional ovarian cysts
- breast tenderness
- depression
- acne
- reduced libido
- weight change `
how long will one progesterone implantation give contraception for?
3 years
it has no impact on bone density
in contraception, what is meant by ‘sterilisation’
sterilisation is the permanent, irreversible contraception.
reversal i sonly 50% in either sex and is never funded by the NHS.
a Filshie clip is used for females.
vasectomy is safe than female sterilisation
prostaglandins and oxytocin will increase intracellular free calcium and hence stimulate uterine contraction for labour - true or false?
true
when does the first stage of labour end?
full dilatation
the first stage begins with regular contractions and ends in full dilatation
when does the second stage of labour end?
The second stage starts with full cervical dilatation and ends with delivery of fetus
what is the third stage of labour?
The 3rd stage is the period in between delivery of fetus and delivery of placenta and fetal membranes.
suggest 4 reasons for a woman to have induced labour
induction of labour is when an attempt is made to instigate labour artificially using medications and/or by artificial rupture of membranes (performing an amniotomy)
- diabetes
- post-dates
- maternal health problem that necessitates planning of delivery
- fetal reasons (oligohydramnios)
whta scoring system is used to clinically asses the cervix for cervical ripening?
the bishops score
the higher the score the more progressive change there is in the cervix and this indicates that induction is likely t be successful.
a lower score indicates that induction may be more likely to fail but can still be attempted once the cervix has dilated and effaced, an amniotomy can be performed
what are the parameters of the Bishops score?
- deliation (cm)
- length of cervix (effacement) (cm)
- position - posterior, mid or anterior
- consistency - firm, medium or soft
- station (cm)
assuming that the cervix is not dilated or has not effaced (a low Bishops score) what methods can be taken to bring the woman higher up on the scale?
- vginal prostaglanings
2. once cervix has dilated and effaced, an amniotomy can be performed
what is an amniotomy?
artificial rupture of the fetal membranes (waters) usually using a sharp device.
once amniotomy is performed, IV oxytocin can be used to achieve adequate contractions - aim for 4-5 in 10 mins
what are the 3 P’s of labour?
P - power (contraction)
P - passages (pelvic tract)
P - passenger (baby)
what does cephalopelvic disproportion (CPD) mean?
the fetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born. in these circumstances the babies head becomes compressed and caput and moulding develop
aside from cephalopelvic disproportion, (CPD) name another reason why there may be inadequate progress in pregnancy
- malposition - foetal head is in the incorrect position for labour and relative CPD occurs.
the two main presentations are occipito-posterior and occipito-transverse - malpresentation (transverse, shoulder, hands, breech, oblique lies)
- inadequate uterine activity - give synthetic IV oxytocin after excluding obstruction
- ovarian cyst/fibroid
- foetal distress
babies can’t be born if they are in the position
left occipito transverse or
right occipito transverse
true or false?
true
suggest 3 things to check foetal well-being in labour
- intermittent auscultation of the fetal heart
- cardiotocography (CTG) - when there are too many contractions to keep up
- fetal blood sampling - when suspicious or pathological CTG. pH will give a measure of likely hypoxaemia - are they getting enough oxygen
- fetal ECG
suggest some complications of performing a C-section
- infection
- bleeding
- VTE
- visceral injury
what is a very serious complication that can occur in the 3rd stage of labour?
retained placenta
for post-partum haemorrhages what are the 4Ts?
tone
trauma
tissue
thrombin
what is primary postpartum haemorrhage?
blood loss >500ml within 24 hours of delivery
what is secondary postpartum haemorrhage?
blood loss>500 from 24 hours postpartum to 6 weeks
this can be caused by
- retained tissue
- endometritis (infection)
- tears
- trauma
suggest 5 common postnatal problems women have
- postpartum haemorrhage
- venous thromboembolism
- sepsis
- psychiatric disorders of the puerperium
- preeclampsia
what are the causes of primary postpartum haemorrhage
- uterine atony
- local causes such as traumatic tears to perineum/vagina/cervix
- retained tissue/placenta
- coagulopathy
- 4Ts
tone
trauma
thrombin
tissues
what are 3 causes of secondary PPH (postpartum haemorrhage
- retained tissue
- endometritis
- tears/trauma
Women with DVT and PE can be relatively asymptomatic compared to their non-pregnant counterparts. suggest 3 reasons why you would be suspicious
- unilateral leg swelling and/or pain
- SOB
- chest pain
- unexplained tachycardia
why would you give LMW heparin to a woman you are concerned has VTE rather than warfarin?
warfarin is teratogenic
what investigations would you do to investigate VTE in a woman?
- doppler
- ECG
- CXR/VQ
- CTPA
treatment is with low molecular weight heparin
what should be done if you suspect a pregnant woman has sepsis?
- IV antibiotics
- full septic screen
- blood cultures
- LVS
- MSSU
- wound swabs - IV fluids
Almost half of women who died between six weeks and one year after pregnancy died from mental-health related causes
true or false?
false.
1/4 women who died between 6 weeks and 1 year after pregnancy died from mental-health related causes.
name 2 common psychiatric problems affecting pregnant women
- postnatal depression
2. puerperal psychosis
what is the function of progesterone?
progesterone will turn the endometrium into the decidua basalis
- increased vascularity between the glands and vessels
- stromal cells enlarge and become pro-coagulant (stops them bleeding).
- thickening of the endometrium
- increased vascularity if the cells
outside of pregnancy there is a monthly shedding occurs from the endometrium/decidual wall lining
what is the name of the cells that produce beta-hCG in the embryo?
trophoblasts
the b-hCG will act on the corpus luteum in the ovary. its function is to stimulate the corpus luteum to produce progesterone which stops the decidua from shedding
suggest 3 factors which may cause a miscarriage
- chromosomal abnormality
- infection
- maternal issues - ill-health, trauma, hormonal
suggest one medical treatment for an ectopic pregnancy
methyltrexate
typical presentations of an ectopic include
- raised b-hCG
- thickened lining of endometrium
- expanded fallopian tube
where is the most common site for ectopic pregnancies?
the fallopian tubes
what is the most common cause of a molar pregnancy?
2 sperm fertilize one egg
Molar pregnancies result in an imbalance in methylated genes (they become switched off).
Molar pregnancy under microscopy will show some enlarged chorionic villi with abundant trophoblasts.
A molar pregnancy has 2 lots of dad’s genes. This is a problem because in the testis, dad has inactivated several genes by adding methyl groups to stretches of DNA
A molar pregnancy is a form of precancer of trophoblast cells. If it persists can (rarely) give rise to a malignant tumour called choriocarcinoma.
what is the most common structural abnormality found in those with trisomy 21
duodenal atresia
TRisomy 21 can be confirmed with amniocentesis and can be first seen with nuchal thickening on an US
name 3 complications of diabetes in pregnancy
- malformations
- huge babies that obstruct labour (CPD?)
- intrauterine death
- neonatal hypoglycaemia
what is acute chorioamnionitis?
an ascending infection causing acute inflammation
- neutrophils present in membranes, cord and fetal plate of the placenta.
- bacteria are typically perineal/perianal flora (e.coli) which ascend vagina and get into the amniotic sac.
- neutrophils produce a cytokine storm which activates some brain cells, which then get damaged by normal hypoxia of labour
in the cervical spine, there are 8 vertebral bodies and 7 spinal nerves - true or false?
false - there are 7 vertebral bodies ad 8 spinal nerves
which myotome is responsible for the abduction of the arm (lateral deltoid)
C5
which myotome is responsible for the flexion of the hip?
L2
tetraplegia is caused by a lumbar spinal cord fracture - true or false?
false - it is caused by a cervical fracture
there is also the risk of respiratory failure due to the loss of innervation of the diaphragm (C3-5)
what is Brown-Sequard syndrome?
follows the hemi-section of the cord and is usually brought on by penetrating injuries.
patient’s will experience paralysis on the side affected (corticospinal) with a loss of proprioception and fine discrimination (dorsal columns). pain and temperature loss on the opposite side below the lesion is also seen (spinothalamic tract)
what is spinal shock?
transient depression of cord function below the level of an injury.
the patient will experience flaccid paralysis and areflexia. it can last several hours to days after injury
when taking a history from a woman regarding infertility, suggest 7 things you will want to discuss with her
- learn this well for OSCE and system exam
- age and duration of subfertility
- any previous pregnancies and does partner have children
- menstrual history
- regularity, pelvic pain, history of STI’s, previous surgery (tubal or ectopic for pregnancy)
- smoking reduces fertility as does drinking
- medical history and drug history to optimise both.
- frequency of sexual intercourse and any problems during sex including erectile dysfunction
- history of undescended testes, mumps
- duration of infertility
- previous contraception
- fertility in previous relationships
- menstrual history
- medical and surgical history
- sexual history
- previous investigations
- psychological assessment
what is hypospadia?
this is a condition in which the opening of the urethra is on the underside of the penis
genetic conditions such as Klinefelter’s (47 XXY) syndrome can also affect the size of the testis
suggest 3 tests that may be carried out at a fertility clinic
- pelvic US
- semen analysis
- tubal patency test
what are 3 common presentations of polycystic ovarian syndrome?
repeat this question as many times as possible - it is known as the Rotterdam criteria (2/3 need to be present for the diagnosis of PCOS)
- androgen excess
- hirsutism
- abnormal testosterone level
- polycystic ovaries
- found with US - infrequent periods
- anovulation
for ovarian disorders, weight plays a big role ion treatment - encourage the patient to achieve a BMI of between 18 and 35
suggest 5 methods of ovulation induction
- clomiphene citrate (binds to oestrogen receptors and thus tricks the hypothalamus into believing the body is in a hypoestrogenic state - triggering anterior pituitary to release more FSH
it also has vasomotor and visual side effects.
- gonadotrophins - used in specialist centre for clomiphene resistant PCOS or low oestrogen with normal FSH.
- Laparoscopic ovarian drilling - only to be used in women with PCOS
- weight loss or gain
- metformin
what does amenorrhoea mean?
amenorrhoea means the absence of menstrual periods
what investigations do you want to carry out for a patient presenting with azoospermia?
