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Reproduction > Reproduction Pathology > Flashcards

Reproduction Pathology Flashcards

1
Q

What is menorrhagia

A

Heavy menstrual bleeding that interferes with QOL

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2
Q

What is the definition of menorrhagia

A

Heavy blood loss
>80ml blood loss
However mainly the patients perspective!!

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3
Q

Risk factors for menorrhagia

A

Age

Obesity

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4
Q

Potential causes of menorrhagia

A 
IUCD (intrauterine contraceptive device)
Fibroids
Endometriosis 
Adenomyosis 
Pelvic infection 
Polyps 
Hypothyroidism 
Coagulation problems
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5
Q

What is dysfunctional uterine bleed

A

Most common cause of menorrhagia

Dx of exclusion

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6
Q

Symptoms of menorrhagi

A 
Changes in 
Clots 
Floods 
Heavy or prolonged vaginal bleed 
Worsening impact on QOL 
Having to use pad and tampon
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7
Q

Ix for menorrhagia

A 
Pregnancy test (exclude)
FBC
Haematinics 
TSH 
Cervical smear
STI screen
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8
Q

If <45yrs with menorrhagia nothing found on initial Ix what is the next step?

A

No further Ix

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9
Q

If >45yrs with menorrhagia what other IX can you do?

A

TVUSS
Hysteroscopy
Endometrial biopsy

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10
Q

1st line Rx for menorrhagia

A

Mirena IUD

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11
Q

2nd line Rx for menorrhagia

A

Antifibrinolytics: Mefenamic acid/Traxemanic acid

COCP

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12
Q

3rd line Rx for menorrhagia

A

Long acting progesterones (Norithisterone)

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13
Q

Surgical Rx for menorrhagia

A

Endometrial ablation

Hysterectomy (last resort)

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14
Q

What should be noted about surgical intervention for menorrhagia

A

It can cause infertility

Need to consider a womans fertility/need for fertility before surgical options

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15
Q

What are the 2 classifications of amenorrhoea

A

Primary

Secondary

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16
Q

Define primary amenorrhoea

A

Menstruation has not occurs by 16yrs

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17
Q

Does norethisterone act as a contraceptive?

A

No

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18
Q

Primary causes of amenorrhoea

A 
Turner syndrome 
Testicular feminisation
Imperforated hymen 
Eating disorder 
Congenital adrenal hyperplasia 
Intense exercise (e.g gymnasts)
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19
Q

Secondary causes of amenorrhoea

A 
Pregnancy (most common)
Contraceptive/hormonal methods 
Polycystic ovaries disease
Thyroid disease
Hyperprolactinaemia (prolactinoma)
Sheehan's Syndrome
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20
Q

Define secondary amenorrhoea

A

Absence of menstruation for 6 months in a women who previously had normal menstruation

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21
Q

FIRST Ix for Amenorrhoea

A 
Pregnancy test (b-HCG)
Urine pregnancy test
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22
Q

Other Ix for amenorrhoea

A 
FBC 
TFTs
FSH 
LH 
Oestradiol 
Prolactin 
Testosterone 
Karyotyping if suspected genetic 
Pelvic USS
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23
Q

Rx for amenorrhoea

A

Treat underlying cause

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24
Q

General Rx for amenorrhoea

A

Weight loss

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25
Q

Rx for amenorrhoea due to ovarian insufficiency

A

HRT

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26
Q

Rx for amenorrhoea due to hypothyroidism

A

Levothyroxine

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27
Q

Rx for amenorrhoea due to PCOS

A 
Weight loss 
Metformin 
Clomifene 
OCP with anti-angrogen effect 
Eflornithine
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28
Q

What is eflornithine used to treat in PCOS

A

Excessive facial hair growth in women

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29
Q

What is the main action of clomifene

A

Induce ovulation

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30
Q

Rx for amenorrhoea due to hyperthyroidism

A

Carbimazole

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31
Q

For how long should you assume women are fertile in amenorrhoea

A

Assume fertile and need contraception unless >2yrs after menopause

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32
Q

Define miscarriage

A

Loss of pregnancy <24 weeks

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33
Q

When do the majority of miscarriages occur

A

First trimester

<12 weeks

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34
Q

What is the most common early pregnancy complication

A

Miscarriage

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35
Q

Potential causes of miscarriage

A 
Abnormal conceptus (chromosomal, genetic, structural)
Uterine abnormality 
Congenital (Mullerian ducts)
Fibroids
Cervical incompetence
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36
Q

Maternal risk factors for miscarriage

A

Increasing age
DM
Acute maternal infection

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37
Q

Define threatened miscarriage

A

Bleeding from gravid uterus <24 weeks
Viable fetus
No evidence of cervical dilatation

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38
Q

Define inevitable miscarriage

A

Cervix already began to dilate

Viable pregnancy

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39
Q

Define Incomplete miscarriage

A

Only partial expulsion of products of conception

Some product of pregnancy remain within the uterus

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40
Q

Define complete miscarriage

A

Complete expulsion of products

In order to confirm Dx need to confirm there was a pregnancy beforehand

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41
Q

Define missed miscarriage (sometimes called silent)

A

Fetus died in utero

Uterus made to attempt to expel products

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42
Q

Describe the cervix in a threatened miscarriage

A

Closed

No evidence of dilatation

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43
Q

Describe the cervix in an inevitable miscarriage

A

Open

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44
Q

Clinical features of miscarriage

A

Bleeding vaginally
Pain

Can be asymptomatic in silent miscarriage

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45
Q

Describe pregnancy test results after a miscarriage

A

Can remain positive for a few days post miscarriage

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46
Q

Ix for miscarriage

A 
USS 
Beta hCG
FBC 
U&amp;E's
Rhesus status
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47
Q

Rx for early miscarriage

A

Usually does not require any medical intervention

Support and counselling

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48
Q

Rx for threatened miscarriage

A

75% will settle

Conservative/monitoring

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49
Q

Rx for evacuation in miscarriage

A

Mifepristone

Prostaglandins (misoprostol)

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50
Q

Rx for potentiatial heavy bleeding in miscarriage

A

Ergometrine

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51
Q

What is ergometrine used for

A

Causes contractions of the uterus to try and stop heavy menstrual bleeding

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52
Q

Define recurrent miscarriage

A

Loss of 3 or more pregnancies <24weeks gestation with the same biological father

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53
Q

Possible causes of recurrent miscarriage

A 
Bacterial vaginosis 
Parental chromosomal disorder 
Uterine abnormality 
Thrombophili 
Alloimmune causes 
Antiphospholipid syndrome
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54
Q

What is the main cause of recurrent miscarriage

A

Many causes the cause is unknown

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55
Q

Rx for recurrent miscarriage

A

Referral to specialist clinic

Will run tests

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56
Q

What needs to be considered regarding the patient in recurrent miscarriage

A

Psychological effects

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57
Q

What is an ectopic pregnancy

A

A pregnancy that implants outside the uterine cavity

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58
Q

Incidence of ectopic pregnancy

A

1 in 90

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59
Q

Risk factors for ectopic pregnancy

A

Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception

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60
Q

Most common site for ectopic pregnancy

A

Ampulla (uterine tube)

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61
Q

2nd most common site for ectopic pregnancy

A

Isthmus (uterine tube)

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62
Q

Rare sits for ectopic pregnancy

A

Cervix

Abdomen

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63
Q

Clinical features of ectopic pregnancy

A 
Period amenorrhoea with +ve pregnancy test
Vaginal bleeding 
Abdo. pain 
GI or urinary symptoms 
Diarrhoea 
Dizziness 
Vomiting 
Collapse
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64
Q

Ix for ectopic pregnancy

A

USS
Serum progesterone levels
Serum B-hCG levels
FBC

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65
Q

Why should you do FBC in ectopic pregnancy

A

To cross match 6 units of blood

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66
Q

Rx for ectopic pregnancy

A

Methotrexate

Use contraception for 3/12

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67
Q

Why should women use contraception for 3 months after Rx with methotrexate

A

Because methotrexate is highly teratogenic

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68
Q

Surgical Rx of ectopic pregnancy

A

Salpingotomy vs Salpingectomy (mostly laparoscopically)

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69
Q

What is a salpingotomy

A

Tubal incision amde

Leaving the uterine tube behind

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70
Q

What is a salpingectomy

A

Removal of the uterine tube

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71
Q

Main risk with salpingotomy

A

Leaving behind a damaged tube

Thus increasing the risk of a further ectopic pregnancy

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72
Q

Define antepartum haemorrhage

A

Haemorrhage from the genital tract >24 weeks pregnancy but before delivery of baby

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73
Q

What are the commonest causes of antepartum haemorrhage

A

Placenta praevia

Placental abruption

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74
Q

What is placenta praevia

A

Condition where the placenta lies low in the uterus and partially or fully covers the cervix

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75
Q

What is vasa praevia

A

Rupture of fetal vessels within fetal membrane

Blood loss is fetal in origin

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76
Q

What is the origin of blood loss in vasa praevia

A

Fetal

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77
Q

Is for APH

A

Blood cross match
U&E’s
Coagulation screens
USS

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78
Q

Rx for APH

A

Admission
Set IVI
Blood cross match

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79
Q

Rx for severe APH

A 
Elevate leg 
IVI 
Take bloods 
Give fresh ABO (Rh compatible)
Catheterise bladder
C-section for placenta praevia
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80
Q

What is placenta praevia

A

When all or part of the placenta implants in the lower uterine segment
Lying in front of the presenting fetus

