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Year 5 > Repro 7 > Flashcards

Repro 7 Flashcards

1
Q

Trichomonas vaginalis

A

Trichomoniasis is a sexually transmitted infection (STI) caused by the flagellated protozoan parasite, Trichomonas vaginalis. It primarily infects the urogenital tract.

Can increase risk of: cervical cancer, PID, pregnancy related complications

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2
Q

Trichomonas symptoms

A
  • Often asymptomatic
  • Urethral discharge and/or dysuria
  • Profuse, frothy, yellow vaginal discharge, vulval irritation, dyspareunia
  • pH >4.5
  • On examination: strawberry cervix sign
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3
Q

Trichomonas investigations and management

A
  • Ix: direct microscopy and culture
  • Management: Oral Metronidazole, abstain from sex for one week or until treatment complete. Contact tracing
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4
Q

Examination of prolapse

A
  1. Height, weight, BMI
  2. Abdomino-pelvic examination: pelvic mass, vaginal atrophy
  3. Various classifications of prolapse
  4. Urodynamic studies if coexisting urinary symptoms
  5. Speculum examination
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5
Q

Urinary incontinence

A
  1. Any involuntary urinary leakage, under reported
  2. Stress urinary incontinence is more common then urgency urinary incontinence
  3. Investigations: urine dip/MSU, urodynamics, bladder diaries, QoL questionaires
  4. Risk factors: age, POH, menopause, hysterectomy, obesity, smoking, functional/cognitive impairment, neuro disease
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6
Q

Effects of urinary incontinence

A
  1. Psychological: depression, feelings of shame, loss of self confidence/self esteem
  2. Social isolation
  3. Sexual problems
  4. Loss of sleep from nocturia
  5. Constipation: limiting fluid intake
  6. Falls and fractures in the elderly
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7
Q

Classification of urinary incontinence

A
  1. Overactive bladder (OAB)/urge incontinence: due to detrusor overactivity, the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
  2. Stress incontinence: leaking small amounts when coughing or laughing. Weak pelvic floor
  3. Mixed incontinence: both urge and stress
  4. Overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement. Chronic urinary retention, no feeling of needing to go
  5. Functional incontinence: comorbid physical conditions impair the patient’s ability to get to a bathroom in time, causes include dementia, sedating medication
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8
Q

Risk factors for incontinence

A
  • Stress: childbirth, hysterectomy. Triggered by coughing or laughing
  • Urge: recurrent UTI’s, high BMI, age, smoking, caffeine
  • Overflow: constipation, neurological conditions
  • Functiomal alcohol, medication
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9
Q

Investigations for incontinence

A
  • Physical exam: speculum and bimanual
  • Questionnaire: about modifiable lifestyle i.e. caffeine and alcohol
  • Bladder diary
  • Urine dip
  • Cytometry: measure bladder pressure, not needed if history is clear
  • Cystogram: if fistula suspected
  • Urodynamic testing, post void residual bladder volume
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10
Q

Management- urge incontinence

A
  1. Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding). Pelvic floor exercises as well
  2. Bladder stabilising drugs: antimuscarinics are first-line. Oxybutynin , tolterodine. Caution with elderly due to delirium
  3. Mirabegron (a beta-3 agonist) if concern about anticholinergic side-effects in frail elderly patients
  4. Botulinum toxin A in the bladder wall
  5. Sacral nerve stimulation
  6. Augmentation cystoplasty
  7. Urinary diversion
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11
Q

Management: stress incontinence

A
  1. Pelvic floor muscle training: at least 8 contractions performed 3 times per day for a minimum of 3 months
  2. Conservative: weight loss, avoid caffeine, diuretics. Dont restrict fluid
  3. Surgical procedures: Mid urthral slings are the gold standard
  4. Duloxetine; offered to women if they decline surgical procedures. A combined noradrenaline and serotonin reuptake inhibitor
  5. Intramural bulking agents
  6. Colposuspension and fascial slings
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12
Q

Uro-genital prolapse risk factors

A
  • Age, Parity
  • Menopause
  • High BMI
  • Previous pelvic surgery
  • Heavy lifting and manual work
  • Smoking, chronic cough
  • Genetic predisposition
  • Connective tissue disease (e.g. Marfan, Ehlers-Danlos)
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13
Q

Braden walker system: Uro-genital prolapse

A
  1. Grade 0: normal
  2. Grade 1: descent halfway to hymen
  3. Grade 2: descent to hymen
  4. Grade 3: descent halfway past the hymen
  5. Grade 4: maximum possible desecent/procidentia
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14
Q