- history
- examination
- FSH, LH, karyotype and PRL
- CF screen
suggest the 4 most common factors causing sub-fertility
- male factors:
- semen abnormality (alcohol, nicotine, varicocele and cancer)
- azoospermia
- immunological
- coital dysfunction
- anovulation - can be caused by premature ovarian failure, turner’s syndrome, surgery, chemo etc
- unexplained
- endometriosis
- tubal factor
suggest 4 primary care investigations of subfertility
- chlamydia screening
- baseline hormonal profile (day 2-5 FSH and LH)
- TSH, prolactin, and testosterone and rubella status (vaccinate if not immune)
- mid-luteal progesterone level to confirm ovulation
- semen analysis - repeat in 3 months if abnormal
suggest 4 secondary care investigations of subfertility
- transvaginal sonography (TVS) - ruling out adnexal masses, submucosal fibroids or endometrial polyps, or help confirm PCOS - polycystic ovarian syndrome
- hysterosalpingogram (HSG) to demonstrate uterine anatomy and tubal patency.
may cause period-like cramping and tubal spasm, giving false positive - only do when the chlamydia swabs are negative - hysterosalpingo-sonography uses US contrast and TVS
- laparoscopy and dye test - gold standard test for assessing tubal patency
suggest 5 factors that may effect the success rates of IVF
- age
- duration of subfertility
- previous pregnancy (higher success rate)
- smoking
- high BMI (low success rate)
- low anti-mullerian hormone (AMH) predict a poorer response
in males, where does spermatogenesis take place
seminiferous tubules
in males, what is the function of LH?
in males, the function of LH is to stimulate Leydig cells to produce testosterone.
the testosterone and FSH will stimulate Sertolli cells to produce essential substances for metabolic support of germ cells and spermatogenesis
plasma FSH is raised in testicular failure - true or false?
true
what tests should you perform on a male experiencing subfertility?
- plasma FSH
- testosterone and LH (androgen deficiency)
- karyotype - to exclude 47XXY
- CF screening (CBAVD - Congenital Bilateral Absence of the Vas Deferens)
main treatment (aside from lifestyle measures) is ICSI
what are the 8 stages of normal labour/birth
- engagement
- descent
- flexion
- internal rotation
- extension
- restitution and external rotation
- expulsion
what stage of labour involves pushing?
stage 2
what are the 3 phases during stage 1 of labour?
- latent phase (0-3cm)
- active phase (3-7cm>)
- transition phase (7-10cm>)
what is the difference in function between the chorion and the amnion
the chorion is responsible for providing the baby with nutrition
the amnion is responsible for providing the baby with warmth and protection
suggest 2 complications of having monoamniotic, monochorionic babies
- placental insufficiency of one of the babies
- cord entanglement
- twin-twin transfusion syndrome
- malpresentation
- hypoxia of the second baby
what is an induction of labour?
this is when an attempt is made to instigate labour artificially using medications and/or by artificial rupture of the amniotic membranes - amniotomy
what is the name of the score used to check cervical ripening?
the bishops score
the higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful. a lower score indicates that induction is likely to take longer and may occasionally fail but can still be attempted
what are the 5 factors considered in the bishop’s score?
- dilatation (cm)
- length of cervix (effacement)
- position
- consistency
- station
suggest 3 absolute contraindications of labour
- fetal lie is not longitudinal (you don’t intentionally want to encourage the onset of labour with an abnormal lie)
- known pelvic obstruction ( a tumour or ovarian cyst)
- placental praevia - need C-section due to placental position
- cardiac disease
- fetal distress
relative contraindications include:
- previous c section - uterus has a scar which is at risk of dehiscence if you artificially stimulate labour
- asthma - can cause respiratory smooth muscle contraction
what are the main methods of labour induction?
- oxytocin
- initiates uterine contractions by attaching to the uterine oxytocin receptors; increases the frequency and force of contractions.
- oxytocin is released by the posterior pituitary gland
- women need CTG because there is a risk of uterine hypertonicity
- may lead to hypotension and hyponatraemia
- prostaglandins
- eicosanoids (arachidonic acid derivation)
- they encourage cervical dilatation and effacement - ripening the cervix so it can be used in the induction of labour. the analogues are inserted PV and placed in the posterior fornix
- can lead to N&V, bowel upset, pyrexia and hypotension. be sure to continuously monitor the fetal heart (CTG)
what is meant by augmentation of labour?
augmentation of labour is required when contractions reduce in frequency or strength in active labour even after the spontaneous onset of labour.
what is the pharmacological management of the third stage of labour
- syntocinon - synthetic oxytocin and can cause uterine contractions
syntocinon can also be given as prophylaxis in post partum haemorrhage (PPH) in women where ergometrine is contraindicated (women who can’t receieve syntometrine)
- syntometrine - a mix of oxytocin and ergometrine (only given as M)
suggest some treatment options for primary post-partum haemorrhage (PPH)
- physical
- bimanual compression
- rubbing up a contraction - surgical
- pharmacological
- syntocinon: causes uterine contractions to treat/prevent PPH
- syntometrine
- carboprost - prostaglandin that causes uterine contractions
- misoprostol
- tranexamic acid - antifibrinolytic
what are the general actions of tocolytic drugs?
they function to inhibit uterine contractions
they can be used:
- to facilitate the transfer of a woman in labour to appropriate hospital/appropriate neonatal unit
- given to allow steroids enough time to work
- fetal distress/emergency CS/obstructed labour/hypertonic uterus causing fetal distress
what are the main recommended drugs for tocolysis?
- oxytocin receptor antagonist (atosiban)
- CCB - nifedipine
- B2 agonist - terbutaline, salbutamol (relaxation of smooth muscle)
- indometacin
what are the safest antihypertensives given to women during pregnancy?
- methyldopa
- hydralazine
- combined alpha and beta blockers - labetalol
labetalol is actually the first line treatment for hypertension (it is a combined alpha and beta blocker)
but be careful as it can be contraindicated in asthmatics and in some cardiac conditions such as bradycardias and cardiac failure.
what is the main drug given to women with symptomatic pre-eclampsia or thought to be at risk of eclampsia?
IV magnesium sulphate
ACEI and ARB’s are contraindicated in pregnancy - true or false?
true
spironolactone is also contraindicated
diclofenac and ibuprofen are contraindicated as analgesics
NSAIDs can cause closure of the ductus arteriosus
give 3 examples of simple analgesia and 3 examples of non-pharmacological analgesia
Non-pharmacological
- breathing exercises
- aromatherapy
- warm baths
- TENS therapy
Simple analgesia
- paracetamol
- codeine
- aspirin (avoid in labour as may increase risk of bleeding
- entonox (gas and air) - nitrous oxide
- opiates
- local anaesthetic
suggest 5 signs of local anaesthetic toxicity
- perioral tingling
- seizures
- confusion
- paraesthesia
- light-headedness
- drowsiness
suggest 4 contraindications for epidural anaesthesia
- thrombocytopaenia
- coagulopathy
- raised ICP
- local sepsis
- septic shock
- allergy to local anaesthetic
- lack of patient consent
- anticoagulants within 12 hours of insertion
suggest 4 disadvantages or risks of using an epidural anaesthetic
- can fail to provide adequate analgesia
- causes hypotension
- reduces woman’s mobility
- epidural haematoma
- risk of respiratory depression
- risk of neurological deficits
what are some surgical interventions for PPH
- intrauterine balloon tamponade
- interventional radiology
- B-Lynch suture
- hysterectomy
- fluid replacement
describe cord prolapse and its management
cord prolapse is the descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of a ruptured membrane
- call for help
- replace the cord into the vagina
- perform a digital elevation of the presenting part
- catheterise and fill bladder to elevate the presenting part
- encourage the mother to adopt the Knee-chest or left lateral position with raised hips
. consider tocolysis - arrange a category 1 CS
what is primary infertility
Primary infertility refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods
Secondary infertility refers to couples who have been able to get pregnant at least once, but now are unable
how do you define infertility
Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse
What do you mean by irregular periods?
Oligomenorrhea is the medical term for infrequent, often light menstrual periods.
Metrorrhagia is the term used for irregular menstruation that occurs between the expected menstrual periods
How do you diagnose PCOS
Diagnosis is made using the Rotterdam criteria (2/3 must be present)
- Polycystic ovaries – 12 or more follicles
- anovulation/oligo-ovulation
- clinical/biochemical signs of hyperandrogenism
also try to exclude other causes of irregular cycles before making diagnoses such as thyroid dysfunction, hyperprolactinaemia and androgen-secreting tumours
Difference between PCO and PCOS
- PCO refers to an ultrasound scan image of the ovaries that appear to be polycystic (ovaries containing high density of partially mature follicles)
PCOS is a metabolic condition that may or may not come with having polycystic ovaries - if a woman has irregular periods and an increased male hormone she could have PCOS without her ovaries being polycystic. However, other conditions such as thyroid or pituitary dysfunction need to be excluded before PCOS diagnosis is made.
PCO is a normal variant of a woman’s ovary, whereas PCOS is a diagnosed condition with short and long-term consequences - Women with PCOS should be aware of the associated risk which may include: diabetes, pregnancy complications (ie. gestational diabetes), cardiovascular disease, obesity and endometrial cancer. Women with PCO do not have the same risk profile
- Conception with PCO may not be difficult, however, women with PCOS may have problems getting pregnant. In addition, women with PCOS have a higher miscarriage rates
- Women with PCO may still possess the hormonal balance and continue to ovulate regularly. Whilst in PCOS, the hormonal balance is distorted which interferes with ovulation. In a large proportion of these women, the mechanism is linked to high insulin release that stimulates the production of androgens from the ovary disturbing ovulation
What is the first line of management of PCOS?
- Weight loss and exercise are the mainstays of treatment (increase insulin sensitisation).
- Smoking cessation. Find and treat diabetes, hypertension, dyslipidaemia and sleep apnoea.
- Metformin – improves insulin sensitivity and may improve menstrual disturbance and ovulatory function but won’t effect hirsutism or acne.
- Clomiphene citrate – will induce ovulation but there is a risk of multiple pregnancy and ovarian cancer.
- Ovarian drilling
- The COCP – controls bleeding and reduce risk of unopposed oestrogen on the endometrium
How will you investigate PCOS?
PCOS is a diagnosis of exclusion.
Other causes of irregular cycles should be excluded before the diagnosis is made if there is clinical suspicion e.g. – thyroid dysfunction, hyperprolactinaemia, congenital adrenal hyperplasia, androgen-secreting tumours, and Cushing’s syndrome. If clinically hyperandrogenic and total testosterone is high then check 17-hydroxyprogesterone and exclude androgen-secreting tumour.
If a woman’s BMI was normal what can you do for anovulation
MEDICAL
Most cases of dysfunctional uterine bleeding respond to either oral or IV oestrogen. Because of the menstrual irregularities associated with anovulation, anaemia is a concern and must be treated with allogenic blood transfusion if blood parameters fall below critical levels. IV oestrogen or high-dose COCP may be needed to terminate the acute bleeding episode
Dilation and curettage should never be the first line treatment.
SURGICAL
Ovarian drilling and ovarian wedge resection are other surgical modalities used in the treatment of anovulation due to PCOS, with a spontaneous ovulation rate of more than 80% after the procedure.
DIET
ACTIVITY
How did you diagnose tubal block
- Hysterosalpingogram – demonstrates that the tubes are open when radiopaque dye spills into the abdominal cavity
- Sonography will demonstrate tubal abnormalities such as hydrosalpinx (indicative of tubal occlusion)
- Laparoscopy – status of tubes can be inspected and a dye can be injected. Laparoscopic chromotubation is the gold-standard of tubal evaluation
what are the implications of a tubal block?