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81
Q

Who is placenta praevia more common in

A

Multiparous women
Multiparous pregnancy
Previous CS

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82
Q

Describe Grade 1 placenta praevia

A

Placenta enroaches the lower uterine segment but not internal cervical OS

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83
Q

Describe Grade 2 placenta praevia

A

Placenta reaches internal cervical OS

But does not cover it

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84
Q

Describe Grade 3 Placenta praevia

A

Placenta eccentrically covers internal cervical OS

Placenta partially covers the internal Cervical OS

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85
Q

Describe Grade 4 placenta praevia

A

Central placenta praevia

Placenta completely covers the internal cervical OS

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86
Q

Clinical features of placenta praevia

A

Painless PV bleeding
Soft
Non-tender uterus
Fetal malpresentation

Incidental finding on USS

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87
Q

What MUST NOT be done in placenta praevia

A

Vaginal examination

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88
Q

Ix for placenta praevia

A

USS (commonly incidental finding)
MRI

Vaginal examination MUST NOT BE DONE

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89
Q

Management of placenta praevia

A

Depends on:
Gestation
Severity of blood loss

Blood transfusion
C-section

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90
Q

How should babies be delivered in placenta praevia

A

C-section

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91
Q

Define placental abruption

A

Haemorrhage resulting from premature separation of the placenta before the birth of the baby

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92
Q

What is placental abruption a major cause of

A

APH

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93
Q

Describe revealed placental abruption

A

Major haemorrhage revealed because blood escapes through cervical OS
The bleeding is apparent

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94
Q

Describe concealed placental abruption

A

Haemorrhage occurs between placenta and uterine wall
Uterine vol increases
The bleeding is not apparent

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95
Q

Describe mixed placenta abruption

A

Some bleeding is revealed but there is other bleeding occurring inside the uterus that is concealed
Some bleeding happening but more going on inside uterus

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96
Q

Clinical features

A 
Severe abdominal pain 
Vaginal bleeding (varying amounts)
Possible contractions
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97
Q

Ix of placental abruption

A

USS

Need to rule out other causes haemorrhage

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98
Q

Rx placental abruption

A

Depends on blood loss and fetal status
Monitoring (if no-one in distress)

Large can be urgent

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99
Q

Rx for large placental abruption

A

Can be as urgent as delivery

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100
Q

Associations with placental abruption

A 
Pre-eclampsia 
Chronic hypertension 
Multiple pregnancy 
Polyhydramnios 
Smoking 
Increasing age
Parity 
Previous abruption 
Cocaine use 
Infection
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101
Q

Complications of placental abruption

A 
Maternal shock 
Collapse
Fetal distress
Maternal DIC 
Renal failure 
Post partum haemorrhage
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102
Q

Definition of preterm labour

A

Onset of labour <37 weeks

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103
Q

Is preterm labour more common in singletons or multiples

A

Multiples
Singletons - 5-7%
Multiples - 30-40%

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104
Q

Define mildly preterm

A

32-36 weeks

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105
Q

Define very preterm

A

28-32 weeks

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106
Q

Define extremely preterm

A

24-28 weeks

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107
Q

Predisposing factors to preterm labour

A 
Multiple pregnancy
Polyhydramnios 
APH 
Pre-eclampsia 
Infection 
Premature rupture of membranes 
Majority no cause!! (idiopathic)
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108
Q

Clinical features of preterm labour

A

Same as normal labour but early
Contractions
Cervical dilatation + uterine contraction

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109
Q

Management of preterm labour

A

Tocolysis

Steroids to aid babies lung development

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110
Q

What is the action of tocolysis

A

To slow down contractions

Can only be used short term 24-48hrs

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111
Q

Why may tocolysis be used?

A

If mother needs transferred

Or to give baby steroids

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112
Q

What is the reason for giving premature labour steroidis

A

To aid with the fetal lung development

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113
Q

Reasons why you would induce preterm

A

Large baby
Pre-eclampsia
Infection
Placenta praevia

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114
Q

Neonatal morbidity resulting from prematurity

A 
Respiratory distress syndrome 
Intraventricular haemorrhage 
Cerebral palsy 
Nutrition 
Temperature control 
Jaundice 
Infection 
Visual impairment 
Hearing loss
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115
Q

What is the pre-invasive stage of cervical cancer known as?

A

Cervical intraepithelial neoplasia

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116
Q

Risk factors for CIN

A 
HPV 16/18 
Persistent high risk HPV infection 
Smoking 
Immunocompromised
COCP 
Multiple partners
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117
Q

At which anatomical location does CIN most commonly occur

A

Squamo-columnar junction

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118
Q

Describe CIN 1

A

Affects lower basal 1/3 cervical epithelium

60% will regress to normal

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119
Q

Describe CIN 2

A

<2/3 thickness of epithelium

may regress

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120
Q

Describe CIN 3

A

> 2/3 or full thickness of epithelium
Severe dysplasia
Unlikely to regress

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121
Q

Name dyskaryotic features

A

Increased nuclear size
Increase nucleus to cytoplasmic ratio
Coarse irregular chromatin
Nucleoli

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122
Q

How is CIN often diagnosed

A

Picked up on routine smear screening

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123
Q

Describe the current cervical screening programme

A 
Women 25-64yrs 
5yrly
All smears tested for cervical cytology 
If negative recalled in 5yrs 
If positive called for colposcopy
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124
Q

What is colposcopy

A

Examination of the cervix by colposcope

Painted with acetic acid

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125
Q

What type of biopsy can be done during colposcopy for histological Dx

A

Punch biopsy

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126
Q

Describe the cervical screening programmes as of 202

A

Women 25-64yrs
5 yrls
All smears tested for HPV
If HPV -ve recalled in 5yrs
If HPV +ve then tested by cytology
If cytology is +ve then called for colposcopy
If cytology is -ve then recalled for smear again in 1yr

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127
Q

Rx for CIN

A

Large loop excision of transformation zone

LLETZ

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128
Q

Other Rx for CIN

A

Cold coagulation
Laser ablation (rarely done)
Cone biopsy

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129
Q

Describe the HPV vaccination

A

Protects against HPV

6/11/16/18

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130
Q

What does the HPV type 6 and 11 cause

A

Genital warts

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131
Q

Which subtypes of HPV are associated with cervical cancer

A

16 and 18

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132
Q

What is the aim of cervical screening

A

Aim is to pick up neoplasms and reduce the risk of cervical cancer

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133
Q

Who is the HPV vaccination offered to>

A

Girls

Age 12

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134
Q

Complications of LLETZ

A

Haemorrhage
Infection
Vaso-vagal symptoms
Cervical stenosis

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135
Q

How often should HIV positive women have smears

A

Annually

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136
Q

What is the main type of cervical cancer

A

Squamous cell carcinoma

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137
Q

What is the 2nd main type of cervical cancer

A

Adenocarcinoma

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138
Q

Risk factors for cervical cancer

A 
Multiple partners 
High risk HPV 16/18
Age 45-55
Immunocompromised 
Long term COCP use 
Early age at 1st intercourse 
HIV 
Smoking
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139
Q

Describe stage 1 cervical cancer

A

Tumours confined to cervix

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140
Q

Describe stage 2 cervical cancer

A

Extended locally to upper 2/3 vagina

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141
Q

Describe stage 3 cervical cancer

A

Spread to lower 1/3 of vagina

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142
Q

Describe stage 4 cervical cancer

A

Spread to bladder or rectum

In IVb: Distant metastases

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143
Q

What is the staging classification system for cervical cancer

A

FIGO

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144
Q

Clinical features of cervical cancer

A 
Discharge 
Intermenstrual bleeding 
Post-coital bleeding 
Post-menopausal bleeding 
Pain
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145
Q

Ix cervical cancer in pre-menopausal woman

A

First chlamydia testing

If -ve urgent colposcopy and biopsy

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146
Q

Ix cervical cancer post-menopausal women

A

Urgent colposcopy and biopsy

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147
Q

Staging Ix for cervical cancer

A

CT chest/abdo/pelvis
PET
MRI
EUA (esp for rectal cancer)

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148
Q

Features of cervical cancer on colposcopy

A

Irregular cervical surface
Abnormal vessels
Dense uptake of acetic acid

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149
Q

Rx of stage Ia1 cervical cancer

A

Local excision

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150
Q

Rx for stage Ib - II a cervical cancer

A

Radical hysterectomy

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151
Q

Rx for stage IIb-IV cervical cancer

A

Chemoradiotherapy

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152
Q

What is the main chemotherapy agent used in cervical cancer

A

Cisplatin

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153
Q

Common metastatic sites for cervical cancer

A

Lung
Liver
Bone
Bowel

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154
Q

Risk factors for vaginal cancer

A 
HPV
Age
Smoking 
Alcohol 
Cervical cancer 
Vaginal adenosis
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155
Q

Is primary or secondary vaginal cancer more common

A

Secondary

Primary cancer of the vagina is rare

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156
Q

Types of vaginal cancer

A 
SCC 
Adenocarcinoma 
Others such as:
Clear cell 
Small cell carcinoma 
Melanoma
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157
Q

What is the most common type of vaginal cancer

A

SCC

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158
Q

Staging classification system used for vaginal cancer

A

FIGO

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159
Q

Rx for vaginal cancer

A

Depends on FIGO staging
Partial or Radical Vaginectomy for early stage

Chemoradiotherapy for later stages

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160
Q

Ix for vaginal cancer

A

Colposcopy and biopsy

Pelvic MRI

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161
Q

Clinical features of vaginal cancer

A 
Intermenstrual bleeding 
Blood stained discharge 
Post-coital bleeding 
Post-menopausal bleeding
Pain 
Fatigue 
Weight loss
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162
Q

What are fibroids

A

benign smooth muscle tumours of the uterus

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163
Q

From which layer of the uterus do fibroids arise from

A

Myometrium

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164
Q

Describe sub-mucous fibroids

A

Protrude into the uterine cavity

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165
Q

Describe intramural fibroids

A

Within uterine wall

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166
Q

Describe subserous fibroids

A

Project outwith the uterus into the peritoneal cavity

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167
Q

Clinical features of fibroids

A 
Many asymptomatic 
Menorrhagia 
Dysmenorrheoa 
Pelvic pain 
Pelvic mass 
Pressure symptoms (frequency, constipation)
Pain during sex
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168
Q

Which type of fibroids would be the most likely to interfere with implantation of an embryo

A

Submucosal

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169
Q

Ix for fibroids

A

USS (abdo., transvaginal)

CT

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170
Q

Rx for fibroids

A

If harmless no RX

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171
Q

Rx for problematic fibroids

A 
GnHR analogues 
Ullupristal acetate
Myomectomy 
Uterine artery embolisation 
Hysterectomy
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172
Q

What are fibroids dependent too?