Types of prolapse

A
  • Cystocele: bladder
  • Urethrocele: urethra
  • Enterocele: small intestine
  • Rectocele: rectum
  • Vaginal vault: roof of the vagina
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15
Q

Symptoms of prolapse

A
  • Pelvic discomfort or a sensation of ‘heaviness’
  • Visible protrusion of tissue from the vagina
  • Urinary symptoms such as incontinence, recurrent urinary tract infections or difficulties voiding
  • Defecatory symptoms, includingconstipationor incomplete bowel emptying
  • Sexual dysfunction, including dyspareunia
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16
Q

Management of uterovaginal prolapse

A
  1. Address lifestyle factors: weight loss, smoking cessation
  2. Physiotherapy: pelvic floor exercises
  3. Pessaries
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17
Q

Surgery for prolapse

A
  • cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • uterine prolapse: hysterectomy, sacrohysteropexy with mesh
  • rectocele: posterior colporrhaphy
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18
Q

UTI features

A
  • dysuria
  • urinary frequency
  • urinary urgency
  • cloudy/offensive smelling urine
  • lower abdominal pain
  • fever: typically low-grade in lower UTI
  • malaise
  • Infection of the bladder, main cause E.coli
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19
Q

UTI treatment not pregnant

A
  • Trimethoprim (first line) or nitrofurantoin for 3 days
  • send a urine culture if: aged > 65 years, visible or non-visible haematuria
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20
Q

UTI treatment pregnant women

A
  • Symptomatic: a urine culture should be sent in all cases, should be treated with an antibiotic for first-line: nitrofurantoin (should be avoided near term), second-line: amoxicillin or cefalexin. Avoid Trimethoprim
  • Asymptomatic bacteriuria in pregnant women: a urine culture should be performed routinely at the first antenatal visit. An immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. 7-day course. A further urine culture should be sent following completion of treatment as a test of cure
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21
Q

UTI treatment: male

A
  • 7 days course of antibiotics
  • trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected
  • a urine culture should be sent in all cases before antibiotics are started
  • Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).
22
Q

UTI treatment: catheterised patient

A
  • do not treat asymptomatic bacteria in catheterised patients
  • if the patient is symptomatic they should be treated with an antibiotic
  • a 7-day, rather than a 3-day course should be given
  • consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
23
Q

Acute pyelonephritis

A
  • For patients with sign of acute pyelonephritis hospital admission should be considered
  • the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
24
Q

Varicella zoster pregnancy

A

Vesicular (‘small blisters’): Contact with vesicular rash à check for immunity to chickenpox

25
Q

Chickenpox (VZV)

A
  • Widespread vesicular rash on face, lesions crop. Prodrome (mild fever/malaise) 48h before rash.
  • Infectious 48h before rash and until vesicles crust over
  • Management: determine maternal immunity status – check for maternal IgG. Consider giving VZ immunoglobulin.
26
Q

Varicella zoster complications for mother and fetus

A
  1. Maternal – pneumonia, hepatitis, encephalitis, death
  2. Fetal – fetal varicella syndrome esp. if before 20 weeks
  3. Neonatal – if at time of delivery can get neonatal varicella 30% mortality. If contract chickenpox within 7d delivery or following, should receive prophylaxis
27
Q

Shingles and pregnancy

A

Shingles (reactivation of latent VZV, cannot be ‘caught’ from chickenpox)

  • Localised vesicular rash – dermatomal distribution
  • No risk to fetus or neonate
28
Q

Congenital varicella syndrome

A
  • Occurs when a non immune woman contracts VZV during the first trimester
  • Clinical effects: low birth weight, limb hypoplasia, skin scarring, microcephaly, eye defects, learning disability
  • Severe neonatal varicella: if rash develops between 5 days before an 2 days after birth, fatal to new-born child 20%
29
Q

Management congenital varicella syndrome

A
  • Women who lack VZV should be counselled to avoid exposure
  • If non immune pregnant women has contact give immunoglobulins. Check blood for immunoglobulins first
  • Management: Acyclovir within 24hrs of rash onset, post delivery neonate gets IV acyclovir
30
Q

Vasa praevia investigations and management

A
  • A-E approach: abdominal palpitation, speculum examination, digital vaginal examination (avoid if suspected placental praevia) and USS
  • Bedside: BP, pulse, respiratory rate, oxygen sats, temp
  • Bloods: FBC, U&E, LFT’s, Clotting profile, group and save, crossmatch
  • CTG and doppler ultrasound: to assess the fetus
  • If significant haemorrhage deliver baby by C-section
31
Q