- Female infertility – blocked tubes are unable to let the ovum and the sperm converge, thus making fertilisation impossible
what are the causes of fallopian tube block?
- Infection – pelvic inflammatory disease (PID)
- Endometritis – infections after childbirth and intraabdominal infections including appendicitis and peritonitis
- The formation of adhesions may not necessarily block a fallopian tube, but render it dysfunctional by distorting or separating it from the ovary. Women with distal tubal occlusion have a higher rate of HIV infection
- Fallopian tubes may be blocked as a method of contraception. In these situations, tubes tend to be healthy and typically patients requesting the procedure have had children. Tubal ligation is considered a permanent procedure
what treatments are available for a tubal block?
TUBOPLASTY – fallopian tubal surgery – goal is to restore patency to the tubes and thus possibly normal function
a. Fimbrioplasty – repairing the fimbriated end of the tubes
b. Lysis of adhesions
c. Salpinostomy – creating an opening for the tube
IN VITRO FERTILIZATION
ALTERNATIVE MEDICINE
describe the differences between IVF and tubal surgery
While IVF therapy has largely replaced tubal surgery in the treatment of infertility, the presence of hydrosalpinx is a detriment to IVF success. It has been recommended that prior to IVF, laparoscopic surgery should be done to either block or remove hydrosalpinges
what is IVF?
In vitro fertilisation is a process by which an egg is fertilised by sperm outside the body: in vitro. IVF is a major treatment for infertility when other methods of assisted reproductive technology have failed. The process involves monitoring a woman’s ovulatory process, removing ovum or ova (egg or eggs) from the woman’s ovaries and letting sperm fertilise them in a fluid medium in a laboratory
What is azoospermia?
Azoospermia is the medical condition of a man whose semen contains no sperm
what are the causes of azoospermia?
PRETESTICULAR
- Inadequate stimulation of normal testis and genital tract. Typically, FSH is low
- Hypopituitarism
- Hyperprolactinaemia
- Exogenous FSH suppression by testosterone
- chemo
TESTICULAR
- testes are abnormal, atrophic, absent and sperm production is severely disturbed/absent.
- FSH is high as the feedback loop is interrupted.
- Cryptorchidism
- Klinefelter’s syndrome
POSTTESTICULAR
- Sperm are produced but are not ejaculated. Main cause is a physical obstruction of the post testicular genital tracts.
- Vasectomy
- CF
UNKNOWN
what is the general outline of a history for a male with azoospermia - what questions will you ask in the history
- General health
- Sexual health
- Past fertility
- Libido
- Sexual activity
- Drug history
a. 5ASA inhibitors (sulfasalazine)
b. Alpha-blockers
c. 5ARIs
d. Chemo
e. Pesticides
f. Weed, alcohol excess
what investigations would you like to carry out for azoospermia
- Transrectal ultrasound (TRUS)
- Genetic testing for CF
- Levels of FSH and LH and gonadotrophins
- Urine test for semen (retrograde ejaculation)
what treatments are available for azoospermia?
- Treatment of hyperprolactinemia
- Stop androgen consumption
- IVF : ICSI
- Testicular sperm extraction (TESE)
what is unexplained infertility?
Unexplained infertility is infertility that is idiopathic in the sense that its cause remains unknown even after an infertility work-up, usually including semen analysis in the man and assessment of ovulation and fallopian tubes in the woman
what are the treatment options for unexplained infertility?
- Ovarian stimulation
a. Clomiphene citrate
b. Anastrozole
c. letrozole - Intrauterine insemination (IUI)
- Intracervical insemination (ICI)
- In vitro fertilization (IVF)
What are the success rates of IVF?
IVF achieves a live birth rate approximately 2-3 times greater than ovarian stimulation combined with IUI (intrauterine insemination)
Suggest 4 reasons why women may be on medications when they are pregnant
- hypertension
- asthma
- epilepsy
- migraine
- mental health disorders (including depression and anxiety)
- long term anti-coagulant use (for atrial fibrillation)
what are the four basic kinetic processes?
- absorption
- oral route (consider morning sickness
- IM route (blood flow increased so absorption may also increase)
- inhalation (increased cardiac output and decreased tidal volume - distribution
increased plasma volume and fat increases distribution. decreased concentration of plasma proteins so fraction of increased drug increases.
- metabolism and elimination
oestrogen and progestogens have an affect on metabolism
- excretion
GFR is increased by 50% leading to an increased excretion of many drugs.
what are the general functions of the placenta?
- provide nutrients to the fetus
- attach the fetus to the uterine wall
- allows fetus to transfer waste products to the mother’s blood (CO2, urea)
- metabolism of certain drugs
what are 4 factors that determine placenta transfer of molecules
- size
- electrical charge (non-ionized will cross)
- protein binding
- lipophilicity (high lipophilicity will increase the placental transfer
when do teratogenicity and fetotoxicity mostly take place?
teratogenicity will take place during the first trimester
fetotoxicity will mainly occur in the second and third trimester`
when are fetuses at greatest risk of fetal abnormlaties?
organogenesis (3-8 weeks). this can occur by many different mechanisms:
- folate antagonism - this is a key process in DNA formation and new cell production
- the main drugs affected here are methotrexate and trimethoprim as well as phenytoin, valproate and carbamazepine - neural crest cell disruption
this mainly includes retinoid drugs - aortic arch anomalies,, ventricular septal defects, craniofacial malformations, oesophageal atresia etc
- endocrine disruption - sex disruption
- oxidative stress
- vascular disruption
- specific receptor (enzyme mediated teratogenesis
drugs which inhibit/stimulate enzymes to produce therapeutic effects may also interact with specific receptors and enzymes damaging fetal development.
fetotoxic drugs will have a toxic effect on the fetus later on in pregnancy (2nd and 3rd trimester). name 4 of the possible issues that may arise
- growth retardation
- structural abnormalities
- fetal death
- functional impairment
- carcinogenesis
what are the side effects of anticonvulsants on the fetus?
valproate is associated with neural tube defects as is carbamazepine and phenytoin
what are the teratogenic effects of anticoagulants
warfarin is associated with haemorrhage in the fetus, as well as multiple malformations in the CNS and skeletal system
explain the tertogenic effects of hypertensive agents
ACEI cause renal damage and may restrict normal growth patterns in the unborn child
what are the teratogenic effects of NSAIDs?
premature closure of the ductus arteriosus
lithium and amiodarone are two drugs which should be AVOIDED in pregnancy - True or false?
true
what is a commensal microorganism?
a micro-organism that derives food or other benefits from another organism without hurting or helping it.
a pathogen is a microorganism that can cause disease. true or false?
true
give 3 venereal diseases
- syphilis (treponema pallidum
- gonorrhoea (Neisseria gonorrhoea)
- chancroid (haemophilus ducreyi)
name 5 systemic symptoms of STDs
- fever
- rash
- lymphadenopathy
- malaise
- infertility
what are 5 questions you would like to ask a male patient for risk assessment of STDs
this i s coming up in the exam so learn well
- have you ever had sexual contact with a man
- have you ever injected drugs
- sexual contact with
- anyone has ever injected drugs
- someone from outside the UK - medical treatment outside the UK
- involvement with sex industry (had sex with a prostitute
what are the general questions you would want to ask someone when taking a history for STD’s?
- last sexual contact
- casual contact or a regular partner
- how long have you being going out with them - were they male/female
- asking about nature of sexual contact is sometimes useful
- anxiety about a specific incident
- if its going to alter where you fwab from? - did you use condoms
- other contraception?
- nationality of contact
give 3 examples of non-STI microbial conditions
- vulvovaginal candidosis
- bacterial vaginosis
- balanitis
what is the name of the species that causes vulvovaginal candidosis?
candida albicans but also can be caused by c. glabrate. this condition is usually acquired from the bowel and asymptomatic.
suggest 3 presentations of vulvovaginal candidosis?
- thrush
- itch
- characteristic discharge - thick, cottage cheese like appearance
- fissuring
- erythema with satellite lesions
vulvovaginal candidiasis is more common in those who have diabetes, are on oral steroids or are on immune suppression (HIV).
it also very common in pregnant women and women who are of reproductive age - maybe th oestrogen leads to glycogen production and thus more food for the yeast.
what are the typical risk factors for developing vulvovaginal candidiasis?
vulvovaginal candidiasis is more common in those who have diabetes, are on oral steroids or are on immune suppression (HIV).
it also very common in pregnant women and women who are of reproductive age - maybe th oestrogen leads to glycogen production and thus more food for the yeast.
what investigations would you like to carry out for someone with vulvovaginal candidiasis?
GRam stained preparation:
- low sensitivity and might look at an unrepresentative patch
Culture - Sabouraud’s medium
- low specificity as yeast are foten commensal
treatment is with antifungals
- clotrimazole
fluconazole
suggest 2 treatment options for vulvovaginal candidiasis?
- clotrimazole
fluconazole
give some of the clinical features of bacterial vaginosis
- asymptomatic in 50% of women
- watery grey/yellow fishy discharge and may be worse after periods or sex
- itch and sore from dampness
- caused by an imbalance of bacteria rather than infection
- reduced lactobacilli
- associated with vitamin D deficiency in black women
- associated with premature labour and increases the risk of HIV acquisition
how is bacterial vaginosis diagnosed?
- characteristic history
- examination findings will see a thin and homogenous discharge
- do a gram stained smear of the vaginal discharge
treatment is with metronidazole or clindamycin (either oral, avoid ethanol or vaginal gel)
what is the treatment of bacterial vaginosis
treatment is with metronidazole or clindamycin (either oral, avoid ethanol or vaginal gel)
name an organism commonly associated with impetigo
staph aureus or strep pyogenes
treatment is with circumcision, antibiotics and hygeine advice
what is the definition of spontaneous miscarriage?
the loss of a pregnancy before 24 weeks gestation with no evidence of life
the incidence of this is 15%
what are the 6 main categories for miscarriage?
- threatened
- bleeding from gravid uterus before 24 weeks gestation when there is a viable fetus with no evidence of cervical dilatation. management here is conservative - inevitable
- abortion becomes inevitable as the cervix has already began to dilate. management is with evacuation if the bleeding is heavy - incomplete
- this is when there is only partial expulsion of the products of conception. following incomplete miscarriage there is always risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion - complete
- passed all products of conception (POC), cervix is closed and bleeding has stopped. - septic
- often seen with incomplete miscarriage. management is with antibiotics and evacuating the uterus. - missed
- aka early fetal demise. pregnancy where the fetus has died but the uterus has made no attempt at expelling the POC. the gestational sac can still be seen but there is no clear fetus (empty gestational sac or a fetal pole and fetal heart. treatment here is conservative. medically give prostaglandins (misoprostol)
give a brief overview of
- missed miscarriage
- incomplete miscarriage
- threatened miscarriage
- missed
- aka early fetal demise. pregnancy where the fetus has died but the uterus has made no attempt at expelling the POC. the gestational sac can still be seen but there is no clear fetus (empty gestational sac or a fetal pole and fetal heart. treatment here is conservative. medically give prostaglandins (misoprostol) - incomplete
- this is when there is only partial expulsion of the products of conception. following incomplete miscarriage there is always risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion - threatened
- bleeding from gravid uterus before 24 weeks gestation when there is a viable fetus with no evidence of cervical dilatation. management here is conservative
give 5 reasons as to why a spontaneous miscarriage may occur
- abnormal conceptus
- chromosomal/genetic/structural - uterine abnormality
- congenital: failure of fusion of mullerian ducts
- fibroids: mainly submucous fibroids due to distortion of the uterine cavity - cervical incompetence
- trauma
- When cervical incompetence is present the cervix opens prematurely with absent or minimal uterine activity and the pregnancy is expelled
- maternal
- increasing age or diabetes
- destruction of the corpus luteum.