A

Oestrogen

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173
Q

When can fibroids enlarge?

A

During pregnancy

When on COCP

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174
Q

When will fibroids tend to atrophy and why?

A

After menopause

As they are oestrogen dependent

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175
Q

In which population are fibroids more common in?

A

Africo-caribbean

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176
Q

What is endometriosis

A

Defined as endometrial tissue outwith the uterine cavity

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177
Q

Who does endometriosis affect

A

Women of reproductive age

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178
Q

Cause of endometriosis

A

Unknown

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179
Q

Risk factors for endometriosis

A 
Early menarche 
FH endometriosis 
Long duration menstrual bleed 
Heavy menstrual bleeding 
Defects in uterus or uterine tubes
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180
Q

Common sites for endometrial tissue to grow in endometriosis

A 
Peritoneal lining 
Pouch of Douglas 
Ovaries 
Uterine tubes 
Tissues lining the pelvis
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181
Q

Rarer sites for endometrial tissue to grow in endometriosis

A

Lungs
Muscles
Eyes
Brain

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182
Q

What is the gold standard Ix for endometriosis

A

Laparoscopy and biopsy

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183
Q

Clinical features of endometriosis

A 
Cyclical pain 
Severe dysmenorrhoea 
Dysuria 
Dyschezia 
Subfertility
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184
Q

Potential signs in endometriosis

A

Tender noduels in rectovaginal septum
Adnexal mass
Limited uterine mobility

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185
Q

Medication Rx for endometriosis

A

Analgesia for pain

Progesterone oral/inject/IUD

Mirena (IUD)

COCP

GnHR analogues

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186
Q

Surgical Rx for endometriosis

A

Excision of deposits fro peritoneum/ovary

Laser ablation

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187
Q

Can endometriosis be cured

A

No

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188
Q

DDx for endometriosus

A

PID
Ectopic pregnancy
Fibroids
IBS

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189
Q

Who does endometrial cancer most commonly occur in

A

Post-menopausal women

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190
Q

At what age is peak incidence for endometrial cancer

A

65-71yrs

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191
Q

Is endometrial cancer more or less common than cervical cancer

A

Less common

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192
Q

What has the increase in endometrial cancer been attributed to

A

Obesity

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193
Q

Risk factors for endometrial cancer

A 
Obesity
Increasing age 
Type II DM 
Nullparity 
Early menarche 
Late menopause 
Breast cancer 
Oestrogen only HRT 
PCOS 
Tamoxifen
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194
Q

Genetic predispositions to endometrial cancer

A

HNPCC/Lynch syndrome

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195
Q

Describe type I endometrial cancer

A 
Endometrioid adenocarcinoma (looks similar to endometrium)
Gland forming
Unopposed oestrogen 
Hyperplasia with atypia precursor 
By far the most common 
Slower growing compared to type II
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196
Q

What is the most common type of endometrial caner

A

Type I

Adenocarcinoma

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197
Q

What is type II endometrial cancer

A

Uterine serous and clear cell carcinoma
high grade, more aggressive, worse prognosis
Not linked to oestrogen

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198
Q

Which is the more aggressive type of endometrial cancer

A

Type II
Uterine serous and clear cell
More aggressive and more likely to spread

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199
Q

What should you do with someone presenting with post-menopausal bleeding

A

Investigate this promptly

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200
Q

Define post-menopausal bleeding

A

Bleeding 1yr after periods have stopped

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201
Q

What tumour marker can be measured in suspected endometrial cancer

A

Ca125

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202
Q

Ix for endometrial cancer

A

TVUSS

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203
Q

When should you biopsy the endometrium in TVUSS looking for endometrial cancer

A

Thickness >4mm

Or irregular

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204
Q

how is endometrial cancer Dx

A

Pipelle biopsy

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205
Q

Staging for endometrial cancer

A

CT/MRI/CXR

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206
Q

What is the earliest visible sign of endometrial cancer

A

PMB

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207
Q

Rx early stage endometrial cancer

A

Total hysterectomy

Bilateral salpingoophrecomtyPeritoneal washings

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208
Q

Rx for high risk histology endometrial cancer

A

Chemotherapy

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209
Q

Rx for advanced endometrial cancer

A

Radiotherapy

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210
Q

Palliation Rx of endometrial cancer

A

Progesterone

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211
Q

Which cancers does HNPCC increase risk of

A

CRC
Endometrial
Ovarian

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212
Q

Which classification system is used to stage endometrial cancer

A

FIGO

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213
Q

Describe stage I endometrial cancer

A

Body of the uterus only

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214
Q

Describe stage II endometrial cancer

A

Body of the uterus and cervix only

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215
Q

Describe stage III endometrial cancer

A

Advancing beyond uterus but not beyond the pelvis

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216
Q

Describe Stage IV endometrial cancer

A

Extending outside the pelvis e.g to bowel or bladder

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217
Q

What is pelvic inflammatory disease

A

Infection of the upper genital tract

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218
Q

Causes of PID

A

STIs
Uterine instrumentation
Post-partum

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219
Q

Risk factors for PID

A

<25yrs
Previous history STIs
New or multiple partners

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220
Q

Clinical features of PID

A 
Vagina discharge may be evident 
Cervical motion tenderness O/E
Lower abdo. pain 
Post-coital bleeding 
Dysmenorrhoea 
Fever 
Discomfort or pain during sex
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221
Q

What % of PID is caused by STI

A

25%

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222
Q

Ix for PID

A

Vulvovaginal/endocervical swabs
FBC
Blood cultures (if febrile)
Beta hCG to exclude pregnancy

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223
Q

Rx PID

A

Start prompt Abx

Outpatient:
500mg Ceftriaxone I/M stat
Doxycycline 100mg PO
Metronidazole 400mg PO 
For 14 days

Inpatient:
Ceftriaxone 2g IV
+ doxycycline 100mg BD for 14 days
+metronidazole 400mg PO BD for 14 days

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224
Q

Complications of PID

A

Ectopic pregnancy
Tubo-ovarian abscess
Fitz-Hugh Curtis syndrome
Recurrent PID

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225
Q

Prevention of PID

A

Barrier contraception
COCP
Mirena

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226
Q

What is the most likely cause of PID

A

Untreated chlamydia or gonorrhoea

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227
Q

What is the 2nd commonest cause of abnormal vaginal discharge

A

Vulvovaginal Candidosis

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228
Q

Is vulvovaginal candidosis classified as an STI

A

No

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229
Q

Who is vulvovaginal candisosis more common in

A 
DM 
Oral steroids
Immunosuppression 
Incl. HIV 
Pregnancy 
Reproductive age group
Many cases occur in women with no pre-disposing factors
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230
Q

What is the commonest organism of vluvovaginal candidosis

A

90% Candida albicans

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231
Q

Other organism cause of vulvovaginal candidosis

A

C.Glabrata

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232
Q

Clinical features of thrush

A 
Itch (may be severe)
Discharge typically thick cottage cheese like
Copius amounts discharge
Fissuring 
Erythema satellite lesions
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233
Q

Ix of vulvovaginal candidosis

A

Characteristic history

Culture e.g Sabouraud’s Medium

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234
Q

Rx of thrush

A

Azole antifungals
Clotrimazole PV once
Fluconazole PO once

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235
Q

What combination of treatment needs to be given in vulvovaginal cadidosis

A

Oral and vaginal treatment

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236
Q

What is the commonest cause of abnormal vaginal discharge in women

A

Bacterial vaginosis

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237
Q

Pathophysiology of bacterial vaginosis

A

Imbalance of bacteria rather than true infection
Biofilm problem:

increase in gardnerella/ ureaplasma/ mycoplasma/ anaerobes

decrease in Lactobacilli

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238
Q

Clinical features of bacterial vaginosis

A 
Thin, homogenous discharge 
Fishy discharge 
May be worse after periods/sex
Vagina not inflamed 
Rarely itchy

Asymptomatic in 50%

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239
Q

Ix of bacterial vaginosis

A

Characteristic history
Examination findings
Gram stained smear of vaginal discharge

