Reproduction Pathology Flashcards
1
Q
What is menorrhagia
A
Heavy menstrual bleeding that interferes with QOL
2
Q
What is the definition of menorrhagia
A
Heavy blood loss
>80ml blood loss
However mainly the patients perspective!!
3
Q
Risk factors for menorrhagia
A
Age
Obesity
4
Q
Potential causes of menorrhagia
A
IUCD (intrauterine contraceptive device) Fibroids Endometriosis Adenomyosis Pelvic infection Polyps Hypothyroidism Coagulation problems
5
Q
What is dysfunctional uterine bleed
A
Most common cause of menorrhagia
Dx of exclusion
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
7
Q
Ix for menorrhagia
A
Pregnancy test (exclude) FBC Haematinics TSH Cervical smear STI screen
8
Q
If <45yrs with menorrhagia nothing found on initial Ix what is the next step?
A
No further Ix
9
Q
If >45yrs with menorrhagia what other IX can you do?
A
TVUSS
Hysteroscopy
Endometrial biopsy
10
Q
1st line Rx for menorrhagia
A
Mirena IUD
11
Q
2nd line Rx for menorrhagia
A
Antifibrinolytics: Mefenamic acid/Traxemanic acid
COCP
12
Q
3rd line Rx for menorrhagia
A
Long acting progesterones (Norithisterone)
13
Q
Surgical Rx for menorrhagia
A
Endometrial ablation
Hysterectomy (last resort)
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
15
Q
What are the 2 classifications of amenorrhoea
A
Primary
Secondary
16
Q
Define primary amenorrhoea
A
Menstruation has not occurs by 16yrs
17
Q
Does norethisterone act as a contraceptive?
A
No
18
Q
Primary causes of amenorrhoea
A
Turner syndrome Testicular feminisation Imperforated hymen Eating disorder Congenital adrenal hyperplasia Intense exercise (e.g gymnasts)
19
Q
Secondary causes of amenorrhoea
A
Pregnancy (most common) Contraceptive/hormonal methods Polycystic ovaries disease Thyroid disease Hyperprolactinaemia (prolactinoma) Sheehan's Syndrome
20
Q
Define secondary amenorrhoea
A
Absence of menstruation for 6 months in a women who previously had normal menstruation
21
Q
FIRST Ix for Amenorrhoea
A
Pregnancy test (b-HCG) Urine pregnancy test
22
Q
Other Ix for amenorrhoea
A
FBC TFTs FSH LH Oestradiol Prolactin Testosterone Karyotyping if suspected genetic Pelvic USS
23
Q
Rx for amenorrhoea
A
Treat underlying cause
24
Q
General Rx for amenorrhoea
A
Weight loss
25
Rx for amenorrhoea due to ovarian insufficiency
HRT
26
Rx for amenorrhoea due to hypothyroidism
Levothyroxine
27
Rx for amenorrhoea due to PCOS
```
Weight loss
Metformin
Clomifene
OCP with anti-angrogen effect
Eflornithine
```
28
What is eflornithine used to treat in PCOS
Excessive facial hair growth in women
29
What is the main action of clomifene
Induce ovulation
30
Rx for amenorrhoea due to hyperthyroidism
Carbimazole
31
For how long should you assume women are fertile in amenorrhoea
Assume fertile and need contraception unless >2yrs after menopause
32
Define miscarriage
Loss of pregnancy <24 weeks
33
When do the majority of miscarriages occur
First trimester
| <12 weeks
34
What is the most common early pregnancy complication
Miscarriage
35
Potential causes of miscarriage
```
Abnormal conceptus (chromosomal, genetic, structural)
Uterine abnormality
Congenital (Mullerian ducts)
Fibroids
Cervical incompetence
```
36
Maternal risk factors for miscarriage
Increasing age
DM
Acute maternal infection
37
Define threatened miscarriage
Bleeding from gravid uterus <24 weeks
Viable fetus
No evidence of cervical dilatation
38
Define inevitable miscarriage
Cervix already began to dilate
| Viable pregnancy
39
Define Incomplete miscarriage
Only partial expulsion of products of conception
| Some product of pregnancy remain within the uterus
40
Define complete miscarriage
Complete expulsion of products
| In order to confirm Dx need to confirm there was a pregnancy beforehand
41
Define missed miscarriage (sometimes called silent)
Fetus died in utero
| Uterus made to attempt to expel products
42
Describe the cervix in a threatened miscarriage
Closed
| No evidence of dilatation
43
Describe the cervix in an inevitable miscarriage
Open
44
Clinical features of miscarriage
Bleeding vaginally
Pain
Can be asymptomatic in silent miscarriage
45
Describe pregnancy test results after a miscarriage
Can remain positive for a few days post miscarriage
46
Ix for miscarriage
```
USS
Beta hCG
FBC
U&E's
Rhesus status
```
47
Rx for early miscarriage
Usually does not require any medical intervention
| Support and counselling
48
Rx for threatened miscarriage
75% will settle
| Conservative/monitoring
49
Rx for evacuation in miscarriage
Mifepristone
| Prostaglandins (misoprostol)
50
Rx for potentiatial heavy bleeding in miscarriage
Ergometrine
51
What is ergometrine used for
Causes contractions of the uterus to try and stop heavy menstrual bleeding
52
Define recurrent miscarriage
Loss of 3 or more pregnancies <24weeks gestation with the same biological father
53
Possible causes of recurrent miscarriage
```
Bacterial vaginosis
Parental chromosomal disorder
Uterine abnormality
Thrombophili
Alloimmune causes
Antiphospholipid syndrome
```
54
What is the main cause of recurrent miscarriage
Many causes the cause is unknown
55
Rx for recurrent miscarriage
Referral to specialist clinic
| Will run tests
56
What needs to be considered regarding the patient in recurrent miscarriage
Psychological effects
57
What is an ectopic pregnancy
A pregnancy that implants outside the uterine cavity
58
Incidence of ectopic pregnancy
1 in 90
59
Risk factors for ectopic pregnancy
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception
60
Most common site for ectopic pregnancy