- SLE, thyroid disease, appendicitis
5. unknown
what is an ectopic pregnancy?
this is a pregnancy that is implanted outside of the uterine cavity
the isthmus is the most common side of ectopic pregnancy. true or false?
false - it is the ampulla.
what are the main risk factors for ectopic pregnancies occurring?
- pelvic inflammatory disease
- previous tubal surgery
- previouss ectopic
- assisted conception
suggest 4 typical presentations of an ectopic pregnancy
- amenorrhoea
- vaginal bleeding
- abdominal pain
- GI/urinary symptoms
what investigations would you like to carry out for a suspected ectopic pregnancy?
- scans - no intrauterine gestational sac - may see adnexal mass and fluid in the pouch of douglas
- serum BHCG levels
- serum progesterone levels
what is the typical management of an ectopic pregnancy
medical - methotrexate
surgical - laparoscopic, salpingotomy
conservative
what is antepartum haemorrhage?
bleeding from the genital tract after 24th week of pregnancy but before the delivery of the baby
APH is one of the gravest obstetric emergencies and is associated with significant maternal and neonatal morbidity and mortality
what is placenta praevia?
this is when all or part of the placenta implants in the lower uterine segment.
it will occur in 1/200 pregnancies. it is more common in multiparous women, multiple pregnancies and previous CS’s. the placenta will lie in front of the presenting part of the fetus.
there are different grades to the placenta praevia condition:
GRADE I – placenta encroaching on the lower segment but not the internal cervical os
GRADE II – placenta reaches the internal os
GRADE III – placenta eccentrically covers the os
what will occur in grade IV placenta praevia?
grade IV is when there is central placental praevia.
what is the presentation of placenta praevia?
- painless PV bleeding
- this is due to the separation of the placenta as the lower uterine segment forms and the cervix effaces.
the blood loss occurs from the venous sinuses in the lower segment. usually the blood loss if painless and recurrent.
- malpresentation of the fetus
- uterus is soft and non-tender with possible fetal malpresentation.
what is the diagnostic methods involved with placenta praevia?
- USS but can be difficult with posterior placenta praevia.
2. MRI scanning - allows identification of the internal os but is not widely available.
what is the management of placenta praevia?
depends on many factors including
- gestation at presentation and the severity of blood loss.
- admission
vaginal examination is contraindicated and diagnosis is confirmed with USS. - cross match blood and blood transfused depending on the maternal condition.
- baby is delivered by CS - there is a risk of PPH in placenta praevia.
- gestation
- severity and CS and watch PPH
what is placental abruption?
placental abruption is where the placenta has started to separate from the uterine wall before the birth of the baby and is associated with a retroplacental clot.
- haemorrhage is the result of a premature separation of the placenta before the birth of the baby.
suggest 4 factors that contribute to the risk of placental abruption
- pre-eclampsia/chronic hypertension
- multiple pregnancy
- polyhydramnios
- smoking, increasing age and parity
- previous abruption
- cocaine use
what is the typical presentation of someone with placental abruption?
- pain
- vaginal bleeding
- increased uterine activity
what is the difference between revealed and concealed placental abruption?
in concealed placental abruption, the bleed occurs between the placenta and the uterine wall causing the uterine contents to increase in volume and the fundal height to be larger than would be consistent for gestation.
in reelaved placental abruption the major haemorrhage is apparent externally because the blood is released from the placenta escapes via the cervical os.
what is couvelaire uterus?
this is when the blood penetrates the uterine wall in concealed placental abruption and then the uterus appears to be bruised
what are the major complications of antepartum haemorrhage?
- maternal shock and collapse
- fetal death
- maternal DIC, renal failure
- PPH - couvelaire uterus
what is the defintion of preterm labour?
onset of labour before 37 weeks of gestation - 259 days. this can be spontaneous or induced.
suggest 4 predisposing factors to preterm labour
- multiple pregnancies
- polyhydramnios
- antepartum haemorrhage
- pre-eclampsia
- infection (UTI)
- pre-labour premature rupture of membrane
remember that the majority of preterm labour cases have no cause
diagnosis is with contractions with evidence of cervical change on the VE
what are the management options for a woman going into preterm labour and she is <24-26 weeks gestation
- tocolytics
- transfer to neonatal unit
- attempt vaginal delivery
- steroids unless contraindicated
what is the systolic and diastolic BP of a woman with mild and severe hypertension?
- mild hypertension = 140-149/90-99
- moderate hypertension = 150-159/100-109
- severe = 160/110
what is pre-eclampsia?
- mild HT on 2 occasions more than 4 hours apart
- moderate to severe HT
and
proteinuria of more than 300mgms/24hours
this is a new hypertension developed after 20 weeks of pregnancy and is associated with significant proteinuria
significant proteinuria:
1. automated regent strip urine protein estimation >1
- spot urinary protein :Creatinine>30mg/mmol
- 24 hours urine protein collection >300mg/day
suggest 3 drugs for BP control that should be avoided in pregnancy
- ramipril
- ARBS - losartan
- antidiuretics
suggest 3 BP control medications safe for women to take while pregnant
- methyldopa
- nifedipine
- labetalol
what are the major risk factors for preeclampsia? name at least 6
- first pregnancy
- extremes of age
- pre-eclampsia in previous pregnancy
a. delivery <34 weeks
b. IUD
c. abruption - pregnancy interval >10 years
- BMI>35
- muliple pregnancy
- underlying medical disorders
a. chronic hypertension
b. pre-existing renal disease
c. pre-existing diabetes
d. autoimmune disorders (Antiphospholipid antibodies - SLE
preeclampsia is a multi-organ disorder. usggest 4 other systems that it will effect
- renal
- liver
- vascular
- cerebral
- pulmonary
what are 5 complications that can result from preeclampsia in the mother
- eclampsia - seizure
- severe hypertension - cerebral haemorrhage
- HELLP - haemolysis, elevated liver enzymes and low platelets
- DIC - disseminated intravascular coagulation
- renal fialure
- pulmonary oedema
complications for the FETUS include:
- impaired placental perfusion
- fetal distress
- prematurity
- increased PN mortality
- IUGR - intrauterine growth restriction
what are the symptoms of preeclampsia?
- headache/blurring of vision, epigastric pain, pail below elbows, vomiting, swelling of hands and face
- severe hypertension > 3+ proteinuria
- clonus/brisk relfexes; papillodaema, epigastric tenderness
- reducing urine output
- convulsions (eclampsia)
suggest some of the biochemical/ laboratory abnormalities present in preeclampsia
- raised liver enzymes, bilirubin if HELLP present
- raised urea
- raised urate
- creatinine is raised
haemotological abnormalities
- low platelets
- low Hb and signs of haemolysis
- features of DIC
what is the typical management of preeclampsia?
- frequent BP checks and urine protein
- check symptomatology - headaches, epigastric pain and visual disturbances
- check for hyperreflexia (clonus), tenderness over the liver
- bloods
a. liver function tests
b. renal function - serum urea, creatinine
and urate
c. coagulation tests if indicated - fetal investigations
a. scan for growth
b. cardiotocography (CTG)
what is the only treatment for preeclampsia?
delivery of the baby and placenta
conservative management is to increase the fetal maturity
- close observation of clinical signs and investigations
- antihypertensives (labetalol, methyldopa and nifedipine)
- steroids for fetal lung maturity <36 weeks
consider the induction of labour /CS if maternal/fetal conditions deteriorates irrespective of gestation. risk of preeclampsia may persist into the puerperium therefore monitoring must be continues post-delivery.
what is the treatment of preeclamptic seizures/impending seizures
- magnesium sulphate bolus +infusion
- control of blood pressure - hydralazine and labetalol
- avoid fluid overload.
prophylaxis is low dose aspirin from 12 weeks till delivery
what are 6 risk factors for TED (thromboembolic disease) in pregnant women
- Older mothers, increasing parity
- Increased BMI, smoker
- IVDA
- PET – pre-eclamptic toxaemia
- Infection
- Decreased mobility
- Dehydration – hyperemesis
- Operative delivery or prolonged labour
- Haemorrhage, blood loss >2l
- Previous VTE (not explained by other predisposing – fractures, injury),
- those with thrombophilia (protein C, S and anti-thrombin III deficiencies etc)
- strong history of VTE
- Sickle cells disease
what is the management and symptoms of TED in pregnancy
MANAGEMENT
- TED stockings
- increased mobility
- prophylactic anticoagulation
SYMPTOMS
- pain in calf
- SOB
- pain of breathing
- cough
- tachycardia
- hypoxia
- calf muscle tenderness
- pleural rub
what is the investigations you should carry out for suspicion of VTE?
- ECG
- blood gasses
- doppler
- VQ scan
- lung scan
- CTPA
what is gestational diabetes?
- carbohydrate intolerance with onset in pregnancy
- abnromal glucose tolerance that returns back to normal after delviery
these women are more at risk of developing type II diabetes later in life.
in pregnancy the insulin reqquirements of the mother will increase
what is the effect of B-HCG and progesterone on insulin
they have anti-insulin properties. as do
cortisol and placental lactogen
in gestational diabetes, fetal hyperinsulinemia occurs. Maternal glucose crosses the placenta and induces increased insulin production in the fetus
what effect does this have on the fetus?
macrosomia - big baby for gestational age
post-natally there is more risk of neonatal hypoglycaemia
what are the associated risks of gestational diabetes
- fetal congenital abnormlaties
- miscarriage
- pre-eclampsia
- fetal macrosomia and polyhydramnios
- opertaive delivery
- worsening of maternal retinopathy, hypoglycaemia and reduced awareness of hypoglycaemia
- infection
- stillbirth and increased perinatal mortality
- neonatal - impaired lung maturity and neonatal hypoglycamia and jaundice
what is the management of gestational diabetes preconception?
- better glycaemic control, keep BG around 4-7mmol/l
- folic acid
- dietary advice
- retinal and renal assessment
what is the management of gestational diabetes during pregnancy?
