Reproduction A Grade Conditions Flashcards
1
Q
What is atrophic vaginitis?
A
Falling levels of oestrogen in postmenopausal women leads to drier, thinner and more fragile vaginal mucosa
2
Q
What is the aetiology behind atrophic vaginitis?
A
Natural menopause or oopherectomy
Ani-oestrogenic treatment (tamoxifen)
Radiotherapy/chemo
Post-partum
3
Q
How does atrophic vaginitis present?
A
Vaginal dryness Burning or itching of vagina or vulva Dyspareunia Vaginal discharge Vaginal bleeding Post coital bleeding Urinary symptoms - increased frequency, nocturia, UTI, dysuria
4
Q
What may be found on examination in atrophic vagina?
A
External genitalia may show reduced pubic hair, reduced turgor or elasticity
Thin mucosa with diffuse erythema
Lack of vaginal folds
Dryness
5
Q
What are the investigations for atrophic vaginitis?
A
Genital Examination
Urine dip/culture if UTI symptoms
Vaginal ph testing (more alkaline)
6
Q
How should atrophic vaginitis be managed?
A
Personal lubricants
Moisturisers
Systemic or topical HRT
Vaginal oestrogen pessaries
7
Q
What is an ectopic pregnancy
?
A
Where a fertilised egg implants itself outside the uterus
8
Q
Epidemiology of ectopic pregnancy
A
11/1000
9
Q
Where is the most common site for an ectopic pregnancy?
A
Fallopian tubes (ampulla or isthmus)
10
Q
What are the risk factors for ectopic pregnancy?
A
IVF History of pelvic inflammatory disease Pelvic adhesions Previous tubal surgery IUCDs
11
Q
How does ectopic pregnancy present?
A
Abdo pain Pelvic pain Amenorrhoea Missed period Vaginal bleeding
Dizziness Breast Tenderness Shoulder tip pain Urinary symptoms Passage of tissue Rectal pain GI symptoms
Adnexal or pelvic tenderness on examination
12
Q
What investigations should be done for a suspected ectopic pregnancy?
A
TV US
hCG levels
13
Q
How is an ectopic pregnancy managed?
A
Anti-D rhesus prophylaxis to all rhesus negative women
Medical Management
- single dose methotrexate
Surgical Management
- adnexal mass >35mm, fetal heartbeat visible on scan, serum hCG >5000 IU/L
14
Q
What is pelvic inflammatory disease?
A
Infection and inflammation of the upper female genital tract. Usually ascending infection from the cervix Common and serious complication of chlamydia and gonnorhoea.
15
Q
What is the epidemiology of PID?
A
Commonly occurs in women aged 20-29
16
Q
What is the aetiology behind PID?
A
Chlamydia trachomatis or Neisseria gonorrhoeae.
Endogenous vaginal flora
Mycobacterium tuberculosis
17
Q
What are the risk factors for developing PID?
A
Young age New sexual partner Multiple sexual partners Lack of barrier contraception Termination of pregnancy
18
Q
How does PID present?
A
Can be asymptomatic Bilateral lower abdominal pain Deep dyspareunia Abnormal vaginal bleeding Purulent cervical or vaginal discharge
On Examination
- lower abdo tenderness
- mucopurulent cervical discharge and cervicitis on speculum discharge
- Cervical motion tenderness and adnexal tenderness on bimanual vaginal examination
- Fever above 38 degrees
19
Q
What investigations should be done for someone with suspected PID?
A
Pregnancy test
Cervical swabs for chlamydia and gonnorhoea
Endocervical swab for c.trachomatis and n. gonnorhoeae
Elevated ESR or CRP
Endometrial biopsy and US
Urinalysis and urine culture
20
Q
How is PID managed?
A
Antibiotic treatment
- IM ceftriaxone 500mg
+ oral doxycycline 100mg + metronidazole 400mg for 14 days
21
Q
What are the complications of PID?
A
Infertility Ectopic pregnancy Chronic pelvic pain Perihepatitis Reactive arthritis
22
Q
What is chlamydia ?
A
An STI caused by chlamydia trachomatis
23
Q
Epidemiology
A
50% of men infected DO NOT show symptoms
70% of women infected DO NOT show symptoms
Most common in people <25
24
Q
What are the risk factors for chlamydia?