Ampulla (uterine tube)
61
2nd most common site for ectopic pregnancy
Isthmus (uterine tube)
62
Rare sits for ectopic pregnancy
Cervix
| Abdomen
63
Clinical features of ectopic pregnancy
```
Period amenorrhoea with +ve pregnancy test
Vaginal bleeding
Abdo. pain
GI or urinary symptoms
Diarrhoea
Dizziness
Vomiting
Collapse
```
64
Ix for ectopic pregnancy
USS
Serum progesterone levels
Serum B-hCG levels
FBC
65
Why should you do FBC in ectopic pregnancy
To cross match 6 units of blood
66
Rx for ectopic pregnancy
Methotrexate
| Use contraception for 3/12
67
Why should women use contraception for 3 months after Rx with methotrexate
Because methotrexate is highly teratogenic
68
Surgical Rx of ectopic pregnancy
Salpingotomy vs Salpingectomy (mostly laparoscopically)
69
What is a salpingotomy
Tubal incision amde
| Leaving the uterine tube behind
70
What is a salpingectomy
Removal of the uterine tube
71
Main risk with salpingotomy
Leaving behind a damaged tube
| Thus increasing the risk of a further ectopic pregnancy
72
Define antepartum haemorrhage
Haemorrhage from the genital tract >24 weeks pregnancy but before delivery of baby
73
What are the commonest causes of antepartum haemorrhage
Placenta praevia
| Placental abruption
74
What is placenta praevia
Condition where the placenta lies low in the uterus and partially or fully covers the cervix
75
What is vasa praevia
Rupture of fetal vessels within fetal membrane
| Blood loss is fetal in origin
76
What is the origin of blood loss in vasa praevia
Fetal
77
Is for APH
Blood cross match
U&E's
Coagulation screens
USS
78
Rx for APH
Admission
Set IVI
Blood cross match
79
Rx for severe APH
```
Elevate leg
IVI
Take bloods
Give fresh ABO (Rh compatible)
Catheterise bladder
C-section for placenta praevia
```
80
What is placenta praevia
When all or part of the placenta implants in the lower uterine segment
Lying in front of the presenting fetus
81
Who is placenta praevia more common in
Multiparous women
Multiparous pregnancy
Previous CS
82
Describe Grade 1 placenta praevia
Placenta enroaches the lower uterine segment but not internal cervical OS
83
Describe Grade 2 placenta praevia
Placenta reaches internal cervical OS
| But does not cover it
84
Describe Grade 3 Placenta praevia
Placenta eccentrically covers internal cervical OS
| Placenta partially covers the internal Cervical OS
85
Describe Grade 4 placenta praevia
Central placenta praevia
| Placenta completely covers the internal cervical OS
86
Clinical features of placenta praevia
Painless PV bleeding
Soft
Non-tender uterus
Fetal malpresentation
Incidental finding on USS
87
What MUST NOT be done in placenta praevia
Vaginal examination
88
Ix for placenta praevia
USS (commonly incidental finding)
MRI
Vaginal examination MUST NOT BE DONE
89
Management of placenta praevia
Depends on:
Gestation
Severity of blood loss
Blood transfusion
C-section
90
How should babies be delivered in placenta praevia
C-section
91
Define placental abruption
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
92
What is placental abruption a major cause of
APH
93
Describe revealed placental abruption
Major haemorrhage revealed because blood escapes through cervical OS
The bleeding is apparent
94
Describe concealed placental abruption
Haemorrhage occurs between placenta and uterine wall
Uterine vol increases
The bleeding is not apparent
95
Describe mixed placenta abruption
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
96
Clinical features
```
Severe abdominal pain
Vaginal bleeding (varying amounts)
Possible contractions
```
97
Ix of placental abruption
USS
| Need to rule out other causes haemorrhage
98
Rx placental abruption
Depends on blood loss and fetal status
Monitoring (if no-one in distress)
Large can be urgent
99
Rx for large placental abruption
Can be as urgent as delivery
100
Associations with placental abruption
```
Pre-eclampsia
Chronic hypertension
Multiple pregnancy
Polyhydramnios
Smoking
Increasing age
Parity
Previous abruption
Cocaine use
Infection
```
101
Complications of placental abruption
```
Maternal shock
Collapse
Fetal distress
Maternal DIC
Renal failure
Post partum haemorrhage
```
102
Definition of preterm labour
Onset of labour <37 weeks
103
Is preterm labour more common in singletons or multiples
Multiples
Singletons - 5-7%
Multiples - 30-40%
104
Define mildly preterm
32-36 weeks
105
Define very preterm
28-32 weeks
106
Define extremely preterm
24-28 weeks
107
Predisposing factors to preterm labour
```
Multiple pregnancy
Polyhydramnios
APH
Pre-eclampsia
Infection
Premature rupture of membranes
Majority no cause!! (idiopathic)
```
108
Clinical features of preterm labour
Same as normal labour but early
Contractions
Cervical dilatation + uterine contraction
109
Management of preterm labour
Tocolysis
| Steroids to aid babies lung development
110
What is the action of tocolysis
To slow down contractions
| Can only be used short term 24-48hrs
111
Why may tocolysis be used?
If mother needs transferred
| Or to give baby steroids
112
What is the reason for giving premature labour steroidis
To aid with the fetal lung development
113
Reasons why you would induce preterm
Large baby
Pre-eclampsia
Infection
Placenta praevia
114
Neonatal morbidity resulting from prematurity
```
Respiratory distress syndrome
Intraventricular haemorrhage
Cerebral palsy
Nutrition
Temperature control
Jaundice
Infection
Visual impairment
Hearing loss
```
115
What is the pre-invasive stage of cervical cancer known as?