- optimize glucose control - insulin requirements will increase
- could continue oral anti-diabetic agents (metformin) but may need to change for better glucose control
- should be aware of the risk of hypoglycaemia - provide glucagon injections/conc
- watch for ketonuria/infections
- repeat retinal assessments
- watch fetal growth
- observe PET
- labour usually induced 38-40 weeks, earlier if fetal/maternal concerns
- Elective C-section if significant macrosomia
- maintain blood sugar in labour with insulin - dextrose insulin infusion
- continuous CTG fetal monitoring in labour
- early feeding of baby to reduce neonatal hypoglycaemia
- diet
- post-delivery - check OGTT 6 to 8 weeks PN
- yearly check on HbA1c/blood sugar as at a higher risk of developing overt diabetes
can go back to pre-pregnancy regimen of insulin post-delivery
what are the risk factors for gestational diabetes mellitus?
- increased BMI
- previous macrosomic baby
- previous GDM
- previous history of diabetes
- family history for diabetes
- women from high risk groups for dveloping diabetes - asian origin
- polyhydramnios/big baby in current pregnancy
- recurrent glycosuria in current pregnancy
how d you measure the symphysiofundal height?
measuring from the symphysis pubis to the top of the fundus of the uterus in cms. it should usually be +/-3 cm gestational age in weeks. after measurement taken then plot on the GAP/GROW charts
after a symphysiofundal height is measured and the baby is either too big or too small for dates then do an USS. what measurements should be made on the USS?
- abdominal circumference (AC)
- femur length (FL)
- head circumference (HC)
from this it is possible to estimate the fetal weight.
- liquor volume - amniotic fluid index
what are 8 possible reasons for a by being small for dates?
- low BMI, maternal build
- age
- ethnicity, familial or genetic
- social class
- smoking
- substance misuse
- alcohol misuse
- maternal diseases such as
a. preeclampsia
b. chronic hypertension
c. severe asthma
d. autoimmune disorders - SLE, antiphopspholipid syndrome and repeated antepartum haemorrhages - infections - toxoplasma and CMV
- fetal abnormality - gastroschisis, chromosomal abnormality like triploidy and turners XO
what are 4 possible reasons for a bay to be large for dates?
- parity )multiparity)
- ethnicity/familial/social class/genetic
- polyhydramnios
a. fetal abnormalities - duodenal atresia,
TOF
b. unexplained - maternal diabetes
5.m multiple pregnancy
tests :
- confirm good fetal movement
- fetal cardiotocgraphy
- good doppler blood flow in umbilical artery
what is female pelvic organ prolapse?
tis refers to the descent of the pelvic organs towards or through the vagina.
what are the 3 main ligaments in the pelvic floor?
- uterosacral ligament
- pubocervical fascia
- rectovaginal fascia
what are the two main muscles of the pelvic diaphragm?
- levator ani
2. coccygeus
what are the risk factors for pelvic organ prolapse?
- pregnancy and vaginal birth
a. forceps delivery
b. large baby
c. prolonged second stage of labour - previous pelvic surgery
- continence procedures
- elevation of bladder neck (may lead to defects in other pelvic departments)
- culposuspension - other
- hormonal factors
- quality of connective tissue
- constipation
- occupation with ehavy lifting
- exercise: weight lifting and high impact aerobics
what is the difference between urethrocele and cystocele?
urethrocele is the prolapse of the lower anterior vaginal wall involving the urethra only
cystocele is the prolapse of the upper anterior vaginal wall involving the bladderr
whats structures are affected by prolapse in uterovaginal prolapse?
- uterus
- upper vagina
- cervix
what is enterocele?
this is the prolapse of the upper posterior wall of the vagina usually containing loops of small bowel - aka apical prolapse
what is rectocele?
this is the prolapse of the lower posterior wall of the vaing involving the rectum bulging forwards into the vagina
what are 4 symptoms of vaginal pelvic organ prolapse?
- sensation of a bulge or prolapse
- seeing/feeling a bulge or protrusion
- pressure
- heaviness
- difficulty in inserting tampons
what are the typical symptoms seen in a woman with urinary pelvic organ prolapse?
- urinary incontinence
- frequency/urgency
- weak or prolonged urinary stream/hesitancy/feeling of incomplete emptying.
- Manual reduction or prolapse to start or complete voiding
what are the typical symptoms found in a patient with bowel pelvic organ prolapse?
- incontinence of flatus/liquid/solid stool
- feeling of incomplete emptying/straining
- straining
- urgency
- Digital evacuation to complete defacation
- splinting/pushing on or around the vagina/perineum to start or complete defacation
suggest 2 objective assessment methods of assessing pelvic organ prolapse
- baden-walker -halfway grading
2. POPQ score - gold standard
what 3 investigations would you want to carry out for Pelvic organ prolapse?
- USS/MRI
- urodynamics
- IVU or Renal USS
syggest 3 methods of prevetnion in pelvic organ prolapse
- avoiding constipation
- effective management of chronic chest pathology
- smaller family size
- improvements in antenatal and intrapartum care
- PFMT - increases pelvic floor strength relieving the tension on the ligaments
what is the definition of an caesarean section?
a caesarean section is defined as the delivery of a fetus through an incision in the abdominal wall and uterine wall.
possible complications are bladder and ureteric injury
where does the ureter enter the pelvis?
over the pelvic brim
it crosses the bifurcation of the common iliac arteries and runs retroperitoneally on the lateral pelvic wall
what is an episiotomy?
an episiotomy is a surgically planned incision on the perineum and posterior vagina wall during the second stage of labour. this may be required for normal birth/forceps delivery and may have a spontaneous tear. an episiotomy may tear further which could be a complication
an episiotomy is a third degree laceration extending from the vaginal opening to the anus.
fibroids are the commonest benign tumour arising from he myometrium and are composed of skeletal muscle - true or false?
false. they are composed of smooth muscle.
they are often asymptomatic but may present with dysmenorrhoea (painful periods), menorrhagia and pressure symptoms/pelvic pain
what does dysmenorrhoea mean?
painful periods
what is the word for painful sex?
dyspareunia
what is endometriosis?
it is the presence of endometrial-like tissue outside of the uterine cavity. the endometriotic tissue detach and bleed - resulting in internal bleeding, degenerate blood and tissue shedding inflammation of the surrounding areas, pain and possibly formation of scar tissue.
what imaging techniques are available for endometriosis and fibroids?
TV USS
laparoscopy
where are the rarest places in the body to find endometriosis?
brain
lungs
eyes
muscles
suggest 4 effects of teratogens
- intrauterine death
- structural (congenital) malformations
- IUGR - intrauterine growth restrictions
- neurodevelopmental/behavioural dysfunction
- developmetnal delay
- carcinogenesis
women taking retinoid drugs for treatment of severe acne must be contraceptives due to potential teratogenicity. true or false?
this is true
suggest some of the potential complications of retinoids in pregnancy
micophalthmia absent ears cardiac anomalies microcephaly cleft lip and palate nervous system abnormalities
suggest some features that would suggest a child/fetus had a mother who abused alcohol while she was pregnant
- small head
- epicanthal folds
- flat midface
- smooth philtrum
- underdeveloped jaw
- thin upper lip
- short nose
- small eye openings
- low nasal bridge
what is the value for safe amount of alcohol consumption in pregnancy
there is no safe amount of alcohol in pregnancy
what is the classical triad of rubella?
- sensorineural deafness
- eye abnormalities - retinopathy, cataract and microphthalmia
- congenital heart disease - especially pulmonary artery stneosis and patent ductus arteriosus
what Gilick competency?
- child<16 can give/withhold consent if doctor feels she understands what is involved in an intervention, but in some certain situations parents can override the girl’s wishes.
What is Fraser competence?
- mature enough to understand advice and implications of treatment
- girl likely to begin or continue to have sex with/without treatment
- doctor tried to persuade girl to inform her parents or to allow her/him to inform them
- girls health would suffer without treatment/advice
- in girls best interest to give treatment or advice
what investigations should you carry out prior to referral for a gynaecological specialist for a 15 year old patient?
- FSH/LH, PRL/ TSH, testosterone and oestrogen
- Pelvic USG
- progesterone withdrawal bleed:
- pregnancy
- not enough oestrogen
how do you treat menorrhagia in paediatric cases? suggest 4 things
- reassure
- talk to girls directly
- progesterone only pill
- tranexamic acid
- mefenamic acid
- ocp
- mirena
what are the symptoms of gonorrhoea in males and females?
MALES
thick profuse yellow discharge dysuria. rectal and pharyngeal infection often asymptomatic
FEMALES
vaginal discharge, dysuria or intermenstrual/post-coital bleeding
what are some of the complications of gonorrhoea?
MALES
epididymitis
FEMALES
pelvic inflammatory disease and Bartholin’s abscess
BOTH
acute monoarthritis in elbow or shoulder. disseminated gonococcal infection and skin lesions- pustular with halo
describe the diagnosis of gonorrhoea
- Nucleic acid amplification test (NAAT) on urine or swab from an exposed site - vagina, rectum, throat. can be self or clinician obtained.
- gram stained smear from urethra/cevix/rectum in symptomatic people
- culture of swab-obtained specimen from an expose site using highly selective lysed blood agar. should be done for all confirmed cases to assess antibiotic sensitivity
what is the treatment for gonorrhoea?
ceftriaxone plus azithromycin
what are the symptoms of chlamydia in men and women w
males
slight watery discharge and dysuria
females
vaginal discharge and dysuria. intermenstrual/post-coital bleeding
both sexes will experience conjunctivitis.
what are the main complications of chlamydia infection in women?
PID and hence ectopic pregnancy
pelvic pain and infertility
men will experience epididymitis
both sexes will experience
reactive arthritis and reiter’s syndrome - urethritis/cervicitis + conjunctivitis and arthritis
how is chlamydia diagnosed?
first void urine in men
self-taken or clinician-taken swab from cervix, urethra, rectum as appropriate
all specimens are tested using NAAT.
what is the treatment for chlamydia?
azithromycin and doxycycline
what organism is responsible for causing syphilis?
treponema pallidum
it is often entirely asymptomatic or mild symptoms which go unreported.
what is the typical presentation of syphilis?
- local ulcer (chancre)
2. rash, mucosal ulceration, neurological symptoms, patchy alopecia and other symptoms
what are the main complications of syphilis?
- neurosyphilis - cranial nerve palsies are commonest, cardiac or aortal involvement
- congenital syphilis
how is syphilis diagnosed?