A
age <25 Two or more sexual partners in the last year Recent change in sexual partner Non-barrier contraception use Infection with another STI
25
What are the symptoms of chlamydia?
Female
- vaginal discharge
- dysuria
- vague lower abdominal pain
- fever
- intermenstrual or post coital bleeding
- deep dyspareunia
Male
- urethritis
- dysuria
- urethral discharge
- epididymo-orchitis presenting with unilateral testicular pain and swelling
26
Signs of chlamydia?
Female
- friable, inflamed cervix
- abdo tenderness
- endocervical discharge
- cervical excitation
Male
- epidydimal tenderness
- mucoid or mucopurulent discharge
- perineal fullness due to prostatitis
27
What investigations can be done for chlamydia?
Female
- vulvovaginal swab
Men
- first catch urine specimen
28
How is chlamydia managed?
Antibiotics
- doxycycline 100mg BD for 7 days
OR
- single dose azithromycin
Repeat test after treatment
Screen for other STIs
Offer partner tracing
Reiterate safe sex practices
29
What are the complications of chlamydia?
```
PID
Infertility
Ectopic pregnancy
Epididymo-orchitis
Reactive arthritis
```
30
What is gonorrhoea?
An STI caused by Neisseria gonorrhoeae which infects the membranes of the urethra, endocervix, rectum, pharynx and conjunctiva
31
How is gonorrhoea transmitted?
Sexually
| Perinatally
32
What is the epidemiology of gonorrhoea?
> risk in MSM
Symptomatic in 90-95% of men
Symptomatic in 50%
33
What are the risk factors for gonorrhoea ?
```
Young age
Hx of prev STI
Co-existent STI
New or multiple sexual partners
Inconsistent condom use
Hx of drug use or commercial sex work
```
34
How does gonorrhoea present ?
Men
- urethral infection (discharge, dysuria,
asymptomatic)
- rectal infection (anal discharge, perianal pain, pruritus, bleeding)
- pharyngeal infection (usually asymptomatic)
Women
- Endocervical infection (frequently asymptomatic, increased vaginal discharge, lower abdo pain, intermenstrual bleeding)
- urethral infection (dysuria)
- rectal infection
- pharyngeal infection
35
What are the signs of gonorrhoea ?
Men
- mucopurulent urethral discharge
- epidydimal tenderness
Women
- mucopurulent endocervical discharge
- easily induced contact bleeding of endocervix
- pelvic/lower abdominal tenderness
- normal examination
36
How is gonorrhoea investigated?
Men
- first pass urine
Women
- endocervical swab
Swab of pharynx and rectum
37
How is gonorrhoea managed?
IM ceftriaxone 500mg
| plus oral azithromycin 1g
38
What are the complications of gonorrhoea?
Prostatitis
Peri-urethral abscess
Perihepatitis
PID
Reactive arthritis
39
What is trichomoniasis vaginalis?
A STI caused by a parasite. Spread thorugh sexual activity. Lives in urethra of men and women, and in the vagina of women
40
How does trichomonas present?
Asymptomatic in 50% of cases
- vaginal discharge (frothy, yellow green and fishy smell)
- itching
- dysuria
- dyspareunia
- balanitis
41
What clinical signs are associated with trichomoniasis?
Strawberry cervix
42
How is trichomoniasis diagnosed?
Charcoal swab with microscopy from vagina
Men:
Urethral swab
First catch urine
43
How should trichomoniasis be managed?
Metronidazole
44
What is HIV?
Human immunodeficiency virus - a RNA retrovirus which destroys CD4 T-helper cells of the immune system
45
What is AIDS?
Acquired Immunodeficiency Syndrome - infections gained when HIV positive
46
How is HIV transmitted?
- Unprotected anal, vaginal or oral sexual activity
- Mother to child at any stage of pregnancy, birth or breastfeeding
- Mucous membranes, blood or open wound exposure to infected blood or bodily fluids
47
Give examples of AIDS defining illnesses?
```
Kaposi's sarcoma
Pneumocystis jirovecii pneumonia
Cytomegalovirus infection
Candidiasis
Lymphomas
TB
```
48
How long after infection do HIV antibodies develop?
Roughly three months
49
How is HIV tested for?
Antibody testing
p24 antigen testing
PCR for HIV RNA tests for viral load
50
How is HIV monitored ?