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240
Q

Rx bacterial vaginosis

A

Metronidazole

Clindamycin

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241
Q

What is balanitis

A

Inflammation of the glans penis

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242
Q

What is posthitis

A

Inflammation of the foreskin

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243
Q

What are the common organism causes of impetigo

A

Staph. Aureus

Strep. Pyogenes

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244
Q

What is the common organism cause of Erisypelas

A

Strep. Pyogenes

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245
Q

What is a prolapse

A

Protrusion of an organ or structure beyond its normal anatomical confines

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246
Q

Define female pelvic organ prolapse

A

Descent of pelvic organs towards or through the vaginal

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247
Q

Risk factors for prolapse

A 
Forceps delivery 
Large baby 
Prolonged 2nd stage labour 
Increasing age 
Obesity 
Previous pelvic surgery 
Quality of connective tissue 
Occupation with heavy lifting 
Exercise
248
Q

Define urethrocele

A

Prolapse of lower anterior vaginal wall involving urethra only

249
Q

Define cystocele

A

Prolapse of upper anterior wall involving bladder

250
Q

Define uterovaginal prolapse

A

Prolapse of uterus, cervix and upper vagina

251
Q

Define enterocele

A

Prolapse of upper posterior all of vaginal usually containing small loops of bowel

252
Q

Vaginal symptoms in POP

A 
Sensation of bulging or protrusion 
Seeing or feeling bulge or protrusion 
Pressure 
Heaviness
Difficulty inserting tampons 
Discomfort or numbness during sex
253
Q

Urinary symptoms in POP

A 
Urinary incontinence 
Frequency/urgency 
Weak or prolonged urinary stream 
Manual reduction in prolapse to start off complete voiding
Feeling of incomplete emptying
254
Q

Bowel symptoms in POP

A

Incontinence of flatus or liquid or solid stools
Urgency
Feeling incomplete emptying
Straining
Digital evacuation to complete defecation
Splinting or pushing in or around the vagina or perineum to start or complete defecation

255
Q

Ix for prolapse

A

USS
MRI
Urodynamics
IVU or renal USS

256
Q

Objective assessments tools for POP

A

Baden-Walker Halfway Grading

POPQ score

257
Q

Rx for POP

A

Pelvic floor muscle training
Pessaries
Surgery

258
Q

What are pessaries generally made from

A

Silicone
Lucite
Rubber or plastic

259
Q

What are pessaries good for

A

Maintaining fertility

260
Q

What are Kegel exercises

A

Pelvic floor exercises

261
Q

What are Kegel exercises good for in POP

A

Mild cases of POP

Younger fertile women

262
Q

Prevention of POP

A 
Avoid constipation (high fibre diet)
Better obstetric practice
Lower parity 
void lifting heavy object
Management of chronic chest pathology
263
Q

Side effects of pessaries

A 
Unpleasant vaginal discharge
Vaginal irritation 
Stress incontinence 
UTI 
Sometimes interferes with sex
264
Q

What is urinary incontinence

A

Involuntary leakage of urine

265
Q

Describe stress urinary incontinence

A

Involuntary leakage of urine on effort or exertion

Or on coughing/sneezing/laughing

266
Q

Describe urgency incontinence

A

Involuntary leakage of urine accompanied or preceded by extreme urgency

267
Q

Which is the most common urinary incontinence in women

A

Stress incontinence

268
Q

Risk factors for stress incontinence

A 
Age
Parity 
Menopause 
Smoking 
Increased intra-abdominal pressure 
Pelvic floor trauma 
Connective tissue disease
Congenital weakness 
Surgery
269
Q

What is the main risk factors for stress incontinence

A

Pregnancy and childbirth

270
Q

Clinical features of stress incontinence

A

Passage of small amounts of urine on coughing, sneezing, laughing or exertion

Effect on QOL

271
Q

Ix for stress incontinence

A 
History 
MSSU (exclude UTI) 
Bladder diaries 
Bladder scan 
Urodynamics
272
Q

Name 2 urodynamic types of studies

A

Cystometry

Uroflowmetry

273
Q

Describe pathophysiology in stress incontinence

A

Increase in detrusor muscles pressure exceeds closing urethral pressure resulting in leakage

Bladder outlet is too weak

274
Q

General Rx of stress incontinence

A 
Weight control 
Fluid control 
Decrease in caffeine 
Decrease in fruit juice
Decrease in alcohol
Smoking cessation 
Optimising control of other conditions (e.g DM, hypertension)

Kegel exercises
Bladder retraining programme

275
Q

Pharmacological Rx stress incontinence

A

Duloxetine (SSRI)

Oestrogen cream

276
Q

Surgical Rx stress incontinence

A

Tension free vaginal tape

Colposuspension (now rarely performed)

277
Q

Describe Kegel exercises

A

Minimum 8 contractions x3 daily

Mixture of fast (1 sec) and slow (10sec) contractions

278
Q

Name aids for pelvic floor training/exercises

A

Vaginal cones
Electrical stimulation
Biofeedback

279
Q

What is urge urinary incontinence

A

Incontinence associated with the sudden urge to pass urine that cannot be avoided

280
Q

What is the commonest cause of urge urinary incontinence

A

Overactive bladder syndrome

281
Q

What is overactive bladder syndrome

A

When the detrusor muscle is instable

contracting at low volumes

282
Q

Clinical features of urge incontinence

A

Sudden urge to pass urine
Frequency
Nocturia
Patient knows every public toilet

283
Q

Ix for urge incontinence

A 
Good history 
MSSU 
Bladder diaries 
Examination 
Bladder scan 
Urodynamic studies
284
Q

General Rx for urge incontinence

A 
Weight control 
Fluid control: Volume and type 
Reduce bladder irritants:
Caffeine 
Fruit Juice 
Alcohol

Pelvic exercises
Bladder retraining
programme

285
Q

Medication for urge incontinence

A

Anti-cholinergics/Anti-muscarinics:
Oxybutynin
Tolterodine
Solifenacin

Beta-3-adrenoeceptors
Botulinum Toxin

286
Q

Side effects of anti-colinergics/anti-muscarinics

A 
Dry mouth 
Dry eyes 
Constipation 
Nausea 
Blurred vision
287
Q

What is overflow incontinence

A

Urine is retained in the bladder due to outlet obstruction

288
Q

What are common obstructions in overflow incontinence

A

Prostatic hypertrophy

Tumour

289
Q

Clinical features in overflow incontiencne

A

Prostatic symptoms

Palpable bladder

290
Q

Ix for overflow incontinence

A 
History 
MSSU 
Bladder diaries 
Examination 
Bladder scan 
Urodynamic studies
291
Q

What does VIN stand for

A

Vulva intraepithelial neoplasia

292
Q

Risk factors for VIN

A

Smoking Other genital intra-epithelial neoplasia
Previous related malignancy
Immunosuppression

293
Q

3 stages of VIN

A

VIN I/II/III

294
Q

What are the 2 types of VIN

A

Usual type VIN

Differentiated type VIN

295
Q

What is VIN

A

Pre-cancerous and pre-invasive condition

296
Q

Ix for VIN

A

Histological Dx

Punch biopsy

297
Q

Rx for VIN

A

Surveillance
Biopsy of suspicious lesions

Topical Rx:
Imiquimod

Laser treatment
Surgery

298
Q

Why is laser treatment not recommended in VIN

A

40-70% recurrence rate

299
Q

When will you be given Rx for VIN

A

If it is high grade

300
Q

Examination features of VIN

A 
Raised papular or plaques lesions
Erosions, nodules, warty 
Keratotic roughened appearance
Sharp border
Differentiated VIN tends to be unifocal ulcer or plaque
Discoloration
red
white
brown/pigmented
301
Q

What is the most common type of vulvar cancer

A

Squamous cell carcinoma

302
Q

What is SCC vulvar cancer associated with

A

VIN

Lichen Sclerosis

303
Q

Name other types of vulvar cancer

A

Basal cell carcinomas

Melanomas

304
Q

Which LN would be involved in vulvar cancer?

A

Inguinal and femoral

305
Q

Which staging system is used to classify vulvar cancer?

A

FIGO

306
Q

Symptoms of vulvar cancer

A 
Itch 
Pain 
Bleeding 
Abnormal discharge
Pain when peeing 
Lump/ulcer 
Lump in the groin
307
Q

Rx for vulvar cancer

A

Surgery:
Local excision
Vulvectomy

Radiotherapy
Chemotherapy

308
Q

What is the pre-invasive phase of vulvar cancer known as?

A

VIN

309
Q

When is the peak age for ovarian cancer?

A

75-84yr F

310
Q

Risk factors for ovarian cancer

A 
Increasing age
Family History 
Smoking 
HRT 
Early menarche
Late menopause 
BRCA1
BRCA2
HNPCC/Lynch syndrome
311
Q

Factors which decrease your risk of ovarian cancer

A

Breast feeding
Tube ligation
Pregnancy
COCP

312
Q

Which LN does ovarian cancer spread to?