- clinical signs
- serology for TP IgGEIA, TPPA ad RPR
- PCR on sample from an ulcer
what is the treatment for syphilis?
benzathine penicillin or doxycycline
what species are mainly responsible for causing genital warts?
human papillomavirus types 6 and 11
the main symptoms are lumps with a surface texture of small cauliflower. occasionally itching or bleeding especially if perianal or intraurethral
what is the diagnosis and treatment for anogenital warts?
diagnosis - appearance and biopsy if unusual to exclude intraepithelial neoplasia
treatment is with podophyllotoxin and imiquimod. cryotherapy is also an option
what is the main cause and complications of trichomoniasis?
cause - trichomonas vaginalis
complications - miscarriage and preterm labour
how is trichomoniasis diagnosed and treated?
diagnosis is with PCR on a vaginal swab
treatment is with metronidazole
herpes is caused by which herpes simplex viruses?
it is caused by herpes simplex virus 1 and 2
80% of people will have no symptoms
the other symptoms may be:
- burning/itching then blistering the tender ulceration
- tender inguinal lymphadenopathy
- dysuria, neuralgic pain in the back, pelvis and legs
what is treatment and diagnosis of herpes?
TREATMENT
acyclovir and lidocaine ointment
DIAGNOSIS
clinical impression and swab from lesion tested using PCR.
what is the 5YS of ovarian cancer?
30%
most will present with advanced stage diseases
what are 4 general symptoms of ovarian cancer?
- indigestion/early satiety/poor apetite
- altered bowel habit/pain
- bloating/discomfort/weight gain
- pelvic mass
- asymptomatic
- pressure symptoms
how is the diagnosis of ovarian cancer made?
- surgical/pathological
- USS abdomen and pelvis
- CT scan
- CA125 (glycoprotein antigen)
CA125 is also associated with colon and pancreatic cancers as well as breast cancer
what US features may be found in a patient with ovarian cancer?
- multilocular
- solid areas
- bilateral
- ascites
- intra-abdominal
what is the treatment of ovarian cancer
- surgery
- chemotherapy - platinum and taxane
- adjuvant and neoadjuvant
suggest 3 reasons why a laparotomy may be useful in the management of ovarian cancer
- obtain tissue diagnosis
- stage disease
- disease clearance
- bulk disease
what is first line chemo for ovarian cancer?
platinum and taxane
this is given within 88 weeks of surgery
population screening has been found to decrease risks of ovarian cancer. true or false?
false.
Ovarian cancer screening is not recommended as there is limited sensitivity and specificity. For high risk women give a prophylactic oophorectomy
Using imaging and CA125 this gives the RMI. Give surgery to stage and to reduce disease bulk. Chemo can also be given but overall there is a poor prognosis.
M is the menopause status
RMI = US x M x CA125
how is endometrial cancer staged?
Surgical/Pathological MRI depth of myometrial invasion cervical involvement lymph node involvement
there are 2 distinct categories of endometrial cancer. compare the features of each
TYPE 1
Endometrioid adenocarcinoma
By far the commonest
Unopposed oestrogen
Hyperplasia with atypia precursor
TYPE 2
Uterine serous & clear cell carcinoma
High grade, more aggressive, worse prognosis
Generally older ladies
Serous intraepithelial carcinoma precursor
what is the treatment of endometrial cancer?
Early Stage - Surgery TAH/BSO/washings High risk histology - Chemotherapy Advanced Stage - Radiotherapy Palliation - Progesterone Radiotherapy- External Beam Caesium Insertion - intra-cavity
endometrial cancer will affect mainly post-menopausal women. true or false?
true
there is high circulating oestrogen levels which can be also affected by
- obesity
- HNPCC/lynch type II familial cancer syndrome
- atypical endometrial hyperplasia
- early menarche/late menopause
what are the symptoms of endometrial cancer?
- abnormal vaginal bleeding
2. post menopausal bleeding
what are the main causes of post-menopausal bleeding?
- 8% of women with PMB will have endometrial cancer
- Hormone Replacement Therapy (HRT)
- Peri-menopausal bleeding
- Atrophic vaginitis
- Polyps cervical/endometrial
- Other cancer eg cervix, vulva, bladder,anal
how is endometrial cancer diagnosed?
histology of endometrium
main treatment is with a total abdominal hysterectomy with removal of tubes and ovaries and peritoneal wshings
what are the two parts of the upper urinary tract?
the kidney and ureters
this is a low pressure distensible conduit with intrinsic peristalsis
it will transport urine from the nephrons via the ureters to the bladder
what are the two parts of the lower urinary trcat?
The bladder and urethra.
which nerve is responsible for storage of urine?
the hypogastric nerve (T10-L2)
it forces the bladder muscles to relax and the external urethral sphincter to contract when in a fight or flight situation
which nerve is responsible for initiating voiding
the pelvic nerve - parasympathetic S2-4.
the pudendal nerve gives voluntary control of urination and is under somatic control
what are the nerve roots of the hypogastric and pudendal nerve?
the hypogastric nerve - T10-L2
the pudendal nerve S”-S4.
Bladder filling is designed to accommodate increasing volume at constantly low pressure. This is via the inhibition of contractions by giving rise to gradual awareness of filling.
- Cortical activity will activate a reciprocal guarding reflex by rhabdosphincter contraction; increase sphincter contraction and resistance
grossly describe these 3 processes
1 activates sympathetic pathways
- reciprcoral inhibition of the parasympathetic pathway
- mediates contraction of bladder base and proximal urethra.
Bladder emptying operates via detrusor contraction - true or false?
true
describe the difference between Stress urinary incontinence (SUI) and urge urinary incontinence (UUI)
UUI - involuntary leakage accompanied by or immediately preceded by urgency
SUI- involuntary leakage on effort or exertion, on sneezing or coughing.
Both stress and urge incontinence arise from the same anatomical defect in the anterior vaginal wall and pubo-urethral ligament (PUL).
what is mixed urinary incontinence?
- Mixed urinary incontinence (UUI): this is the involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion, or on sneezing or coughing
suggest 6 risk factors for urinary incontinence
- age
- parity
- menopause
- smoking
- medical problem
a. diabetes
b. hypertension
c. glaucoma - increased abdominal pressure
- pelvic floor trauma
- denervation
- connective tissue damage
- surgery
what are the typical symptoms associated with urinary incontinence? name 4
- nocturia
- dysuria
- haematuria
- increased daytime frequency
- urgency
what is the triad of overactive bladder?
- frequency
- nocturia
- urge incontinence
name the 4 incontinence symptoms and the 3 voiding symptoms
INCONTINENCE
- stress UI
- urgency UI
- coital incontinence
- severity - how many pads a day
VOIDING
- straining to void
- interrupted flow
- recurrent UTI
when taking a rena history for a female and you want to enquire about prolapse and bowel symptoms what questions do you want to ask?
PROLAPSE
- vaginal lump
- dragging sensation in the vagina
BOWEL SYMPTOMS
- anal incontinence
- constipation
- faecal evacuation dysfunction
- IBS
what may be involved in a 3-day urinary diary
- fluid intake - quality and quantity
- urine output
- daytime frequency
- nocturia
- average voided time
a urine dipstick test would also be a good idea.
what investigations should you consider for pelvic floor problems such as prolapse and incontinence
- urinalysis - multistix and MSSU
- post-voiding residual volume assessment - usually bladder scanning only if symptoms of voiding difficulties
- urodynamics - only indicated if surgical treatment is contemplated
what is the general management of urinary incontinence?
- lifestyle changes
a. smoking
b. weight
c. diet
d. alcohol and caffeine - medical treatments
- physiotheapy
- surgery
Stress urinary incontinence occurs when: intraabdominal pressure exceeds urethral pressure resulting in leakage. suggest 3 ways to increase urethral closure pressure
- Pelvic floor muscle training
1. Reinforcement of cortical awareness of muscle groups
2. Hypertrophy of existing muscle fibres
3. General increase in muscle tone and strength - Surgery
a. colposuspension
b. tension free vaginal tape - Pharmacodynamic agents - duloxetine
in primary carem if PFMT has failed then give duloxetine
what is Tension-free vaginal tape?
Tension-free vaginal tape (TVT) is a minimally invasive procedure to reinforce the structures supporting the urethra. It depends on the hammock theory for continence. It uses polypropylene permanent synthetic tape; monofilament and macro-porous.
- TVT is as effective as culposuspension for the treatment of primary SUI. It has now replaced culposuspension as the first-choice procedure in the surgical treatment of SUI.
TVT’s main surgical complication is bladder perforation as well as vaginal and urethral erosions. There can be several vascular injuries, all attributed to blind penetration of the retro-pubic space
which muscle is mainly involved in overactive bladder syndrome?
the detrusor muscle - detrusor overactivity (DO). the main symptoms are
- Urgency: the complaint of a sudden, compelling desire to pass urine that is difficult to defer
- Urge incontinence: the complain of involuntary leakage of urine accompanied or immediately preceded by urgency
- Frequency: usually accompanies urgency with or without urge incontinence and is the complaint by the patient who considers that he/she voids to often by day.
- Nocturia: usually accompanies urgency with or without urge incontinence and is the complaint that the individual has to wake at night one or more times to void
suggest 4 risk factors for OAB syndrome
- age
- diabetes
- UTI’s
- smoking
you can use anti-depressants to treat OAB - imipramine
- botulinum toxin A and B
- solifenacin
- fesoteridine
what are the 3 main GALS screening questions?
GAIT
- observe gait
- observe the patient in anatomical position
ARMS
- observe movement - hands behind head
- observe palms
- asess power grip and grip strength 7
- assess frine precision pinch
- squeeze MCPJs
LEGS
- assess full flexion and extenmsion
- assess internal rotation of the hips
- perform pattellar tap
- insepct feet
- squeeze MTPJ
SPINE
- inspect spine
- inspect laterall flexion of neck
- assess lumbar spine movement.
- do you have any pain or stiffness in your joints
- can you dress without difficulty
- can you walk up and down stairs?
if all these questions are negative then there is unlikely significant msk problem.
what are the 3 things you are always looking for in an MSK examination of the joints/muscles?
- swelling
- deformity
- discolouration (redness, pallor and bruising)
- wasting
- shortening
- LOOK – skin/scars/wounds/sinuses, colour, swelling, wasting, deformity
what are you inspecting for when performing the MOVE section of an MSK clinical examination
- stiffness
- range of movements
- limp
- instability
- crepitus
also enquire whether the patient was woken up by their pain and do they feel this stiffness in the morning?
it may be worth discussing their daily tasks of living - socks, shoelaces, cutting nails, baths etc. how far are they able to walk? can they do their own shopping?
suggest 4 red flag signs when taking a MSK history from a patient
- severe and worsening pain
- night pain disturbing sleep
- non-mechanical pain
- general malaise, febrile or rigors
- unexplained wieght loss, anorexia and night sweats
- past history of malignant disease
what is the mnemonic used to evaluate a PMH in MSK
MISTI THREAD
MI
Stroke
Thrombolysis (DVT/PE)
Icterus (jaundice)
TB Hypertension Rheumatoid Epilepsy Asthma Diabetes
Allergy
- AKDA?
- penicillin?
- iodine?
- GA?
- latex?
- elastoplast?
what are the 6 main aspects of taking a drug history from an MSK patient?
- current and recent medications
- are they on any prescription drugs from their own doctor?