```
CD4 count (500-1200 = normal, <120 = end stage HIV)
Viral Load
```
51
How is HIV treated?
ART medications
- protease inhibitors
- integrase inhibitors
- NRTIs
- NNRTIs
- Entry Inhibitors
Prophylactic co-trimoxazole to protect against PCP
Yearly cervical smears
Cardiac monitoring
Yearly vaccination
52
What is syphilis ?
STI caused by treponema pallidum which enters via skin or mucous membranes, replicates and then disseminates throughout the body
53
How is syphilis transmitted?
Oral, vaginal or anal sex involving direct contact with the area
Vertical transmission
IV drug use
Blood transfusions and other transplants
54
What are the stages of syphilis?
Primary syphilis
- painless chancre at original site of infection
Secondary Syphilis
-systemic symptoms of skin and mucous membranes that resolve within 3-12 weeks
Latent stage
- symptoms disappear and patient becomes asymptomatic despite being infected
Tertiary
- can occur after many years after the initial infection. Can affect many organs of body, gummas develop and CV and neuro complications arise
55
How does syphilis present?
Primary
- chancre
Secondary
- maculopapular rash
- wart like lesions around genitals/rectum
- low grade fever
- alopecia
- oral lesions
Tertiary
- Gummas
- aortic aneurysms
- neurosyphilis
Neurosyphilis
- headache
- altered behaviour
- dementia
- ocular syphilis
- tabes dorsalis
56
What eye sign can be seen in neurosyphilis?
Argyll-roberston pupil - pupil accomodates when focusing on near object, it does not react to light
57
How is syphilis diagnosed?
Antibody testing for t pallidum
Swabs from infected area then dark field microscopy and PCR
58
How is syphilis managed?
Deep IM injection of benzathine benzylpenicillin
Contact tracing
Information about other STIs
Screening for other STIs
Education on prevention
59
What is a post partum haemorrhage?
Bleeding after the delivery of the baby and placenta, and is the most common cause of significant obstetric haemorrhage
Defined as:
over 500ml of blood loss after vaginal delivery
over 1000ml of blood loss after c-section
60
What is a minor PPH?
<1000ml blood loss
61
What is major PPH?
>1000ml blood loss
62
What is moderate PPH?
1000-2000ml blood loss
63
What is severe PPH?
>2000ml blood loss
64
What is primary PPH?
Bleeding within 24 hours of birth
65
What is secondary PPH?
Bleeding from 24hrs to 12 weeks after birth
66
What are the causes of of PPH?
4 Ts
- Tone
- Trauma
- Tissue
- Thrombin
67
What are the risk factors ?
```
Previous PPH
Multiple pregnancy
Obesity
Large Babies
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta Accreta
Retained Placenta
Instrumental delivery
Episiotomy or perineal tear
```
68
How can you reduce the risk and consequences of a PPH?
Treating anaemia during the antenatal clinic
Giving birth with an empty bladder
Active management of the third stage of labour
IV tranexamic acid during C-Section in high risk patients
69
How is a PPH managed?
ABCDE approach
Lie patient flat and insert two large bore cannula
Bloods for FBC, U&E and clotting screen
Grouped and cross match 4 units
Warmed IV fluids and blood resuscitation as required
Oxygen
Fresh frozen plasma after 4 units
70
What treatments are used to stop the bleeding?
Mechanical
- rubbing uterus to stimulate uterine contraction
- catheterisation
Medical
- Oxytocin
- Ergometrine (contraindicated in HTN)
- Carboprost
- Misopristol
- Tranexamic Acid
Surgical
- Intrauterine balloon tamponade
- B-Lynch suture
- Uterine artery ligation
- Hysterectomy
71
What is the most common cause of secondary post partum haemorrhage?
Retained products of conception
| Infection
72
How do you investigate a secondary post partum haemorrhage?
US
| Endocervical and high vaginal swabs
73
How is a secondary PPH managed?
Evacuation
| Antibiotics
74
What is maternal sepsis?
A condition where the body launches a large immune response to infection, causing systemic inflammation and affecting organ function
75
What are the two most common causes of maternal sepsis?
Chorioamnionitis
| Urinary Tract Infections
76
What is chorioamnionitis ?
Infection of chorioamniotic membranes and amniotic fluid
77
How does maternal sepsis present?