A

Para-aortic LN

Similarly to testis

313
Q

Why is ovarian cancer often detected at a late stage

A

As the symptoms can be very vague/misleading

314
Q

Symptoms of ovarian cancer

A 
Bloating 
Unexplained weight loss 
Indigestion 
Early satiety 
Fatigue 
Urinary symptoms - urgency/frequency 
Change in bowel habits
315
Q

Which tumour marker in the blood can be tested for in ovarian cancer

A

Ca125

316
Q

Potential O/E findings for ovarian cancer

A

Fixed mass
Ascites
Pleural effusion
lymphadenopathy

317
Q

Ix for ovarian cancer

A 
FBC 
LFTs 
U&amp;E's 
Ca125
USS 
CT/abdo/ches
318
Q

Rx for ovarian cancer

A 
Full staging laporotomy 
Tissue Dx 
Stage Disease
Disease clearance - early stage
Debulk disease - late disease

Chemotherapy

319
Q

What are the main chemotherapy agents used in ovarian cancer

A

Carboplatin (Platinum)

Paclitaxol (Taxol)

320
Q

High risk geentics for ovarian cancer

A

BRCA1
BRCA2
HNPCC/Lynch syndrome

321
Q

Which staging system is used in ovarian cancer

A

FIGO

322
Q

Describe stage I ovarian cancer

A

Limited to one or both the ovaries

323
Q

Describe stage II ovarian cancer

A

Limited to the pelvis

324
Q

Describe stage III ovarian cancer

A

Limited to the abdomen including regional LN metastases

325
Q

Describe stage IV ovarian cancer

A

Distant metastases outwith the abdomen

326
Q

What is the lifetime risk of the BRCA genes with ovarian cancer

A

15-45%

327
Q

Which contraception provides a protective mechanism to ovarian cancer

A

COCP

328
Q

what are ovarian cancer syptoms often mistaken for

A

IBD

Diverticular disease

329
Q

What is the most common bacterial STI in the UK

A

Chlamydia

330
Q

What is chlamydia an important cause of

A

Tubal infertility

331
Q

Which organism causes chlamydia

A

Chlamydia Trachomatis

332
Q

Main symptom of chlamydia

A

ASYPMPTOMATIC in most cases

333
Q

Potential symptoms of chlamydia

A 
Dysuria 
Vaginal discharge 
Interestrual bleeding 
Post-coital bleeding 
Conjunctivitis
334
Q

When should you test for chlamydia reinfection

A

3-12 months

335
Q

Rx of chlamydia

A

Azithromycin 1g single dose

Doxycycline 100mg Bd 7 days

336
Q

Who is it essential to treat in chlamydia infection

A

Treat sexual partners

337
Q

Rx Chlamydia in pregnancy

A

Erythromycin

338
Q

Ix chlamydia

A

Vulvovaginal swabs
Endocervical swabs
First void urine men for NAAT

339
Q

Complications Chlamydia in females

A 
PID 
Perihaptitis 
Urethritis
Tubal infertility 
Ectopic pregnancy
340
Q

Complications chlymadia in males and females

A

Reactive arthritis

Reiter’s syndrome

341
Q

Complication chlamydia in pregnancy

A

Increased risk of:
Preterm rupture of membranes
Premature delivery
Neonatal conjunctivitis and pneumonia

342
Q

Complications of chlamydia in males

A

Epididymitis

343
Q

What is the main worry with gonorrhoea

A

there is an increase in abx resistant cases

344
Q

Organisms of gonorrhoea

A

Neisseria Gonorrhoea

345
Q

How is gonorrhoea transmitted

A

Sexual contact with infected individual

346
Q

How is gonorrhoea prevented

A

Use of condoms

347
Q

Ix for gonorrhoea

A

First void urine
Vulvovaginal/endocervical swabs
NAAT

348
Q

Symptoms gonorrhoea in females

A 
Often asymptomatic 
Lower abdo. pain 
Vaginal bleeding 
Intermenstrual bleeding 
Post-coital bleeding 
Vaginal discharge (thick, yellow, green)
Conjunctivities 
Dysuria
349
Q

Symptoms gonorrhoea in males

A

Thick profuse yellow discharge
Dysuria
Infallamtion of foreskin

350
Q

Rx for gonorrhoea

A

Blind Rx Ceftriaxone 500mg IM once

+ Azithromycin PO 1g stat

351
Q

Who else do you need to treat in gonorrhoea

A

Treat sexual partners

Contact trace

352
Q

What is the Rx for gonorrhoea in pregnancy

A

Same as not in pregnancy

353
Q

Complications of gonorrhoea in females

A

Bartholin’s Abscess
Tubal infertility
Increase risk ectopic pregnancy

354
Q

Complications of gonorrhoea in males

A

Epididymitis

355
Q

Which organism causes anogenital warts

A

HPV types 6+11

356
Q

Clinical features of anogenital warts

A 
Lumps with surface texture of small cauliflower
Papilliform or flat warts
May be pigmented
May bleed 
May itch
357
Q

1st line Rx anogenital warts

A

Topical podophyllum

Cryotherapy

358
Q

2nd line Rx anogenital warts

A

Imiquimod cream

359
Q

Ix anogenital warts

A

Clinical Dx based on O/E

Biopsy if unusual but rarely needed

360
Q

Which types of HPV cause cervical cancer

A

Type 16 and 18

361
Q

What strains of HPV does the quadrivalent vaccine protect against

A

6/11/16/18

362
Q

Which virus cuses genital herpes

A

Herpes simplex virus 1 and 2

363
Q

Symptoms of genital herpes

A 
80% asymptomatic 
Burning/itching 
BListering then tender ulceration 
Tender inguinal lymphadenopathy 
Dysuria
364
Q

Ix for genital herpes

A

Clinical O/E

PCR viral swab

365
Q

Rx for primary genital herpes

A

Aciclovir

366
Q

Rx for infrequent recurrences of genital herpes

A

Lidocaine ointment

Aciclovir daily until symptoms are gone

367
Q

Rx for frequent recurrences of genital herpes

A

Aciclovir 400bg long term as immunosuppression

368
Q

Does type I or Type II herpes simplex typically cuse genital herpes

A

Type II typically
But not strict rule
It can be type I

369
Q

Syphilis organism

A

Treponema Pallidum

370
Q

Primary syphilis symptoms

A

Chancre (local)

Often painless

371
Q

Secondary syphilis symptoms

A

Rash (can be local or widespread)
Mucosal ulceration
Patchy alopecia

372
Q

Early latent syphilis symptoms

A

No symptoms but <2yrs since caught

373
Q

Late latent syphilis symptoms

A

No symptoms but >2yrs since caught the infection

374
Q

Tertiary syphilis symptoms

A

can involve:
Neurological
Cardiovascular
Gummata formation

375
Q

Ix Syphilis

A 
Clinical signs 
Serology for:
TPPA 
RPR
IgGEIA 
TP 
PCR on sample from ulcer
376
Q

Rx for Early sypihlis with no neurological invovlement

A

Benzathine penicillin
Or
Doxycycline (penicillin allergic)

377
Q

Rx for sypihlis in pregnancy

A

Benzylpencillin as normal
If penicllin allergic cannot give dxycycline as teratorgenic
So desensitise to penicillin then prescribe

378
Q

Why can doxycycline not be given in pregnancy

A

Teratogenic

379
Q

Fetal Rx of congenital syphilis

A

Penicillin

380
Q

Why is congenital syphilis now extremely rare

A

As mothers are screened during pregnancy

381
Q

Definition of infertility

A

inability of a couple to conceive after 1yr of trying

382
Q

Female causes of infertility

A 
Increasing age
PCOS 
STI's 
Body weight Fibroids 
PID 
Antisperm antibodies
383
Q

How does a womans age affect her fertility

A

Increasing age

Decreases fertility

384
Q

How can PCOS cause inferility

A

Can cause anovulatory subfertility

385
Q

What is the leading cause of infertility

A

STIs

386
Q

Example of STI which can cause a complication of infertility

A

Chlamydia

387
Q

How can body weight affect fertiltiy

A 
Fat cells produce oestrogen 
Too much fat can act in the same mechanism as birth control 
Too little (anorexia) can also lead to fertility problems
388
Q

How can fibroids affect fertility

A

Commonest benign tumour of uterus

Can cause problems with implantation

389
Q

Primary Ix for infertility

A 
Chlamydia screening 
Measure BMI 
Baseline hormonal profile
TSH 
Prolactin 
Testosterone 
Rubella status 
Mid-luteal progesterone 
Semen analysis
390
Q

Secondary Ix for infertility:

A 
TVS:
Adnexal mass 
Fibroids 
PCOS 
Pelvic USS
391
Q

Lifestyle changes Rx for infertility

A 
Smoking cessation 
Alcohol decrease 
Folic acid 
Weight loss/gain 
Regular intercourse
392
Q

Rx for ovulation induction for infertility

A

Weight loss

Clomifene

393
Q

Which anti-diabetic agent can be used to treat PCOS

A

Metformin

394
Q

Indications for IVF

A 
Tubal disease
Male factor subfertility  
Anovulation (not responding to Rx)
Endometriosis 
Unexplained infertility >2yrs 
Maternal age
395
Q

When is laparoscopic ovarian drilling used for

A

Can trigger ovulation in patients with PCOS

396
Q

Describe NHS funded assisted conception inclusion criteria

A 
Couples with no children 
Non-smokers 
BMI<30 
<40yrs offered 3 cycles 
40-42yrs offered 1 cycle
397
Q

Define subfertility in males

A

Inability to cause pregnancy in a fertile females

398
Q

Causes of male subfertility

A 
Epididymitis 
Congenital e.g Klinefelter's Syndrome 
CF (congenital bilateral absence of vas deferens)
ASA (antisperm antibodies)
Varicocele 
Impotence 
Overheated testicles 
Oligozoospermia
399
Q

How can epididymitis cause infertility?