Cervical intraepithelial neoplasia
116
Risk factors for CIN
```
HPV 16/18
Persistent high risk HPV infection
Smoking
Immunocompromised
COCP
Multiple partners
```
117
At which anatomical location does CIN most commonly occur
Squamo-columnar junction
118
Describe CIN 1
Affects lower basal 1/3 cervical epithelium
| 60% will regress to normal
119
Describe CIN 2
<2/3 thickness of epithelium
| may regress
120
Describe CIN 3
>2/3 or full thickness of epithelium
Severe dysplasia
Unlikely to regress
121
Name dyskaryotic features
Increased nuclear size
Increase nucleus to cytoplasmic ratio
Coarse irregular chromatin
Nucleoli
122
How is CIN often diagnosed
Picked up on routine smear screening
123
Describe the current cervical screening programme
```
Women 25-64yrs
5yrly
All smears tested for cervical cytology
If negative recalled in 5yrs
If positive called for colposcopy
```
124
What is colposcopy
Examination of the cervix by colposcope
| Painted with acetic acid
125
What type of biopsy can be done during colposcopy for histological Dx
Punch biopsy
126
Describe the cervical screening programmes as of 202
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
127
Rx for CIN
Large loop excision of transformation zone
| LLETZ
128
Other Rx for CIN
Cold coagulation
Laser ablation (rarely done)
Cone biopsy
129
Describe the HPV vaccination
Protects against HPV
| 6/11/16/18
130
What does the HPV type 6 and 11 cause
Genital warts
131
Which subtypes of HPV are associated with cervical cancer
16 and 18
132
What is the aim of cervical screening
Aim is to pick up neoplasms and reduce the risk of cervical cancer
133
Who is the HPV vaccination offered to>
Girls
| Age 12
134
Complications of LLETZ
Haemorrhage
Infection
Vaso-vagal symptoms
Cervical stenosis
135
How often should HIV positive women have smears
Annually
136
What is the main type of cervical cancer
Squamous cell carcinoma
137
What is the 2nd main type of cervical cancer
Adenocarcinoma
138
Risk factors for cervical cancer
```
Multiple partners
High risk HPV 16/18
Age 45-55
Immunocompromised
Long term COCP use
Early age at 1st intercourse
HIV
Smoking
```
139
Describe stage 1 cervical cancer
Tumours confined to cervix
140
Describe stage 2 cervical cancer
Extended locally to upper 2/3 vagina
141
Describe stage 3 cervical cancer
Spread to lower 1/3 of vagina
142
Describe stage 4 cervical cancer
Spread to bladder or rectum
In IVb: Distant metastases
143
What is the staging classification system for cervical cancer
FIGO
144
Clinical features of cervical cancer
```
Discharge
Intermenstrual bleeding
Post-coital bleeding
Post-menopausal bleeding
Pain
```
145
Ix cervical cancer in pre-menopausal woman
First chlamydia testing
| If -ve urgent colposcopy and biopsy
146
Ix cervical cancer post-menopausal women
Urgent colposcopy and biopsy
147
Staging Ix for cervical cancer
CT chest/abdo/pelvis
PET
MRI
EUA (esp for rectal cancer)
148
Features of cervical cancer on colposcopy
Irregular cervical surface
Abnormal vessels
Dense uptake of acetic acid
149
Rx of stage Ia1 cervical cancer
Local excision
150
Rx for stage Ib - II a cervical cancer
Radical hysterectomy
151
Rx for stage IIb-IV cervical cancer
Chemoradiotherapy
152
What is the main chemotherapy agent used in cervical cancer
Cisplatin
153
Common metastatic sites for cervical cancer
Lung
Liver
Bone
Bowel
154
Risk factors for vaginal cancer
```
HPV
Age
Smoking
Alcohol
Cervical cancer
Vaginal adenosis
```
155
Is primary or secondary vaginal cancer more common
Secondary
| Primary cancer of the vagina is rare
156
Types of vaginal cancer
```
SCC
Adenocarcinoma
Others such as:
Clear cell
Small cell carcinoma
Melanoma
```
157
What is the most common type of vaginal cancer
SCC
158
Staging classification system used for vaginal cancer
FIGO
159
Rx for vaginal cancer
Depends on FIGO staging
Partial or Radical Vaginectomy for early stage
Chemoradiotherapy for later stages
160
Ix for vaginal cancer
Colposcopy and biopsy
| Pelvic MRI
161
Clinical features of vaginal cancer
```
Intermenstrual bleeding
Blood stained discharge
Post-coital bleeding
Post-menopausal bleeding
Pain
Fatigue
Weight loss
```
162
What are fibroids
benign smooth muscle tumours of the uterus
163
From which layer of the uterus do fibroids arise from
Myometrium
164
Describe sub-mucous fibroids
Protrude into the uterine cavity
165
Describe intramural fibroids
Within uterine wall
166
Describe subserous fibroids
Project outwith the uterus into the peritoneal cavity
167
Clinical features of fibroids
```
Many asymptomatic
Menorrhagia
Dysmenorrheoa
Pelvic pain
Pelvic mass
Pressure symptoms (frequency, constipation)
Pain during sex
```
168
Which type of fibroids would be the most likely to interfere with implantation of an embryo
Submucosal
169
Ix for fibroids
USS (abdo., transvaginal)
| CT
170
Rx for fibroids
If harmless no RX
171
Rx for problematic fibroids
```
GnHR analogues
Ullupristal acetate
Myomectomy
Uterine artery embolisation
Hysterectomy
```
172
What are fibroids dependent too?
Oestrogen
173
When can fibroids enlarge?
During pregnancy
| When on COCP
174
When will fibroids tend to atrophy and why?
After menopause
| As they are oestrogen dependent
175
In which population are fibroids more common in?