```
Fever
Tachycardia
Raised RR
Reduced oxygen saturations
Low blood pressure
Altered consciousness
Reduced urine output
Raised WBC
Evidence of fetal compromise on CTG
```
78
What signs and symptoms are related to chorioamnionitis?
Abdominal Pain
Uterine Tenderness
Vaginal Discharge
79
What signs and symptoms of maternal sepsis are related to UTI ?
```
Dysuria
Urinary frequency
Suprapubic Pain
Renal angle pain
Vomiting
```
80
What investigations should be done for maternal sepsis?
```
FBC
U&Es
LFTs
CRP
Clotting
Blood cultures
Blood Gas
```
Urine dipstick and cultures
High vaginal swab
81
How should maternal sepsis be managed?
Maternal and fetal monitoring
- if foetus distressed then C-Section indicated. Spinal anaesthesia should be avoided in sepsis.
```
SEPSIS 6
Take
- lactate
- blood cultures
- urine output
```
Give
- IV fluids
- IV antibiotics (amoxicillin, clindamycin and gentamycin)
- Oxygen
82
What is thrombosis a result of?
Stagnation of blood and hyper-coaguable states
83
What are the risk factors for developing a VTE in pregnancy?
```
Smoking
Parity >/= 3
Age >35
BMI>30
Reduced mobility
Multiple Pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
FH of VTE
Thrombophilia
IVF Pregnancy
```
84
When is VTE prophylaxis advised?
In first trimester, if there are three risk factors
At 28 weeks if there are four or more risk factors
If patient has had previous VTE, medical conditions such as cancer or arthritis, surgical procedures during pregnancy, hospital admission during pregnancy
85
What VTE prophylaxis is used in pregnancy?
LMWH e.g. dalteparin, enoxaparin
Compression stockings
86
How does a VTE present?
DVT
- unilateral leg pain
- calf swelling
- oedema
- colour changes to the leg
PE
- shortness of breath
- cough +/- blood
- pleuritic chest pain
- tachypnoea
- tachycardia
- pleuritic chest pain
- hypoxia
- low grade fever
- haemodynamic instability causing hypotension
87
How is a VTE investigated?
Doppler US of leg for suspected DVT
PE
- CXR
- ECG
- CTPA
- VQ Scan
88
How is VTE managed in pregnancy?
LMWH immediately if VTE suspected. Treatment can be stopped if VTE is excluded
89
What is pre-eclampsia?
New high blood pressure and end organ dysfunction, notably proteinuria, which occurs after 20 weeks gestation. This occurs because the spiral arteries of the placenta form abnormally, leading to high vascular resistance in these vessels
90
What is the pre-eclampsia triad?
Hypertension
Proteinuria
Oedema
91
What is chronic hypertension?
HTN which exists before 20 weeks gestation and is longstanding
92
What is gestational hypertension?
Hypertension occurring after 20 weeks gestation, without proteinuria
93
What is eclampsia?
Seizures that occur as a result of pre-eclampsia
94
What are the risk factors for developing pre-eclampsia?
```
Pre existing HTN
Prev HTN in pregnancy
Existing autoimmune condition
Diabetes
CKD
Older than 40
BMI >35
>10 years since last pregnancy
Multiple pregnancy
First pregnancy
FH of pre-eclampsia
```
95
What symptoms present in pre-eclampsia?
```
Headache
Visual Disturbance
Nausea and vomiting
Upper abdominal or epigastric pan due to liver swelling
Oedema
Reduced urine output
Brisk Reflexes
```
96
How is pre-eclampsia diagnosed?
BP monitoring
- systolic >140
- diastolic >90
Urine dipstick
- proteinuria
Blood tests
- raised liver enzymes, raised creatinine, thrombocytopenia, haemolytic anaemia
US
- fetal growth restriction
Clinic Hx - seizures/headaches/visual changes
97
How is proteinuria quanitified?
Albumin:creatinine ratio >30mg/mmol
| Urine protein:creatinine ratio >8mg/mmol
98
How is pre-eclampsia managed?
Aspirin prophylaxis at 12 weeks (if 1 risk factor present)
Monitor BP, urine dipstick and symptoms
Medical
- labetalol
- nifedipine
- methyldopa
- IV hydralazine
- IV magnesium sulphate
- Fluid restriction
Corticosteroids should be given to women having a premature birth to encourage lung development
99
What medications are not safe to use for hypertension control in pregnancy?