A

Due to infection with STI

400
Q

How can CF cause infertility in males

A

Due to bilateral absence of the vas deferens

401
Q

Ix for male subfertility

A 
BMI 
Genital examination 
Testicular size 
Baseline hormonal profiles:
FSH 
Testosterone 
Karyotype ( to check for genetic abnormalities)
CF screen 
SSemen analysis
402
Q

What is measures in semen analysis

A

Number of sperm
Motility of sperm
Sperm morphologically

403
Q

What is the main fertility treatment for male infertility

A

Intracytoplasmic sperm injection

404
Q

Is all infertility explained?

A

No

1/3 of the 1 in 7 couple with fertility issues have unexplained infertility

405
Q

Rx for male subferility

A 
Regular sexual intercourse 
Smoking cessation 
Decrease alcohol 
Lose/gain weight 
Regular exercise 
Gonadotrophin

IVF
ICSI

406
Q

What is the commonest malpresentation in obstetrics?

A

Breech presentation

407
Q

Causes of breech presentation

A 
Idiopathic 
Uterine abnormalities (fibroids, bicorunate uterus)
Prematuriy 
Placenta praevia 
Oligohydramnios 
Fetal abnormalities
408
Q

What are the 3 types of breech

A

Extended breech
flexed breech
Footling breech

409
Q

Describe extended/Frank breech

A

Flexed at highs but extended at th eknees

410
Q

Describe Flexed breech

A

Hips and knees both flexed

Presenting is feet, external genitalia and buttocks

411
Q

Describe Footling breech

A

The foot is presenting lower than the buttock

412
Q

Examination findings of breech baby

A

No head felt in pelvis

Fundus of uterus: smooth round mass (head)

413
Q

Ix of breech

A

Examination findings
USS
Try to Dx antenatally

414
Q

Rx for breech

A

External cephalic version

415
Q

What is ECV

A

External cephalic version
Turning breech baby
by manouvering forward somesault

416
Q

When is C-Section recommended in multiples

A

If 1st/presenting twin is breech

417
Q

Describe vaginal breech delivery

A 
Hands off approach 
Baby not touched until scapulae visible 
Hook arms at elbow 
allow body to hang 
Once nape of neck visible 
2 fingers over maxilla and 2 finger over occiput
418
Q

When is external cephalic version CI

A 
Placenta praevia 
Multiple pregnancy 
APH last 7 days 
Ruptured membranes 
Mother with uterine scars/abnormality 
Fetal abnormality 
Pre-elampsia 
Growth restricted babies
419
Q

When is vaginal delivery CI in breech

A 
Inexperienced clinicial 
Footling breech 
Low fetal weight 
Previous LSCS 
Placenta praevia 
Hyperextended fetal neck
420
Q

Is cord prolapse serious?

A

Yes

It is an obstetric emergency qWhat is cord prolapse

421
Q

What is cord prolapse

A

Descent of the umbilical cord through the cervix

Below presenting part after membrane rupture

422
Q

Why is cord prolapse an emergency?

A

As cord compression and vasospasm of the cord can ccause fetal asphyxia

423
Q

Risk factors for cord prolapse

A 
Fetal malpresentation (e.g breech)
Unstable lie 
Polyhydramnios 
Prematurity 
Low birth weight (small baby)
Multiple gestation 
Spontaneous rupture of membranes
424
Q

How does fetal hypoxia occur in cord prolapse?

A

Occlusion of the cord (by presenting fetus0 occluding blood flow
Arterial vasospasm of the umbilical cord due to exposure to cold atmosphere

425
Q

Clinical features of cord prolapse

A

Cord at introitus
Fetal bradycardia
Variable fetal heart decelerations

426
Q

Management steps for cord prolapse

A

Get senior help

Aim to delivery <15 mins

427
Q

Steps to minimise cord compression and vasospasm

A 
Displace presenting part by putting hand in the vagina and pushing it back up 
Keep touching of the cord to a minimum 
Knee to chest position 
Saline into the bladder
Tocolytics
428
Q

Best delivery method for cord prolaspe

A

Whichever is quickest

If cervix fully dilated then use forceps for vaginal delivery

429
Q

How quick should a baby be delivered in cord prolapse

A

<15 mins crucial

430
Q

What is primary post partum haemorrhage

A

Loss of >500ml blood within 24hrs

431
Q

What is secondary post partum haemorrhage

A

> 500ml blood loss after 24hrs up to 6 weeks after delivery

432
Q

Risk factors for post-partum haemorrhage

A 
Previous PPH 
Previous retained placenta 
BMI>35 
APH 
Multiparity 
Maternal age >35yrs 
Uterine malformation 
Retained placenta 
Over distended uterus (e.g twins, polyhydramnios)
Induction or oxytocin use 
Operative birth or C-section 
Feltal macrosomia
433
Q

4 Ts of post-partum haemorrhage

A

Tissue
Tone
Trauma
Thrombin

434
Q

Give Tone causes of PPH

A

Uterine atony
Placenta praevia
Multiple pregnanct
Polyhydramnios

435
Q

Give Tissue causes of PPH

A

Reatined products of coception

Retained placenta

436
Q

Give trauma causes of PPH

A

Genital tract trauma
C-section
Episiotomy
Macrosomia

437
Q

Give thrombin causes of PHH

A

Clotting disorders
Pre-eclapmsia
Placental abruption
Pyrexia in labour

438
Q

Ix for PPH

A

Cross match bloods

439
Q

Initial management of PPH

A 
Senir help 
high flow O2 
Fluids IV 
Catheterise 
Delivery placenta 
Massage uterus 
Drugs to contract uterus 
Repair of tears
440
Q

Examples of drugs which contract the uterus

A 
Syntometrine 
Oxytocin infusion 
Ergometrine 
Misoprostol 
Carboprost
441
Q

Rx for PPH if ongoing bleeding

A 
Take to theatre 
Explore with laparotomy 
Rusch balooon 
B-lynch suture 
Hysterectomy
442
Q

Predisposing factors to twins

A 
Previous twins 
FH twins 
Increase in maternal age 
Induced ovulation 
IVF
443
Q

Describe monozygotic twins

A

1 egg
1 sperm
1 zygote
Splits to form 2 babies

444
Q

Describe dizygotic twins

A

2 sperm
2 egg
2 separate zygotes formed

445
Q

Describe monochorionic Monoamniotic twins

A 
1 placenta 
1 amniotic sac
1 chorionic sac 
Rarst type 
Always monozygotic
Share the placenta 
Risk of TTTS
446
Q

Describe monochorionic diamniotic twins

A 
1 placenta 
1 chorionic sac 
2 amniotic sacs 
Share the placenta
Almost always monozygotic
447
Q

Describe dichorionic diamnitoic twins

A

2 chorionic sacs
2 amniotic sacs
Most commonly seen dizygotic twins
2 placentas (can be fused or separate)

448
Q

Clinical features of twins

A

Large uterus for due dates
2 poles felt
More than 1 fetal HR

449
Q

Ix for twins

A 
USS confirms 
Distinguish how many placentas 
Name twins 
Twin 1 and Twin 2
Know which twin is presenting
450
Q

Who leads twin pregnancy care

A

Consultant led care as high risk pregnncies

451
Q

When should elective birth be offered for uncomplicated twins

A

37 weeks

452
Q

When should elective birth be offered for uncomplicated triples

A

35 weeks

453
Q

When is a C-section recommended in twins

A

When twin 1/presenting twin is breech

454
Q

When can a vaginal delivery be offered in twins

A

When first twin is cephalic

2nd twin may be breech

455
Q

Risks associated with shared placenta in twins

A

Twin to twin transfusion

456
Q

What is twin to twin transfusion

A

Disproportionate transfer of blood between twins

There is a donor and recipient twin

457
Q

Rx for TTS

A

Specialist centre in Glasgow

Lasers used to separate the fetal blood supply

458
Q

Risk associated with twins sharing the same sac

A

Cord entanglement

459
Q

Fetal complications in multiple pregnancy

A

Perinatal mortality increased
Prematurity risk
TTTS
Growth restriction

460
Q

What is shoulder dystocia

A

When the anterior shoulder of the baby becomes impacted in the maternal pubic symphysis

461
Q

What can delay in delivery in shoulder dysotica cause

A

Hypoxia in baby

Worse case cerbral palsy

462
Q

Associations with shoulder dysotics

A 
Large/post mature fetus 
Maternal BMO>30 
Induced or oxytocin augmented labour 
Assisted vaginal delivery 
Long 1st or 2nd stage 
Previous shoulder dystocia  
DM (macrosomia)
463
Q

Management for shoulder dysotica

A

Call for senior help
episiotomy (to make room for manoeuvres - does not relieve obstruction itself)
McRoberts Position
Suprapubic pressure applied

464
Q

Describe McRobert’s position

A

Hyperflex maternal hips (knees to chest)

465
Q

Other manouveres that can be used in shoulder dystocia

A

Zavanelli Man
Wood Screw Procedure
Rubin man

466
Q

What is last resort in shoulder dystocia

A

Fracturing babys clavicle

467
Q

Complications of shoulder dystocia

A

Vaginal tears (3rd/4th degree)
Erb’s palsy
Cerebral palsy

468
Q

How often is McRoberts position in shoulder dystocia

A

90% of cases it will work

469
Q

What are Braxton hicks

A

False labour

Milder cramps

470
Q

Clinical features of Braxton Hicks

A

Irregular contractions
Milder cramps
Do not increase in frequency
Do not increase in intensity