Africo-caribbean
176
What is endometriosis
Defined as endometrial tissue outwith the uterine cavity
177
Who does endometriosis affect
Women of reproductive age
178
Cause of endometriosis
Unknown
179
Risk factors for endometriosis
```
Early menarche
FH endometriosis
Long duration menstrual bleed
Heavy menstrual bleeding
Defects in uterus or uterine tubes
```
180
Common sites for endometrial tissue to grow in endometriosis
```
Peritoneal lining
Pouch of Douglas
Ovaries
Uterine tubes
Tissues lining the pelvis
```
181
Rarer sites for endometrial tissue to grow in endometriosis
Lungs
Muscles
Eyes
Brain
182
What is the gold standard Ix for endometriosis
Laparoscopy and biopsy
183
Clinical features of endometriosis
```
Cyclical pain
Severe dysmenorrhoea
Dysuria
Dyschezia
Subfertility
```
184
Potential signs in endometriosis
Tender noduels in rectovaginal septum
Adnexal mass
Limited uterine mobility
185
Medication Rx for endometriosis
Analgesia for pain
Progesterone oral/inject/IUD
Mirena (IUD)
COCP
GnHR analogues
186
Surgical Rx for endometriosis
Excision of deposits fro peritoneum/ovary
Laser ablation
187
Can endometriosis be cured
No
188
DDx for endometriosus
PID
Ectopic pregnancy
Fibroids
IBS
189
Who does endometrial cancer most commonly occur in
Post-menopausal women
190
At what age is peak incidence for endometrial cancer
65-71yrs
191
Is endometrial cancer more or less common than cervical cancer
Less common
192
What has the increase in endometrial cancer been attributed to
Obesity
193
Risk factors for endometrial cancer
```
Obesity
Increasing age
Type II DM
Nullparity
Early menarche
Late menopause
Breast cancer
Oestrogen only HRT
PCOS
Tamoxifen
```
194
Genetic predispositions to endometrial cancer
HNPCC/Lynch syndrome
195
Describe type I endometrial cancer
```
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
```
196
What is the most common type of endometrial caner
Type I
| Adenocarcinoma
197
What is type II endometrial cancer
Uterine serous and clear cell carcinoma
high grade, more aggressive, worse prognosis
Not linked to oestrogen
198
Which is the more aggressive type of endometrial cancer
Type II
Uterine serous and clear cell
More aggressive and more likely to spread
199
What should you do with someone presenting with post-menopausal bleeding
Investigate this promptly
200
Define post-menopausal bleeding
Bleeding 1yr after periods have stopped
201
What tumour marker can be measured in suspected endometrial cancer
Ca125
202
Ix for endometrial cancer
TVUSS
203
When should you biopsy the endometrium in TVUSS looking for endometrial cancer
Thickness >4mm
| Or irregular
204
how is endometrial cancer Dx
Pipelle biopsy
205
Staging for endometrial cancer
CT/MRI/CXR
206
What is the earliest visible sign of endometrial cancer
PMB
207
Rx early stage endometrial cancer
Total hysterectomy
| Bilateral salpingoophrecomtyPeritoneal washings
208
Rx for high risk histology endometrial cancer
Chemotherapy
209
Rx for advanced endometrial cancer
Radiotherapy
210
Palliation Rx of endometrial cancer
Progesterone
211
Which cancers does HNPCC increase risk of
CRC
Endometrial
Ovarian
212
Which classification system is used to stage endometrial cancer
FIGO
213
Describe stage I endometrial cancer
Body of the uterus only
214
Describe stage II endometrial cancer
Body of the uterus and cervix only
215
Describe stage III endometrial cancer
Advancing beyond uterus but not beyond the pelvis
216
Describe Stage IV endometrial cancer
Extending outside the pelvis e.g to bowel or bladder
217
What is pelvic inflammatory disease
Infection of the upper genital tract
218
Causes of PID
STIs
Uterine instrumentation
Post-partum
219
Risk factors for PID
<25yrs
Previous history STIs
New or multiple partners
220
Clinical features of PID
```
Vagina discharge may be evident
Cervical motion tenderness O/E
Lower abdo. pain
Post-coital bleeding
Dysmenorrhoea
Fever
Discomfort or pain during sex
```
221
What % of PID is caused by STI
25%
222
Ix for PID
Vulvovaginal/endocervical swabs
FBC
Blood cultures (if febrile)
Beta hCG to exclude pregnancy
223
Rx PID
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
224
Complications of PID
Ectopic pregnancy
Tubo-ovarian abscess
Fitz-Hugh Curtis syndrome
Recurrent PID
225
Prevention of PID
Barrier contraception
COCP
Mirena
226
What is the most likely cause of PID
Untreated chlamydia or gonorrhoea
227
What is the 2nd commonest cause of abnormal vaginal discharge
Vulvovaginal Candidosis
228
Is vulvovaginal candidosis classified as an STI
No
229
Who is vulvovaginal candisosis more common in
```
DM
Oral steroids
Immunosuppression
Incl. HIV
Pregnancy
Reproductive age group
Many cases occur in women with no pre-disposing factors
```
230
What is the commonest organism of vluvovaginal candidosis
90% Candida albicans
231
Other organism cause of vulvovaginal candidosis
C.Glabrata
232
Clinical features of thrush
```
Itch (may be severe)
Discharge typically thick cottage cheese like
Copius amounts discharge
Fissuring
Erythema satellite lesions
```
233
Ix of vulvovaginal candidosis
Characteristic history
| Culture e.g Sabouraud's Medium
234
Rx of thrush
Azole antifungals
Clotrimazole PV once
Fluconazole PO once
235
What combination of treatment needs to be given in vulvovaginal cadidosis
Oral and vaginal treatment
236
What is the commonest cause of abnormal vaginal discharge in women
Bacterial vaginosis
237
Pathophysiology of bacterial vaginosis
Imbalance of bacteria rather than true infection
Biofilm problem:
increase in gardnerella/ ureaplasma/ mycoplasma/ anaerobes
decrease in Lactobacilli
238
Clinical features of bacterial vaginosis
```
Thin, homogenous discharge
Fishy discharge
May be worse after periods/sex
Vagina not inflamed
Rarely itchy
```
Asymptomatic in 50%
239
Ix of bacterial vaginosis
Characteristic history
Examination findings
Gram stained smear of vaginal discharge
240
Rx bacterial vaginosis
Metronidazole
| Clindamycin
241
What is balanitis
Inflammation of the glans penis
242
What is posthitis
Inflammation of the foreskin
243
What are the common organism causes of impetigo