- any other drugs - recreation/paracetamol
- OCP
- aspirin/warfarin/clopidogrel
- NSAIDs
- Steroids
what is meant by real and apparent limb length?
a. Real – (ASIS/greater trochanter/tibial tuberosity to medial malleolus) – legs in the same position
b. Apparent – midline marker e.g. xiphisternum or umbilicus to medial malleolus
suggest 4 non-operative options of treatment of foot problems
- analgesia
- shoe wear modification
- activity modification
- weight loss
- physiotherapy
- orthotics including insoles and bracing
Hallux valgus, metatarsalgia, morton’s neruoma and hallux rigidus are all probems of the forefoot. true or fase?
true
hallux valgus is the lateral deviation of the greater toe.
hallux rigidus is arthritis of the first MTP
morton’s neuroma is a type of interdigital neuralgia
Hallux valgus (lateral deviation of great toe) is commonly described as bunions and can be brought on due to genetics or by footwear etc. There is a significant female preponderance. Symptoms include pressure (shoe wear), pain from crossing over of toes and metatarsalgia
briefly outline the diagnostic method and the methods of management.
DIAGNOSIS
diagnosis is typically made with XR or is made clinically
MANAGEMENT
(non-operative)
- shoe wear modification
- orthotics to offload pressure
- activity modification
- analgesia
(operative)
- release lateral soft tissue
- osteotomy 1st metatarsal
generally good outcome but recurrence is inevitable.
which metatarsal does hallux rigidus mainly effect?
also describe the features of diagnosis and management
hallux rigidus will mainly affect the 1st metatarsophalangeal joint..
patients will experience pain and limitation with range of movement. diagnosis is with clinical examination and use of radiographs.
MANAGEMERNT
(non-operative)
- activity modeficiation
- shoe wear with a rigid sole
- analgesia
(operative)
- arthroplasty (articular surface of a joint is replaced remodelled or realigned by osteotomy)
- arthrodesis (artificial ankylosis, induction of joint ossification)
- cheilectomy (removing a bony lump at top of main joint of big toe)
something to remember is that the gold standard for treatment of Hallux Rigidus is 1st MTPJ fusion or 1st MTPJ hemiarthroplasty
what digits are mainly affected in morton’s neuroma?
It typically affects the 3rd followed by the 2nd webspace/toes. There is neuralgic burning pain into toes that comes intermittently. There is also altered sensation in the toes.
Morton’s neuroma is a type of interdigital neuralgia. This is a mechanically induced degenerative neuropathy that affects females aged 40-60. It is frequently associated with wearing high heels.
how is Morton’s neuroma diagnosed?
- clinical
- Mulder’s click
- USS
- MRI
Management is with injections for small lesions and surgery for the excision of lesions including a section of normal nerve. the surgery may lead to numbness, recurrence and 1/3rd of patients have pain 1 year post surgery
What is metatarsalgia?.
Metatarsalgia is a symptom and not a diagnosis. Careful examination should be able to localise the cause (synovitis, arthritis, bursitis, neuralgia or neuromata). If there is no obvious cause of metatarsalgia then consider a tight gastrocnemius.
i. To treat either CHANGE shoe wear/orthotics/activity or
ii. Many of the other described techniques or 1st MTPJ arthrodesis or 2-5th toe excision arthroplasty
where do dorsal foot ganglia arise?
they arise from the tendon sheath and can be idiopathic or characteristic of underlying arthritis or tendon pathology.
symptoms can be pain from pressure from shoe wear or pain from another underlying problem.
Management can be aspiration, family bible or excision. there is a very high rate of recurrence.
what is the mainstay treatment for midfoot arthritis?
- activity/shoe wear/orthotics
- injections - XR guided
- operation - fusion
Plantar Fibromatosis
AKA Ledderhouse disease or Dupuytren’s of the foot is a progressive condition that is usually asymptomatic unless very large or on weight bearing area
what are the main treatment oiptons
Non-Operative:
- Avoid pressure
- Shoe wear/orthotics
Operative:
- Excision (up to 80% risk of recurrence)
Radiotherapy
Combination of radiotherapy/surgery has a low recurrence rate but a high complication rate
how do you investigate for achilles tendinopathy
- clinical examination -tenderness and tests for rupture
- lab investigations - XR and MRI
- simmonds test - gently squeezing the soleus muscle and seeing if the foot moves.
MANAGEMENT Non-operative: - Activity modification - Weight loss - Shoe wear modification – slight heel - Physiotherapy – eccentric stretching - Extra-corporeal shockwave treatment - Immobilisation (in below knee cast) Operative Treatment - Gastrocnemius recession - Release and debridement of tendon
what is the pathology behind plantar fasciitis?
This should really be referred to as plantar fasciosis. This is a chronic degenerative change with fibroblast hypertrophy and an absence of inflammatory cells. the blood vessels and collagen are disorganised and dysfunctional and body cant make extra cellular matrix required for repair and remodelling.
Symptoms will see pain on weight bearing after rest (post-static dyskinesia), first thing in the morning and located at the origin of the plantar fascia. The symptoms tend to be long lasting (>2 years)
The diagnosis is made with clinical reasoning and occasionally XR, US and MRI.
what is the treatment for plantar fasciitis?
- Rest, change training
- Stretching – achilles +/- direct stretching
- Ice
- NSAIDs
- Orthoses – Heel pads
- Physiotherapy
- Weight Loss
- Injections – Corticosteroids
- Night splinting
The newer 3rd line treatments are listed below:
1. Extracorporeal shockwave therapy
2. Topaz Plasma Coblation
3. Nitric Oxide
4. Platelet Rich Plasma
5. Endoscopic/ Open surgery
what is the treatment for ankle arthritis?
- Arthrodesis is the gold standard treatment for ankle arthritis. It has a very good long-term outcome also.
- Joint replacement should also be considered to maintain the range of movement.
describe the treatment for diabetic foot ulcers
- Diabetic control
- Smoking
- Vascular supply
- External pressure (splints/shoes/weight bearing)
- Internal pressure (deformity)
- Infection
- Nutrition
Surgical treatment’s aim is to:
- Improve vascular supply
- Debride ulcers and get deep samples for microbiology
- Correct any deformity to offload area
- Amputation
Type I diabetes is the most common cause of Charcot Neuropathy - true or false?
Obi regardless of the answer to this question make sure you understand the information on the next side as may come up in exam
true
Diagnosis is often made with a high index of suspicion but also consider in any diabetic patient with acutely swollen erythematous foot especially with neuropathy. It is frequently not painful. Imaging with radiographs and MRI scanning is useful.
Management again is with prevention. Immobilise/ make it non-weight bearing until the acute fragmentation has resolved and then correct the deformity (deformity leads to ulceration leads to infection leads to amputation)
the musculocutaneaous nerve and the ulnar nerve arise from which cords of the brachial plexus?
the musculocutaneous nerve will arise from the lateral cord
the ulnar nerve will airse from the medial cord.
what cord does the axillary (C5,6) and radial (C5-T1) nerve arise from?
posterior cord
give 4 risk factors for brachial plexus injury
- high birth weight
- shoulder dystocia
- maternal diabetes
- forceps delivery
- clavicle fracture
- prolonged labour
what is the difference between neuropraxia and axonotmesis
neuropraxia - myelin damage and axonal stretching that resolves within weeks.
Axonotmesis is when there is axonal rupture and myelin damage, nerve sheath intact but takes months to resolve
neurotmesis is a total nerve rupture requiring operative repair
what nerve roots does Erb’s palsy affect?
C5 and 6.
Erb’s palsy will give the waiter’s tip appearance and affects C5,6 and sometimes 7. The shoulder is internally rotated, elbow extended, wrist flexed and pronated. It is also very likely for the total plexus to be involved in the damage (C5-T1) and this will leave a completely flaccid limb
Erb’s palsy is managed with early physiotherapy to maintain the range of movement and prevent shoulder stiffness/contracture is essential. However, most will spontaneously fully recover
what is Horner’s syndrome?
the interruption of the stellate ganglion and can result in ptosis, myosis (excessive constriction of pupils) and enopthalmos (posterior displacement of the eye)
what is torticollis?
is the shortening of the sternocleidomastoid muscle. It is a painless ccondition
- developmental hip dysplasia
metatarsus adductus and plagiocephaly are associated conditions
breech deliveries are a common risk factor for the condition.
what is the treatment for torticollis?
- Physiotherapy
- USS hips
- Plain radiograph c-spine for congenital abnormalities
Torticollis tends to resolve within the first 12 months and rarely requires surgical intervention.
if a parent has had DDH (developmental hip dysplasia) then what is the likelihood the child being affected?
12%
- If a parent and a child have DDH the risk of a subsequent child having it is 36%.
If the diagnosis is missed it can be picked up in an older child with the use of imaging US or XR or just clinical examination.
Treatment can be with:
- Hip abduction braces
- Pavlik Harness (with clothes placed over them
what is Geleazzi’s sign?
with the knees flexed and heels carefully aligned the knees are seen to be at a different level implying the femoral (or tibial) segment is short. When seen in an infant it raises the possibility of DDH. In bilateral hip abnormality, asymmetry may not be a feature but when unilateral there is limited hip abduction
name 2 commonly associated conditions with calcaneovalgus
. It is in association with oligohydramnios and DDH. It is a soft tissue contracture foot deformity characterized by excessively dorsiflexed hindfoot with some valgus.
There is excessive hindfoot dorsiflexion correctable to neutral. The dorsum of the foot is often in contact with the anterior tibia.
what is the clinical presentation of calcaneovalgus?
- rigid flatfoot with a rocker-bottom appearance of the foot
- persian slipper appearance
- calcaneus in fixed equinus
- achilles tendon is very tight7
- the hindfoot is in valgus
- the head of the talus is found medially in the sole
- the forefoot is abducted and dorsiflexed
. Treatment is reverse the ponsetti serial casting
in clubfoot, what does CTEV?
congenital, Talipes, equino and varus.
The foot affected is smaller. The hindfoot has equinus and supination (varus) whereas the forefoot/midfoot is adducted and cavus. The leg has mild length discrepancy and muscle wasting.
There is a distinction between positional and structural club foot:
Positional
- Intrauterine positioning and crowding theory. It is associated with hip dysplasia. There is an abnormal postural position that is entirely passively correctable but spring back.
Structural
- If the foot foes not correct then it is a true clubfoot. There is true bone anatomical malalignment. It is not fixed as often but there may be a variable amount of passive correction
The piriani score is used to assess the severity of clubfoot. The total worst score is 6 – the max score for the midfoot is 3 and hindfoot is also 3.
what does menopause mean?
the last ever period
the average age for this occurring is 51 years old. premature menopause occurs <40.
what is the main pathological cause of menopause?
ovarian insufficiency
- oestradiol falls and the FSH levels rise
there is still some oestriol from the peripheral conversion of adrenal androgens in fat
it may be natural or follow an oopherectomy/chemo or radiotherapy
what are the main symptoms of menopause?