471
Q

What is the preffered direction of episiotomy in UK

A

Mediolateral

472
Q

What is an episiotomy

A

Intentional incision of perineum to assist delivery

473
Q

What is the main cause of perineal tears

A

Vaginal childbirth

474
Q

Describe 1st degree perineal tear

A

Superficial tear

Does not damage the muscle

475
Q

Describe 2nd degree perineal tears

A

Involve perineal muscle but not anal sphincter

476
Q

Describe 3a degree perineal tear

A

Partial tear of external anal sphincter <50% thickness

477
Q

Describe 3b perineal tears

A

> 50% thickness of anal sphincter

478
Q

Describe 3c perineal tears

A

Internal and external anal sphincter torn

479
Q

Describe 4th degree tears

A

Involves anal/rectal mucosa

480
Q

Rx for episiotomy

A

Dissolvable stiches

481
Q

Rx for 3rd and 4th degree tears

A

Require repair by surgeon
Under GA or epidural
Require abx. prophylaxis

482
Q

Rx for episiotomy and tears in general

A

Analgesia
high fibre diet to prevent constipation and straining
Arrange physio/pelvic floor exercises

483
Q

Complications of episiotomy and perineal tears

A 
Painful intercourse 
Pain 
Faecal incontinence 
Infection 
Scar tissue
484
Q

What is a C-section

A

Delivery of fetus through incision in the abdomen wall and uterus

485
Q

Indications for C-section

A

Repeat CD
Fetal compromise (e.g fetal bradycardia, prolapse)
Failure of progression of labour
Malpresentation
Severe pre-eclampsia
Twin pregnancy with presenting twin non-cephalic
Placenta praevia

486
Q

Describe category 1 C-section

A

Crash
Immediate threat to life of mother or fetus
Aim <30mins

487
Q

Describe category 2 C-section

A

Is for maternal or fetal compromise
Not immediately life threatening
Aim 30-60 minutes

488
Q

Describe Category 3 C-section

A

Semi-elective

E.g pre-eclampsia or failed induction of labour

489
Q

Describe category 4 c-section

A

Elective
E.g term Singleton breech
Should be carried out >39 weeks

490
Q

Intraoperative complications of C-section

A 
Blood loss
Uterine lacerations 
Bladder laceration 
Bowel injury 
Ureteral injury
491
Q

Post-operative complications of C-section

A 
Wound 
Infection 
Endometritis 
UTI 
Venous thromboembolism
492
Q

What are the 2 main types of instruments used in vaginal delivery

A

Forceps

Ventouse

493
Q

Pros and cons of forceps

A

Safer for baby

But can cause serious maternal genital tract trauma

494
Q

Pros and cons of ventouse

A 
Associated with decreased maternal genital tract trauma 
But fetal complications:
Cephalohaematoma 
Retinal haemorrhage 
More likely to fail
495
Q

Maternal indications for C-section

A

Prolonged 2nd stage
Maternal exhaustion
Medical avoidance of pushing (severe cardiac disease)
Pushing not possible e.g tetraplegia, paraplegia

496
Q

Criteria for instrumentation assisted vaginal delivery

A 
Consent for procedure 
Ruptured membranes
Adequate analgesia (epidural or pudendal block)
Adequate contractions 
Empty bladder 
Fully dilated cervix 
Cephalic presentation 
Neonatal doctor  in attendance
497
Q

Fetal reasons for instrumented vaginal delivery

A

Suspected fetal distress

498
Q

Complications of instrumented vaginal delivery for mother

A

Maternal genital tract trauma

499
Q

Fetal complications of forceps operative vaginal delivery

A

Facial nerve palsy
Skull fractures
Orbital injury
Intracranial haemorrhage

500
Q

Fetal complications of ventouse operative vaginal delivery

A 
Cephalohaematoma 
Subgaleal haematoma 
Retinal haemorrhage 
Scalp lacerations 
Scalp avulsions
501
Q

Absolute CI to operative vaginal delivery

A 
Unengaged fetal head in singleton 
Incompletely dilated cervix 
True cephalo-pelvis disproportion 
breech and face presentation 
Preterm gestation
502
Q

Risk factors for uterine rupture

A 
Dehiscence of scars
Obstructed labour in multiparous 
Pervious uterine surgery or cervical surgery 
Internal version 
Breech extraction
503
Q

Reasons to offer induction of labour

A

Gestational DM
Overdue (7-12 days)
Fetal reasons

504
Q

Commonest cause uterine rupture UK

A

Dehiscence of CS scars

505
Q

Risks associated with induction of labour

A 
Increased risk regional anaesthetic 
Increased risk fetal distress
Increased risk hyperstimulation of uterus 
Increased risk C-section 
Increased risk infection 
Increased risk bleeding
506
Q

Which score is used to asses the cervix

A

Bishops Score

507
Q

What does being overdue increase the risk of

A

Stillbirth

508
Q

Ix for induced labour

A

Continous fetal monitoring
CTG
Partogram

509
Q

Steps of induction of labour

A

Vaginal sweep
Vaginal prostaglandins pessaries or IV medication
Cook balloon
Amniotomy (once cervix have dilated and effaced)
IV oxytocin to stimulate contractions

510
Q

Define induction of labour

A

Induction of labour is when an attempt is made to instigate labour artificially using medications and/or by artificial rupture of the amniotic membranes (performing an amniotomy).

511
Q

What is an amnitomy

A

Artifical rupture of fetal membranes

512
Q

What does a higher Bishops score indicate

A

Indication to perform an amnitomy

513
Q

CI for induction of labour

A 
Malpresentation 
Fetal distress
Placenta praevia 
Vasa praevia 
Pelvic tumours
514
Q

what is the role of oxytocin in induction of labour

A

To induce contractions

515
Q

Define stillbirth

A

Babies born dead that were alive >24 week

516
Q

Causes of stillbirth

A 
Majority no cause is found 
Placental causes (e.g abruption)
APH or intrapartum haemorrhage 
Major congenital abnormality 
Infection 
Hypertension in pregnancy 
Pre-eclampsia 
Maternal disease
Mechanical e.g cord prolapse/entanglement
517
Q

Is the risk of stillbirth increased or decreased in multiples

A

Increased

518
Q

Clinical features of stillbirth

A

Absent of fetal movements
Absence of fetal HR
Dx by USS

519
Q

Ix for suspected stillbirth

A

Dx by absent fetal HR on USS

520
Q

What is Lichen Sclerosis

A

Chronic inflammatory skin disease of the anogenital region in women

521
Q

Where does Lichen Scleroris affect

A

Anogenital region

522
Q

Who does Lichen Sclerosis affect

A

Women

523
Q

Describe the bimodal incidence of Lichen Sclerosis sin females

A

Peaking in:
Prepubescent women
Post menopausal women

524
Q

What is the main clinical significance/risk of Lichen Sclerosis

A

Has the potential to progress to Squamous cell carcinoma

525
Q

Rx for Lichen Sclerosis

A

Topical steroids

526
Q

Ix for Lichen Sclerosis

A

Usually clinical O/E

Biopsy: when unsure or suspecting malignancy

527
Q

Clinical features of Lichen Sclerosis

A 
White atrophic patches (anogenital region)
Itching 
Pain 
Fusion of parts of anogenital region 
Pain during sex/toilet
528
Q

Which organism causes Trichomoniasis

A

Parasite

Trichomonas Vaginalis

529
Q

what is the main symptoms of Trichomoniasis

A

Majority asymptomatic

530
Q

Potential symptoms of Trichomoniasis

A

Discharge
Dysuria
Itching/burning genitals

531
Q

Complications of Trichomoniasis in pregnancy

A

Miscarriage

Preterm labour

532
Q

Rx Trichomoniasis

A

Metronidazole

533
Q

Which type of organism causes Trichomoniasis

A

Parasitic STI

534
Q

What is Hypermesis Gravidarum

A

Persistent/severe vomiting in pregnancy

535
Q

Risk factors for Hypermesis Gravidarum

A

Multiple pregnancy
Molar pregnancy
Previous HG pregnancy

536
Q

Rx for Hypermesis Gravidarum

A 
Admit if severe enough 
Anti-emetics 
IV fluid replacement 
Daily U&amp;Es measurement 
High dose Folic acid
537
Q

Ix for Hypermesis Gravidarum

A

U&Es
Urine dipstick
FBC

538
Q

Clinical features of Hyperemesis Gravidarum

A

Dehydration
Persistent vomiting
Hypovolaemia
Electrolyte disturbance

539
Q

What is a stillbirth

A

Babies born dead that were alive >24 weeks

540
Q

Causes of stilbirth

A 
No cause found 
Placental causes (abruption)
Ante or intrapartum haemorrhage 
Major congenital abnormality 
Infection 
Hypertension in pregnancy 
Pre-eclampsia 
Maternal disease
Mechanical e.g cord prolapse/entanglement
541
Q

Clinical features of stillbirth

A

No fetal heart sounds

Absent fetal movements

542
Q

Dx for stillbirth

A

Absent fetal HR on USS

Repeat if mother requests

543
Q

Rx to induce labour in stillborn

A

Mifeprostune
Prostaglandins
Oxytocin

544
Q

Which support group can help support parents of still born

A

SANDs

545
Q

When would you advise delivery in stillbirth

A 
Pre-eclampsia 
Abruption 
Sepsis 
Membrane rupture 
Coagulopathy
546
Q

What do you need before carrying out a post mortem on a fetus

A

Written consent

547
Q

Which infections can cause stillbirth

A 
Rubella 
Flu 
Cytomegalovirus 
Herpes simplex 
Lyme disease
Toxoplasmosis 
Q fever
Malaria
548
Q

Risk factors for stillbirth

A 
Twins/multiple
>35yrs
Smoking, drinking, drug use 
Obesity 
Pre-existing health conditions e.g epilepsy
549
Q

By law do stillbirths have to be registered?