Staph. Aureus
| Strep. Pyogenes
244
What is the common organism cause of Erisypelas
Strep. Pyogenes
245
What is a prolapse
Protrusion of an organ or structure beyond its normal anatomical confines
246
Define female pelvic organ prolapse
Descent of pelvic organs towards or through the vaginal
247
Risk factors for prolapse
```
Forceps delivery
Large baby
Prolonged 2nd stage labour
Increasing age
Obesity
Previous pelvic surgery
Quality of connective tissue
Occupation with heavy lifting
Exercise
```
248
Define urethrocele
Prolapse of lower anterior vaginal wall involving urethra only
249
Define cystocele
Prolapse of upper anterior wall involving bladder
250
Define uterovaginal prolapse
Prolapse of uterus, cervix and upper vagina
251
Define enterocele
Prolapse of upper posterior all of vaginal usually containing small loops of bowel
252
Vaginal symptoms in POP
```
Sensation of bulging or protrusion
Seeing or feeling bulge or protrusion
Pressure
Heaviness
Difficulty inserting tampons
Discomfort or numbness during sex
```
253
Urinary symptoms in POP
```
Urinary incontinence
Frequency/urgency
Weak or prolonged urinary stream
Manual reduction in prolapse to start off complete voiding
Feeling of incomplete emptying
```
254
Bowel symptoms in POP
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
Ix for prolapse
USS
MRI
Urodynamics
IVU or renal USS
256
Objective assessments tools for POP
Baden-Walker Halfway Grading
| POPQ score
257
Rx for POP
Pelvic floor muscle training
Pessaries
Surgery
258
What are pessaries generally made from
Silicone
Lucite
Rubber or plastic
259
What are pessaries good for
Maintaining fertility
260
What are Kegel exercises
Pelvic floor exercises
261
What are Kegel exercises good for in POP
Mild cases of POP
| Younger fertile women
262
Prevention of POP
```
Avoid constipation (high fibre diet)
Better obstetric practice
Lower parity
void lifting heavy object
Management of chronic chest pathology
```
263
Side effects of pessaries
```
Unpleasant vaginal discharge
Vaginal irritation
Stress incontinence
UTI
Sometimes interferes with sex
```
264
What is urinary incontinence
Involuntary leakage of urine
265
Describe stress urinary incontinence
Involuntary leakage of urine on effort or exertion
| Or on coughing/sneezing/laughing
266
Describe urgency incontinence
Involuntary leakage of urine accompanied or preceded by extreme urgency
267
Which is the most common urinary incontinence in women
Stress incontinence
268
Risk factors for stress incontinence
```
Age
Parity
Menopause
Smoking
Increased intra-abdominal pressure
Pelvic floor trauma
Connective tissue disease
Congenital weakness
Surgery
```
269
What is the main risk factors for stress incontinence
Pregnancy and childbirth
270
Clinical features of stress incontinence
Passage of small amounts of urine on coughing, sneezing, laughing or exertion
Effect on QOL
271
Ix for stress incontinence
```
History
MSSU (exclude UTI)
Bladder diaries
Bladder scan
Urodynamics
```
272
Name 2 urodynamic types of studies
Cystometry
| Uroflowmetry
273
Describe pathophysiology in stress incontinence
Increase in detrusor muscles pressure exceeds closing urethral pressure resulting in leakage
Bladder outlet is too weak
274
General Rx of stress incontinence
```
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
Pharmacological Rx stress incontinence
Duloxetine (SSRI)
| Oestrogen cream
276
Surgical Rx stress incontinence
Tension free vaginal tape
Colposuspension (now rarely performed)
277
Describe Kegel exercises
Minimum 8 contractions x3 daily
| Mixture of fast (1 sec) and slow (10sec) contractions
278
Name aids for pelvic floor training/exercises
Vaginal cones
Electrical stimulation
Biofeedback
279
What is urge urinary incontinence
Incontinence associated with the sudden urge to pass urine that cannot be avoided
280
What is the commonest cause of urge urinary incontinence
Overactive bladder syndrome
281
What is overactive bladder syndrome
When the detrusor muscle is instable
| contracting at low volumes
282
Clinical features of urge incontinence
Sudden urge to pass urine
Frequency
Nocturia
Patient knows every public toilet
283
Ix for urge incontinence
```
Good history
MSSU
Bladder diaries
Examination
Bladder scan
Urodynamic studies
```
284
General Rx for urge incontinence
```
Weight control
Fluid control: Volume and type
Reduce bladder irritants:
Caffeine
Fruit Juice
Alcohol
```
Pelvic exercises
Bladder retraining
programme
285
Medication for urge incontinence
Anti-cholinergics/Anti-muscarinics:
Oxybutynin
Tolterodine
Solifenacin
Beta-3-adrenoeceptors
Botulinum Toxin
286
Side effects of anti-colinergics/anti-muscarinics
```
Dry mouth
Dry eyes
Constipation
Nausea
Blurred vision
```
287
What is overflow incontinence
Urine is retained in the bladder due to outlet obstruction
288
What are common obstructions in overflow incontinence
Prostatic hypertrophy
| Tumour
289
Clinical features in overflow incontiencne
Prostatic symptoms
| Palpable bladder
290
Ix for overflow incontinence
```
History
MSSU
Bladder diaries
Examination
Bladder scan
Urodynamic studies
```
291
What does VIN stand for
Vulva intraepithelial neoplasia
292
Risk factors for VIN
Smoking Other genital intra-epithelial neoplasia
Previous related malignancy
Immunosuppression
293
3 stages of VIN
VIN I/II/III
294
What are the 2 types of VIN
Usual type VIN
| Differentiated type VIN
295
What is VIN
Pre-cancerous and pre-invasive condition
296
Ix for VIN
Histological Dx
| Punch biopsy
297
Rx for VIN
Surveillance
Biopsy of suspicious lesions
Topical Rx:
Imiquimod
Laser treatment
Surgery
298
Why is laser treatment not recommended in VIN
40-70% recurrence rate
299
When will you be given Rx for VIN
If it is high grade
300
Examination features of VIN
```
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
What is the most common type of vulvar cancer
Squamous cell carcinoma
302
What is SCC vulvar cancer associated with
VIN
| Lichen Sclerosis
303
Name other types of vulvar cancer
Basal cell carcinomas
| Melanomas
304
Which LN would be involved in vulvar cancer?