ACEi (Ramipril)
ARB (losartan)
Thiazide/Thiazide-like diuretics (indapamide)
100
What medications are safe to use to treat hypertension in pregnancy?
Labetalol
CCBs - nifedipine
Alpha Blockers (doxazosin)
101
How much folic acid should be taken by women with epilepsy if they are planning to get pregnant?
5mg from before conception to reduce risk of neural tube defects
102
What anti-epileptics can be used during pregnancy?
Leveteracetam, lamotrigene, carbamezapine
103
What anti-epileptics should be avoided during pregnancy?
Sodium valproate
| Phenytoin
104
What does obesity during pregnancy put you at risk of?
```
Pre eclampsia
Thrombosis
Gestational diabetes
Miscarriage
Large for gestational age babies
```
105
What is gestaional diabetes?
Diabetes triggered by pregnancy, caused by reduced insulin sensitivity during pregnancy, and resolves after birth
106
What are the complications of having gestational diabetes?
Macrosomia
Large for dates fetus
Shoulder dystoica
Long term increased risk of type 2 diabetes outwith pregnancy
107
What are the risk factors for developing gestational diabetes?
```
Prev. gestational diabetes
Prev. macrosomic baby (>4.5 kg)
BMI>30
Ethnic origin
FH of diabetes
```
108
How is gestational diabetes diagnosed?
OGTT at 24-28 weeks gestation if risk factors identified
Fasting results should be <5.6
At two hours, should be <7.8
109
How is gestational diabetes managed?
Four weekly ultrasound from 28 weeks
Fasting glucose <7 = trial of diet and exercise for 2 weeks, then metformin, then insulin
Fasting glucose >7 = insulin and metformin
Fasting glucose >6 + macrosomia = insulin and metformin
110
If ladies with pre-existing diabetes decide to become pregnant, what should be done?
5mg of folic acid from before conception until 12 weeks gestation
111
How should pre-existing type 1 and 2 diabetes be managed in pregnancy?
Good insulin control
Type2 - stop other oral diabetic medications - metformin and insulin are safe
Retinopathy screening after booking and at 28 weeks
Planned delivery for 37-38+6 weeks + consider sliding scale insulin
112
What are babies of mothers with diabetes at risk of ?
```
Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart disease
Cardiomyopathy
```
113
What is placenta praevia ?
When the placenta presents in the lower portion of the uterus, lower that the presenting part of foetus.
Covers the cervical os
114
What are the risks of having placenta praevia?
```
Antepartum Haemorrhage
Emergency c-section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth
Stillbirth
```
115
What are the risk factors for developing placenta praevia?
```
Prev c-section
Prev placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (fibroids)
Assisted reproduction
```
116
What are the grades of placenta praevia?
Grade I = Placenta is in the lower segment of uterus but does not reach the internal cervical os
Grade II - Placenta reaches but does not cover the internal os
Grade III - placenta partially covers the interal os
Grade IV - placenta completely covers the os
117
How is placenta praevia diagnosed?
20 week US scan
118
How does placenta praevia present?
Can be asymptomatic
| Painless vaginal bleeding usually after 36 weeks
119
How is placenta praevia managed?
Repeat TV US at 32 weeks and then again at 36 weeks
Corticosteroids given at 34 and 35+6 weeks due to risk of preterm labour
Planned delivery betwen 36-37 weeks to avoid spontaneous labour and bleeding. C-section.
120
What is the main complication of placenta praevia ?
Haemorrhage before, during and after delivery
121
What is placental abruption?
When placenta separates from the wall of the uterus during pregnancy.
122
What are the risk factors for placental abruption?
```
Pre Eclampsia
Bleeding early in pregnancy
Trauma (?domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or amphetamine use
```
123
How does placental abruption present?
Sudden and severe abdominal pain that is severe
Vaginal bleeding
Shock
Abnormalities on CTG
Woody abdomen on palpitation, suggesting a large haemorrhage
124
How is placental abruption managed?
Clinical diagnosis
Management
- 2x grey cannula
- bloods - FBC, UE, LFT, Coagulation Studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the foetus
- Close monitoring of the mother
- Emergency section if mother unstable or fetus distressed
Kleihauer test and prophylactic Anti-D
Corticosteroids at 24 and 36 weeks
Active management of third stage of labour