A

Yes

550
Q

What is the main risk with retained placenta

A

Haemorrhage

551
Q

When is the placenta considered delayed

A

Not delivered within 30 mins of active management

Not delivered within 60 mins of physiological management

552
Q

Associations with retained placenta

A 
Previous RP 
Preterm delivery 
Maternal age >35yrs 
Placental weight <600g 
Partity>5
Induced labour 
Pethidine used in labour
553
Q

Complications of retained placenta

A

Haemorrhage

Infection

554
Q

Management of retained placenta

A

Avoid excessive cord traction:
Cord may snap
Or uterus may invert

Rub up a contraction 
Put baby to breast
(stimulate oxytocin production)
Give 20IU oxytocin 
Proximally clamp cord 
Empty bladder
555
Q

What should you avoid doing in retained placenta and why

A

Avoid excessive cord traction

As the cord may snap or uterus may invert

556
Q

What can cause inverted uterus

A

Mismanagement of 3rd stage labour

e.g with cord traction

557
Q

Management of inverted uterus

A 
Call for help 
Immediate replacement
Insert 2 large bore cannulas
IV fluids 
Transfer to theatre
Tocolytic drugs to relax uterus
Try manual replacement 
If this fails laparoscopically approach
558
Q

Compare the risk of venous thrombo-embolis in pregnant vs non-pregnant women

A

Increased risk in pregnancy

559
Q

RF for venous thromboembolism in pregnancy

A 
Age
 BMI 
Smoking 
IV drug abuse 
PET 
Dehydration 
 mobility 
Infections 
Operative delivery 
Prolonged labour 
Haemorrhage 
Previous VTE 
Sickle cell disease
560
Q

Why are pregnant ladies in a hypercoaguable state

A

to protect mothers against haemorrhage post-delivery

561
Q

Prophylaxis of venous thrombosis-embolism in pregnancy

A

TED stockings
Increased mobility
Anti-coagulation - LMWH

562
Q

Rx for venous thrombosis-embolism in pregnancy

A

Appropriate Rx with anti-coagulation

563
Q

Ix for venous thromboembolism

A 
ECg 
ABG 
Doppler
V/Q scan 
CTPA
564
Q

Which test used normally in venous thromboembolism disease in considered unhelpful in pregnancy

A

D-dimer

565
Q

Clinical features of venous thromboembolism disease in pregnancy

A 
DVT:
Calf pain 
Tenderness
Swelling 
Warmth 
Discolouration 
Tachycardia 
PE:
SOB 
Chest pain 
Haemoptysis 
Tachycardia 
Collapse
566
Q

What are the 2 main manifestations of thromboembolic disease in pregnancy

A

DVT

PE

567
Q

What is the leading direct cause of maternal death

A

Thrombosis and thromboembolism

568
Q

Why is LMWH used in pregnancy

A

Does not cross the placenta

not secreted into breast milk

569
Q

Which blood changes occur in pregnancy

A

fibrinogen
platelets
anti-coagulants
fibrinolysis

570
Q

Define gestational diabetes

A

Women without diabetes suffers high blood sugar levels during pregnancy
Abnormal glc. tolerance reverts to normal after delivery

571
Q

2 classes of diabetes in pregnancy

A

Pre-existing (can be type I or type II)

Gestational DM

572
Q

What happens to maternal insulin requirements during pregnancy

A

Insulin requirements of mother increase

Due to production of anti-insulin hormones in pregnancy (many of which produced by placenta)

573
Q

Why can fetal hyperinsulinaemia occur in pregnancy

A

Maternal glucose crosses the placenta and induces insulin production in the fetus
Fetal hyperinsulinemia promotes fetal growth
Causes macrosomia

574
Q

What can fetal hyper-insulinaemia cause

A

Macrosomia

575
Q

What does gestational diabetes increase the risk for mothers in later life

A

Type II DM

576
Q

What is the foetus at risk of after delivery if it suffers from hyper-insulinaemia

A

More risk for neonatal hypoglycaemia

577
Q

Maternal complications of gestational DM

A

Increased risk pre-eclampsia
Increased risk infections
Increased risk LSCS delivery
Increased risk miscarriage

578
Q

Fetal complications of maternal DM

A 
Macrosomia (operative delivery, shoulder dystocia)
Erb’s Palsy
Malformation rates
Polyhydramnios
Preterm labour 
Still birth
PN mortality
579
Q

Preconception Rx for DM and pregnancy

A

Avoid unplanned pregnancies
Adjust insulin to optimise blood glc control
Aim for HbA1c <43mmol/mol pre-conception
Folic acid 5mg
Dietary assessment
Stop oral hypoglycaemics (except metformin)
Retinal and renal assessment

580
Q

During pregnancy management of pre-existing DM

A 
Optimise glucose control 
Insulin requirements will 
Could continue metformin 
May need to add in insulin for tighter glc. control 
Be aware of risks of hypoglycaemia 
Repeat retinal and renal assessment 
Watch for fetal growth
581
Q

Delivery for pregnancy and pre-existing DM

A

Hospital
Elective at 38-40 weeks
Corticosteroids: promote fetal lung development in neonates
CTG fetal monitoring
C-section if sig. macrosomia
Monitor fetal growth (USS 4 weekly from 28 weeks)

582
Q

Risk factors for gestational DM

A 
BMI >30 
Previous macrosomic baby 
Previous GDM 
FH DM 
Women from high risk groups of DM (e.g Asian)
Recent glycosuria in current pregnancy
583
Q

Which has the higher risk of complications pre-existing DM or gestational DM

A

Pre-existing

584
Q

Screening for gestational DM

A

Risk factor present
Offer HbA1c at booking
75mh OGTT to be done

If normal repeat OGTT at 24-28 weeks

585
Q

Management of gestational DM

A

Control sugars
Diet
Metformin
Insulin (in some cases)

586
Q

Post-Delivery management of gestational DM

A

Check OGTT 6-8 weeks PN

Yearly check HbA1C as risk developing type II DM later

587
Q

Post delivery management of pre-existing DM in pregnancy

A

Can go back to pre-pregnancy regiment of insulin post delivery

588
Q

Why does gestational DM require a yearly HbA1C

A

Cause of increased risk of Type II DM after having gestational DM

589
Q

What can babies suffer from if mother was diabetic during the pregnancy

A

Hypoglycaemia

590
Q

Which 2 tablets are given to induce TOP

A

Mifepristone

Misoprostol

591
Q

What is the action of Misoprostol in TOP

A

Prostaglandin that acts to innate contractions of the uterus

592
Q

What is the action of Mifepristone in TOP

A

Primes the cervix

593
Q

When can an abortion be carried out until

A

Up to 24 weeks

594
Q

How long is the gap between the two tablets in medical abortion

A

24-48hrs

595
Q

What are the two types of abortion

A

Medical

Surgical

596
Q

Complications of Abortion

A 
Failed TOP 
Infection 
Haemorrhage 
Uterine perforation 
Uterine rupture 
Cervical trauma
597
Q

What are the 2 broad categories of pregnancy termination

A

Medical

Surgical

598
Q

What type of tumour is a choriocarcinoma

A

Germ cell tumour

599
Q

What can choriocarcinoma occur after

A 
Normal birth 
Miscarriage 
Ectopic pregnancy 
Molar pregnancy 
Abortion
600
Q

Clinical features of choriocarcinoma

A

Persistent high hCG

Persistent vaginal bleeding

601
Q

Where does choriocarcinoma most commonly spread to

A

Lungs

602
Q

What is choriocarcinoma a type of

A

Gestational Trophoblastic disease

603
Q

What is the main Rx for choriocarcinoma

A

Methotrexate combination chemotherapy

604
Q

What does choriocarcinoma have a very good Rx response to

A

Chemotherapy

605
Q

Ix for choriocarcinoma

A

CXR hCG

CT

606
Q

What type of disease is a molar pregnancy

A

Gestational Trophoblastic disease

607
Q

In a small proportion of molar pregnancies what can occur

A

Tissue from the molar pregnancy can remain and transform into choriocarcinoma

608
Q

Clinical features of molar pregnancy

A 
Very high hCG
Missed periods 
Positive pregnancy test
Severe nausea/vomiting 
Vaginal bleeding
609
Q

Ix to Dx molar pregnancy

A

After miscarriage:
Histology for Dx

During pregnancy:
USS
hCG levels
Histology after evacuation

610
Q

Rx for molar pregnancy

A

Suction removal
Methotrexate

Give Anti-D if woman is rhesus -ve

611
Q

What must you not do after Rx of molar pregnancy

A

Get pregnancy for 6 months - 1 year

612
Q

Describe a partial mole pregnancy

A

2 sperm fertilise the egg instead of one

75-80%

613
Q

Describe complete mole pregnancy

A

One sperm (or even 2) fertilise an egg/ovum containing no genetic material (empty ovum)

20-25%

614
Q

Describe transverse malpresentation

A

Shoulder presentation

When baby is lying transversely

615
Q

Describe face malpresentation

A

When the face presents at the birth canal

616
Q

What is brow presentation

A

When the babies head is between full flexion and full extension

617
Q

Rx for transverse malpresentation

A

ECV
If this fails
Fails at 37 weeks C/section

Reproduction (14 decks)

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