Inguinal and femoral
305
Which staging system is used to classify vulvar cancer?
FIGO
306
Symptoms of vulvar cancer
```
Itch
Pain
Bleeding
Abnormal discharge
Pain when peeing
Lump/ulcer
Lump in the groin
```
307
Rx for vulvar cancer
Surgery:
Local excision
Vulvectomy
Radiotherapy
Chemotherapy
308
What is the pre-invasive phase of vulvar cancer known as?
VIN
309
When is the peak age for ovarian cancer?
75-84yr F
310
Risk factors for ovarian cancer
```
Increasing age
Family History
Smoking
HRT
Early menarche
Late menopause
BRCA1
BRCA2
HNPCC/Lynch syndrome
```
311
Factors which decrease your risk of ovarian cancer
Breast feeding
Tube ligation
Pregnancy
COCP
312
Which LN does ovarian cancer spread to?
Para-aortic LN
| Similarly to testis
313
Why is ovarian cancer often detected at a late stage
As the symptoms can be very vague/misleading
314
Symptoms of ovarian cancer
```
Bloating
Unexplained weight loss
Indigestion
Early satiety
Fatigue
Urinary symptoms - urgency/frequency
Change in bowel habits
```
315
Which tumour marker in the blood can be tested for in ovarian cancer
Ca125
316
Potential O/E findings for ovarian cancer
Fixed mass
Ascites
Pleural effusion
lymphadenopathy
317
Ix for ovarian cancer
```
FBC
LFTs
U&E's
Ca125
USS
CT/abdo/ches
```
318
Rx for ovarian cancer
```
Full staging laporotomy
Tissue Dx
Stage Disease
Disease clearance - early stage
Debulk disease - late disease
```
Chemotherapy
319
What are the main chemotherapy agents used in ovarian cancer
Carboplatin (Platinum)
| Paclitaxol (Taxol)
320
High risk geentics for ovarian cancer
BRCA1
BRCA2
HNPCC/Lynch syndrome
321
Which staging system is used in ovarian cancer
FIGO
322
Describe stage I ovarian cancer
Limited to one or both the ovaries
323
Describe stage II ovarian cancer
Limited to the pelvis
324
Describe stage III ovarian cancer
Limited to the abdomen including regional LN metastases
325
Describe stage IV ovarian cancer
Distant metastases outwith the abdomen
326
What is the lifetime risk of the BRCA genes with ovarian cancer
15-45%
327
Which contraception provides a protective mechanism to ovarian cancer
COCP
328
what are ovarian cancer syptoms often mistaken for
IBD
| Diverticular disease
329
What is the most common bacterial STI in the UK
Chlamydia
330
What is chlamydia an important cause of
Tubal infertility
331
Which organism causes chlamydia
Chlamydia Trachomatis
332
Main symptom of chlamydia
ASYPMPTOMATIC in most cases
333
Potential symptoms of chlamydia
```
Dysuria
Vaginal discharge
Interestrual bleeding
Post-coital bleeding
Conjunctivitis
```
334
When should you test for chlamydia reinfection
3-12 months
335
Rx of chlamydia
Azithromycin 1g single dose
| Doxycycline 100mg Bd 7 days
336
Who is it essential to treat in chlamydia infection
Treat sexual partners
337
Rx Chlamydia in pregnancy
Erythromycin
338
Ix chlamydia
Vulvovaginal swabs
Endocervical swabs
First void urine men for NAAT
339
Complications Chlamydia in females
```
PID
Perihaptitis
Urethritis
Tubal infertility
Ectopic pregnancy
```
340
Complications chlymadia in males and females
Reactive arthritis
| Reiter's syndrome
341
Complication chlamydia in pregnancy
Increased risk of:
Preterm rupture of membranes
Premature delivery
Neonatal conjunctivitis and pneumonia
342
Complications of chlamydia in males
Epididymitis
343
What is the main worry with gonorrhoea
there is an increase in abx resistant cases
344
Organisms of gonorrhoea
Neisseria Gonorrhoea
345
How is gonorrhoea transmitted
Sexual contact with infected individual
346
How is gonorrhoea prevented
Use of condoms
347
Ix for gonorrhoea
First void urine
Vulvovaginal/endocervical swabs
NAAT
348
Symptoms gonorrhoea in females
```
Often asymptomatic
Lower abdo. pain
Vaginal bleeding
Intermenstrual bleeding
Post-coital bleeding
Vaginal discharge (thick, yellow, green)
Conjunctivities
Dysuria
```
349
Symptoms gonorrhoea in males
Thick profuse yellow discharge
Dysuria
Infallamtion of foreskin
350
Rx for gonorrhoea
Blind Rx Ceftriaxone 500mg IM once
| + Azithromycin PO 1g stat
351
Who else do you need to treat in gonorrhoea
Treat sexual partners
| Contact trace
352
What is the Rx for gonorrhoea in pregnancy
Same as not in pregnancy
353
Complications of gonorrhoea in females
Bartholin's Abscess
Tubal infertility
Increase risk ectopic pregnancy
354
Complications of gonorrhoea in males
Epididymitis
355
Which organism causes anogenital warts
HPV types 6+11
356
Clinical features of anogenital warts
```
Lumps with surface texture of small cauliflower
Papilliform or flat warts
May be pigmented
May bleed
May itch
```
357
1st line Rx anogenital warts
Topical podophyllum
| Cryotherapy
358
2nd line Rx anogenital warts
Imiquimod cream
359
Ix anogenital warts
Clinical Dx based on O/E
| Biopsy if unusual but rarely needed
360
Which types of HPV cause cervical cancer
Type 16 and 18
361
What strains of HPV does the quadrivalent vaccine protect against
6/11/16/18
362
Which virus cuses genital herpes
Herpes simplex virus 1 and 2
363
Symptoms of genital herpes
```
80% asymptomatic
Burning/itching
BListering then tender ulceration
Tender inguinal lymphadenopathy
Dysuria
```
364
Ix for genital herpes
Clinical O/E
| PCR viral swab
365
Rx for primary genital herpes
Aciclovir
366
Rx for infrequent recurrences of genital herpes
Lidocaine ointment
| Aciclovir daily until symptoms are gone
367
Rx for frequent recurrences of genital herpes
Aciclovir 400bg long term as immunosuppression
368
Does type I or Type II herpes simplex typically cuse genital herpes
Type II typically