- vasomotor - hot flushes
- vaginal dryness/pain
- low libido
- muscle and joint aches
- mood changes/poor memory
- osteoporosis?
Osteoporosis is the silent change of menopause. suggest 8 other risks of developing osteoporosis in women who have undergone meopause
- thin
- white
- smokers
- alcohol
- positive family history
- amenorrhoea
- malabsorption
- steroids
- hyperthyroid
what is the prevention and treatment of osteoporosis?
- WB exercise
- adequate calcium and vitamin D
- HRT
- bisphosphonates
- calcitonin, strontium
- denosumab
suggest 2 hormonal methods of treatment for women with osteoporosis
- local - vaginal oestrogen pessary/ring/cream
- systemic - transdermal/oral
Transdermal avoids first pass metabolism
a. oestrogen only if no uterus is present
b. oestrogen and progesterone if the uterus is present
c. progesterone oral, transdermal or LNG IUS - Levonorgestrel Intrauterine System
Contraindications to HRT are not the same as contraindications to combined hormonal contraception – very few CI
suggest 3 contraindications of using hormonal replacement therapy
- Current hormone dependent cancer breast/endometrium
- Current active liver disease
- Uninvestigated abnormal bleeding
Seek advice if previous VTE, thrombophilia or family history of VTE. Also seek advice if there are previous cases of breast Ca or BRCA carrier
what is the gage limit allowed to use the mirena levonorgestrel Intrauterine System method of contraception?
there is no age limit.
it is often supplemented with daily oestrogen when used in HRT treatment
what is the cardiovascular risk when using hormonal replacement therapy?
there is no CV risk increase if started before the age of 60
Other risks
a. Ca Breast
b. Ca Ovary
c. VTE
d. Fracture femur
e. Ca Colon
name 4 risks of using hormonal replacement therapy
a. Ca Breast
b. Ca Ovary
c. VTE
d. Fracture femur
e. Ca Colon
HRT should ALSO be used for treatment of severe vasomotor symptoms but review this annually
It is for women with premature ovarian insufficiency. HRT benefits outweigh risks until the age of 50. Not as first line for osteoporosis prevention/ treatment (bisphosphonates instead). Vaginal oestrogen should be given for vaginal symptoms.
at what age do the benefits of using HRT outweigh the risks?
50 years old
It is for women with premature ovarian insufficiency. Not as first line for osteoporosis prevention/ treatment (bisphosphonates instead).
what does andropause mean?
Andropause is when the testosterone falls by 1% a year after 30. DHEAS (Dehydroepiandrosterone) also falls. Fertility remains and there is no sudden change
at is the difference between primary and secondary amenorrhoea?
primary - never had a period
secondary - no period in the last 6 months
name 5 causes of secondary amenorrhoea
- pregnancy/breast feeding
- contraception related - current or recent use of depoprovera
- polycystic ovaries
- early menopause
5/ thyroid disease/cushing - raised prolactin - prolactinoma/medication related
- hypothalamic - stress/weight change/exercise
- androgen secreting tumour (testosterone)
- sheehan’s syndrome - pituitary failure
- Asherman’s syndrome - intrauterine adhesions
suggest 5 things you may see under examination that can suggest a diagnosis of secondary amenorrhoea
- BP/BMI/hirsutism, acne, cushingoid
- enlarged clitoris/deep voice
- abdominal/bimannual
- urine pregnancy test +dipstick for glucose
- Bloods
a. FSH
b. LH
c. Oestradiol
d. Thyroid function
e. testosterone - pelvic US -PCO (polycystic ovaries)
what is the treatment for secondary amenorrhoea?
Treat specific causes
- aim for a BMI between 20 and 25.
- If premature ovarian insufficiency then offer HRT till 50 emotional support
- Assume that the patient is fertile and need contraception unless 2 years after confirmed menopause
what are the typical presentation of polycystic ovarian syndrome?
2 out of 3
- Oligo/amenorrhoea – infrequent or no periods
- Androgenic symptoms – excess hair/acne
- Anovulatory infertility
PCO results in a higher risk of diabetes and CVD for any given BMI. There is also a risk of endometrial hyperplasia if <4 periods a year (not on hormones). Polycystic ovaries do not cause weight gain or pain
dont forget
- There is plenty of oestrogen but also high androgens. -
There may also be an underlying insulin resistance
what is the management of Polycystic ovarian syndrome?
- Weight loss and exercise can help all symptoms whilst increasing sex hormone binding globulin SHBG so there are less free androgens. There is also an increased risk of NIDDM. Do a glucose tolerance test.
- Give antiandrogen – combined hormonal contraception (CHC), spironolactone, eflornithine cream facial hair.
- Endometrial protection CHC, progestogens, mirena IUS
- Fertility Rx clomiphene/metformin
- Metformin- helps ovulation but not good evidence that help androgenic SE or weight loss.
what are the typical ages of menarche and menopause?
menarche - 13
menopause - 51
Menstruation is triggered by fall in progesterone 2 weeks after ovulation if not pregnant
what does menorrhagia mean?
heavy periods
what does dysmenorrhoea mean?
painful periods
Intermenstrual bleeding means bleeding between periods. Postcoital bleeding means bleeding after intercourse. Oligomenorrhoea means infrequent bleeding
- what type examination(s) would you want to carry out for a woman presenting with menstrual problems?
- what investigations would you also want to carry out for a woman presenting with menstrual problems - name 4
- General
- Abdominal
- Speculum
- Bimanual
2.
- Full blood count if
menorrhagia
- Endometrial biopsy
- Chlamydia
- Only check
thyroid/coagulation if
other symptoms
- Pregnancy test
what investigations would you also want to carry out for a woman presenting with menstrual problems - name 4
also suggest what imaging you would like to order
- Full blood count if menorrhagia
- Endometrial biopsy
- Chlamydia
- Only check thyroid/coagulation if other symptoms
- Pregnancy test
- TV ultrasound scan
- Hysteroscopy
- Laparoscopy
- Not dilation and curettage
what is endometriosis?
is when there is endometrial type tissue found outside the uterine cavity
Usually ovary, pouch of Douglas or pelvic peritoneum. It may be asymptomatic and may resolve without Rx.
It can be the cause of a retrograde bleed or peritoneal neoplasia
what is the typical presentation of endometriosis?
- premenstrual pain
- dysmenorrhoea
- deep dyspareunia
- subfertility
The condition doesn’t always present with signs but there can also be tender nodules inside the rectovaginal septum and limited uterine mobility
suggest 3 imaging techniques used to investigate a suspected diagnosis of endometriosis
- laparoscopy
- MRI
- USS endometrioma
what are the main treatments for endometriosis?
SURGICAL –
- excision of deposits from peritoneum
- ovary diathermy
- laser ablation of deposits hysterectomy
- oophorectomy
MEDICAL
- progestogen oral/inject/
- Mirena IUS.
- Or combined pill 3 months at a time.
- GnRH analogues – leuprorelin
how is adenomyosis diagnosed?
Diagnosis:
- Probably normal USS
- laparoscopy
- hysteroscopy (MRI may suggest diagnosis but limited availability)
- Histology of uterine muscle – not an endometrial biopsy
as for treatment the mirena may help. Often failed medical Mx/ablation and diagnosed on pathology at hysterectomy
fibroids are benign - true or false?
true
diagnosis is with US, hysteroscopy and clinicaL EXAM
how are fibroids diagnosed?
- Clinical exam
- US
- Hysteroscopy
they may grow fast in pregnancy causing bleeding, pain and obstruction
how does a submucous fibroid differ from a subserosal fibroid?
submucosal - protrudes into the uterine cavity
subserosal will project out of the uterus into the peritoneal cavity
aside from submucosal and subserosal fibroids, what other type of fibroid are found in the uterus?
intramural - within the wall of the uterus
what are the treatment options for fibroids? name 5 things
- do nothing
- standard menorrhagia Rx
- GnRH analogues
- ulipristal oral Rx (an antiprogestogen)
- transcervical resection (submucosal fibroids)
- myomectomy - can cause haemorrhage however
- uterine artery ablation
suggest 3 methods of fertility conserving treatment
- tranexamic acid - blood loss but doesnt affect cycle (antifibrinolytic)
- mefenamic acid - blood losses
- combined contraceptive reduces bleeding and pain and will regulate the cycles
The mirena progestogen IUS reduces bleeding – initial 3-4 months or irregular bleeding
why would you not offer a lady endometrial ablation and/or hysterectomy who is <30
if her family is not complete then this treatment is too radical
what does endometrial ablation involve?
This is the one-off removal of endometrium to below the basal layer using either diathermy or a thermal balloon
what is a hysterectomy?
This is the surgical removal of the uterus
In a total hysterectomy, the cervix and uterus are removed but in a subtotal hysterectomy the uterus is removed and the cervix is left
what is a salpingo-oophorectomy ?
the removal of the tubes and ovaries
what is the definition of maternal mortality?
the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
what is the difference between the maternal mortality ratio and the maternal mortality rate
maternal mortality ratio is the number of maternal deaths during given time per 100’000 live births during the same time. It represents the risk associated with each pregnancy – the obstetric risk
The maternal mortality rate is the number of maternal deaths in given time per 100’000 women of reproductive age, or woman-years of risk exposure, in same time. It considers not only the obstetric risk, but also the frequency with which women are exposed to that risk
The proportionate mortality ratio is the maternal deaths as proportion of all female deaths of those of reproductive age – usually defined as 15-49 years – in each time - true or false?
true
what are the 3 delays in the typical model or factors causing maternal death
- DELAY IN DECISION TO SEEK CARE
i. Lack of understanding of complications
ii. Acceptance of maternal death
iii. Socio-cultural barriers to seeking care
iv. Low social status of women - DELAY IN REACHING CARE
i. Mountains, islands, rivers – poor organisation - DELAY IN RECEIVING CARE
i. Supplies, personnel
ii. Poorly trained personnel with punitive attitude
iii. Finances
when is the most common time for a woman to die following a pregnancy?
day 1
suggest 4 methods that can be used to prevent maternal deaths
- Antenatal care:
a. 4 visits, monitoring weight, blood pressure and
proteinuria, folic acid and malaria. - Skilled attendant at birth
- Emergency obstetric care
Clean delivery
Active management of 3rd stage
Parental antibiotics/oxytocics/magnesium sulphate
Manual removal of placenta/products of conception
Blood transfusion
Caesarean section/operative deliver
what is the definition of a still-birth?
the birth of a dead baby after 20/24/28 weeks of gestation or weighing more than 500g.
stillbirth rate is the number of stillbirths per 1000 births.
what are the 4 essential factors in newborn care?
- Ensuring that the baby is breathing
- Starting the newborn on exclusive breastfeeding right away
- Keeping the baby warm and
- Washing hands before touching the baby
what is the difference between neonatal, infant and child mortality?
Early neonatal death is the death of a bay within the week of life
Infant mortality is the death of an infant within the first year of life
Child mortality is the death of a child within the first 5 years of life