Vasa praevia symptoms

A
  • Definition; rare complication where foetal vessels run through the membranes and close to/over the cervical os. Prone to rupture during rupture of membranes which can result in haemorrhage
  • Symptoms: painless PV bleed, ruptured membranes, a soft, non-tender uterus, foetal bradycardia (vasa praevia is the only APH where blood loss is directly from the foetus
32
Q

Vasa praevi risk factors, investigations and management

A
  • Risk factors: IVF pregnancy, low lying placenta, multiple pregnancy
  • Ix; transabdominal and transvaginal US, CTG
  • Management: an elective c-section at 35-36 weeks, give Corticosteroids from 32 weeks
  • Complications: HIE, preterm labour
33
Q

VTE in pregnancy management

A
  • LMWH to treat then continue for pregnancy and 6 weeks postnataly
  • Massive PE: unfractionated heparin, thrombolysis, surgical embolectomy
  • Prophylaxis with LMWH from 28 weeks if three risk factors and the first trimester if >4 risk factors. Continued through the antenatal period and 6 weeks postnatal. Stop during labour
  • If contraindicated to LMWH: use intermittent pneumatic compression and compression stockings
  • Risk assessment is done at booking and after birth
  • Don’t use Wells core or D-dimer in pregnancy
34
Q

Risk factors for VTE in pregnancy

A
  • Smoking
  • Parity ≥ 3
  • Age > 35 years
  • BMI > 30
  • Reduced mobility
  • Multiple pregnancy
  • Pre-eclampsia
  • Gross varicose veins
  • Immobility
  • Family history of VTE
  • Thrombophilia
  • IVF pregnancy
35
Q

VTE in puerperium

A

If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy

36
Q

Vulval cancer symptoms

A
  • vulval pain or soreness
  • persistent vulval itching
  • a vulval lump or ulceration
  • thickened, raised patches which can be red, white or dark
  • Unexplained vulval bleeding
37
Q

Causes of vulval cancer

A

Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.

38
Q

Vulval cancer risk factors

A
  • Human papilloma virus (HPV) infection
  • Vulval intraepithelial neoplasia (VIN)
  • Immunosuppression
  • Age
  • Lichen sclerosus
39
Q

Vulval cancer features

A
  • lump or ulcer on the labia majora
  • inguinal lymphadenopathy
  • may be associated with itching, irritation
  • 2WW: unexplained vulval lump, ulceration or bleeding
40
Q

Vulva cancer treatment

A
  • Watch and wait with close follow up
  • Wide local excision (surgery) to remove the lesion
  • If advanced: radical vulvectomy with bilateral inguinal lymphadectomy
  • Neoadjuvent chemo
  • If no surgery: radiotherapy
  • Imiquimod cream
  • Laser ablation
41
Q

Vulva cancer investigations

A
  • Biopsy of the lesion
  • Sentinel node biopsy to demonstrate lymph node spread
  • Further imaging for staging (e.g. CT abdomen and pelvis)
42
Q

Condoms

A
  • MOA: physical barrier
  • Relatively low success rate, particularly when used by young people
  • Helps protect against STI’s
43
Q

Combined oral contraceptive pill

A
  • Inhibits ovulation
  • Increases risk of Venous thromboembolism
  • Increases risk of breast and cervical cancer
44
Q

Progesterone only pill MoA

A
  • Thickens cervical mucus
  • Irregular bleeding a common side effect
45
Q

Injectable contraceptive (medroxyprogesterone acetate) MoA

A
  • Primary: inhibits ovulation also thickens cervical mucus
  • Lasts 12 weeks
46
Q

Implantabel contraceptive (etanogestrel) MoA

A
  • Primary: inhibits ovulation, also thickens cervical mucus
  • Irregular bleeding a common side effect, lasts 3 years
47
Q

Intrauterine MoA

A

Intrauterine contraceptive device: decreases sperm motility and survival

Intrauterine system (levonorgestrel)
- Primary: prevents endometrial proliferation also thicken cervical mucus
- Irregular bleeding is a common side effect

48
Q

Morning after pill

A

levonorgestrel and ulipristal, a progesterone receptor modulator.

49
Q

Levonorgestrel

A
  • Acts both to stop ovulation and inhibit implantation
  • should be taken as soon as possible - efficacy decreases with time
  • must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
  • the dose should be doubled for those with a BMI >26 or weight over 70kg
  • if vomiting occurs within 3 hours then the dose should be repeated
  • can be used more than once in a menstrual cycle if clinically indicated
  • hormonal contraception can be started immediately afterwards
50
Q

Ulipristal

A
  • a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
  • 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
  • concomitant use with levonorgestrel is not recommended
  • Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
  • caution should be exercised in patients with severe asthma
  • Can be used more than once in the same cycle
  • breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Year 5 (24 decks)

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