But not strict rule
It can be type I
369
Syphilis organism
Treponema Pallidum
370
Primary syphilis symptoms
Chancre (local)
| Often painless
371
Secondary syphilis symptoms
Rash (can be local or widespread)
Mucosal ulceration
Patchy alopecia
372
Early latent syphilis symptoms
No symptoms but <2yrs since caught
373
Late latent syphilis symptoms
No symptoms but >2yrs since caught the infection
374
Tertiary syphilis symptoms
can involve:
Neurological
Cardiovascular
Gummata formation
375
Ix Syphilis
```
Clinical signs
Serology for:
TPPA
RPR
IgGEIA
TP
PCR on sample from ulcer
```
376
Rx for Early sypihlis with no neurological invovlement
Benzathine penicillin
Or
Doxycycline (penicillin allergic)
377
Rx for sypihlis in pregnancy
Benzylpencillin as normal
If penicllin allergic cannot give dxycycline as teratorgenic
So desensitise to penicillin then prescribe
378
Why can doxycycline not be given in pregnancy
Teratogenic
379
Fetal Rx of congenital syphilis
Penicillin
380
Why is congenital syphilis now extremely rare
As mothers are screened during pregnancy
381
Definition of infertility
inability of a couple to conceive after 1yr of trying
382
Female causes of infertility
```
Increasing age
PCOS
STI's
Body weight Fibroids
PID
Antisperm antibodies
```
383
How does a womans age affect her fertility
Increasing age
| Decreases fertility
384
How can PCOS cause inferility
Can cause anovulatory subfertility
385
What is the leading cause of infertility
STIs
386
Example of STI which can cause a complication of infertility
Chlamydia
387
How can body weight affect fertiltiy
```
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
How can fibroids affect fertility
Commonest benign tumour of uterus
| Can cause problems with implantation
389
Primary Ix for infertility
```
Chlamydia screening
Measure BMI
Baseline hormonal profile
TSH
Prolactin
Testosterone
Rubella status
Mid-luteal progesterone
Semen analysis
```
390
Secondary Ix for infertility:
```
TVS:
Adnexal mass
Fibroids
PCOS
Pelvic USS
```
391
Lifestyle changes Rx for infertility
```
Smoking cessation
Alcohol decrease
Folic acid
Weight loss/gain
Regular intercourse
```
392
Rx for ovulation induction for infertility
Weight loss
| Clomifene
393
Which anti-diabetic agent can be used to treat PCOS
Metformin
394
Indications for IVF
```
Tubal disease
Male factor subfertility
Anovulation (not responding to Rx)
Endometriosis
Unexplained infertility >2yrs
Maternal age
```
395
When is laparoscopic ovarian drilling used for
Can trigger ovulation in patients with PCOS
396
Describe NHS funded assisted conception inclusion criteria
```
Couples with no children
Non-smokers
BMI<30
<40yrs offered 3 cycles
40-42yrs offered 1 cycle
```
397
Define subfertility in males
Inability to cause pregnancy in a fertile females
398
Causes of male subfertility
```
Epididymitis
Congenital e.g Klinefelter's Syndrome
CF (congenital bilateral absence of vas deferens)
ASA (antisperm antibodies)
Varicocele
Impotence
Overheated testicles
Oligozoospermia
```
399
How can epididymitis cause infertility?
Due to infection with STI
400
How can CF cause infertility in males
Due to bilateral absence of the vas deferens
401
Ix for male subfertility
```
BMI
Genital examination
Testicular size
Baseline hormonal profiles:
FSH
Testosterone
Karyotype ( to check for genetic abnormalities)
CF screen
SSemen analysis
```
402
What is measures in semen analysis
Number of sperm
Motility of sperm
Sperm morphologically
403
What is the main fertility treatment for male infertility
Intracytoplasmic sperm injection
404
Is all infertility explained?
No
| 1/3 of the 1 in 7 couple with fertility issues have unexplained infertility
405
Rx for male subferility
```
Regular sexual intercourse
Smoking cessation
Decrease alcohol
Lose/gain weight
Regular exercise
Gonadotrophin
```
IVF
ICSI
406
What is the commonest malpresentation in obstetrics?
Breech presentation
407
Causes of breech presentation
```
Idiopathic
Uterine abnormalities (fibroids, bicorunate uterus)
Prematuriy
Placenta praevia
Oligohydramnios
Fetal abnormalities
```
408
What are the 3 types of breech
Extended breech
flexed breech
Footling breech
409
Describe extended/Frank breech
Flexed at highs but extended at th eknees
410
Describe Flexed breech
Hips and knees both flexed
| Presenting is feet, external genitalia and buttocks
411
Describe Footling breech
The foot is presenting lower than the buttock
412
Examination findings of breech baby
No head felt in pelvis
| Fundus of uterus: smooth round mass (head)
413
Ix of breech
Examination findings
USS
Try to Dx antenatally
414
Rx for breech
External cephalic version
415
What is ECV
External cephalic version
Turning breech baby
by manouvering forward somesault
416
When is C-Section recommended in multiples
If 1st/presenting twin is breech
417
Describe vaginal breech delivery
```
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
When is external cephalic version CI
```
Placenta praevia
Multiple pregnancy
APH last 7 days
Ruptured membranes
Mother with uterine scars/abnormality
Fetal abnormality
Pre-elampsia
Growth restricted babies
```
419
When is vaginal delivery CI in breech
```
Inexperienced clinicial
Footling breech
Low fetal weight
Previous LSCS
Placenta praevia
Hyperextended fetal neck
```
420
Is cord prolapse serious?
Yes
| It is an obstetric emergency qWhat is cord prolapse
421
What is cord prolapse
Descent of the umbilical cord through the cervix
| Below presenting part after membrane rupture
422
Why is cord prolapse an emergency?
As cord compression and vasospasm of the cord can ccause fetal asphyxia
423
Risk factors for cord prolapse
```
Fetal malpresentation (e.g breech)
Unstable lie
Polyhydramnios
Prematurity
Low birth weight (small baby)
Multiple gestation
Spontaneous rupture of membranes
```
424
How does fetal hypoxia occur in cord prolapse?
Occlusion of the cord (by presenting fetus0 occluding blood flow
Arterial vasospasm of the umbilical cord due to exposure to cold atmosphere
425
Clinical features of cord prolapse
Cord at introitus
Fetal bradycardia
Variable fetal heart decelerations
426
Management steps for cord prolapse
Get senior help
| Aim to delivery <15 mins
427
Steps to minimise cord compression and vasospasm
```
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
Best delivery method for cord prolaspe
Whichever is quickest
| If cervix fully dilated then use forceps for vaginal delivery
429
How quick should a baby be delivered in cord prolapse
<15 mins crucial
430
What is primary post partum haemorrhage
Loss of >500ml blood within 24hrs
431
What is secondary post partum haemorrhage
>500ml blood loss after 24hrs up to 6 weeks after delivery
432
Risk factors for post-partum haemorrhage
```
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
4 Ts of post-partum haemorrhage
Tissue
Tone
Trauma
Thrombin
434
Give Tone causes of PPH
Uterine atony
Placenta praevia
Multiple pregnanct
Polyhydramnios
435
Give Tissue causes of PPH
Reatined products of coception
| Retained placenta
436
Give trauma causes of PPH
Genital tract trauma
C-section
Episiotomy
Macrosomia
437
Give thrombin causes of PHH
Clotting disorders
Pre-eclapmsia
Placental abruption
Pyrexia in labour
438
Ix for PPH
Cross match bloods
439
Initial management of PPH
```
Senir help
high flow O2
Fluids IV
Catheterise
Delivery placenta
Massage uterus
Drugs to contract uterus
Repair of tears
```
440
Examples of drugs which contract the uterus
```
Syntometrine
Oxytocin infusion
Ergometrine
Misoprostol
Carboprost
```
441
Rx for PPH if ongoing bleeding
```
Take to theatre
Explore with laparotomy
Rusch balooon
B-lynch suture
Hysterectomy
```
442
Predisposing factors to twins
```
Previous twins
FH twins
Increase in maternal age
Induced ovulation
IVF
```
443
Describe monozygotic twins
1 egg
1 sperm
1 zygote
Splits to form 2 babies
444
Describe dizygotic twins
2 sperm
2 egg
2 separate zygotes formed
445
Describe monochorionic Monoamniotic twins
```
1 placenta
1 amniotic sac
1 chorionic sac
Rarst type
Always monozygotic
Share the placenta
Risk of TTTS
```
446
Describe monochorionic diamniotic twins
```
1 placenta
1 chorionic sac
2 amniotic sacs
Share the placenta
Almost always monozygotic
```
447
Describe dichorionic diamnitoic twins
2 chorionic sacs
2 amniotic sacs
Most commonly seen dizygotic twins
2 placentas (can be fused or separate)
448
Clinical features of twins
Large uterus for due dates
2 poles felt
More than 1 fetal HR
449
Ix for twins
```
USS confirms
Distinguish how many placentas
Name twins
Twin 1 and Twin 2
Know which twin is presenting
```
450
Who leads twin pregnancy care
Consultant led care as high risk pregnncies
451
When should elective birth be offered for uncomplicated twins
37 weeks
452
When should elective birth be offered for uncomplicated triples
35 weeks
453
When is a C-section recommended in twins
When twin 1/presenting twin is breech
454
When can a vaginal delivery be offered in twins
When first twin is cephalic
| 2nd twin may be breech
455
Risks associated with shared placenta in twins
Twin to twin transfusion
456
What is twin to twin transfusion
Disproportionate transfer of blood between twins
| There is a donor and recipient twin
457
Rx for TTS
Specialist centre in Glasgow
| Lasers used to separate the fetal blood supply
458
Risk associated with twins sharing the same sac
Cord entanglement
459
Fetal complications in multiple pregnancy
Perinatal mortality increased
Prematurity risk
TTTS
Growth restriction
460
What is shoulder dystocia
When the anterior shoulder of the baby becomes impacted in the maternal pubic symphysis
461
What can delay in delivery in shoulder dysotica cause
Hypoxia in baby
| Worse case cerbral palsy
462
Associations with shoulder dysotics
```
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
Management for shoulder dysotica
Call for senior help
episiotomy (to make room for manoeuvres - does not relieve obstruction itself)
McRoberts Position
Suprapubic pressure applied
464
Describe McRobert's position
Hyperflex maternal hips (knees to chest)
465
Other manouveres that can be used in shoulder dystocia
Zavanelli Man
Wood Screw Procedure
Rubin man
466
What is last resort in shoulder dystocia
Fracturing babys clavicle
467
Complications of shoulder dystocia
Vaginal tears (3rd/4th degree)
Erb's palsy
Cerebral palsy
468
How often is McRoberts position in shoulder dystocia
90% of cases it will work
469
What are Braxton hicks
False labour
| Milder cramps
470
Clinical features of Braxton Hicks
Irregular contractions
Milder cramps
Do not increase in frequency
Do not increase in intensity
471
What is the preffered direction of episiotomy in UK
Mediolateral
472
What is an episiotomy
Intentional incision of perineum to assist delivery
473
What is the main cause of perineal tears
Vaginal childbirth
474
Describe 1st degree perineal tear
Superficial tear
| Does not damage the muscle
475
Describe 2nd degree perineal tears
Involve perineal muscle but not anal sphincter
476
Describe 3a degree perineal tear
Partial tear of external anal sphincter <50% thickness
477
Describe 3b perineal tears
>50% thickness of anal sphincter
478
Describe 3c perineal tears
Internal and external anal sphincter torn
479
Describe 4th degree tears
Involves anal/rectal mucosa
480
Rx for episiotomy
Dissolvable stiches
481
Rx for 3rd and 4th degree tears
Require repair by surgeon
Under GA or epidural
Require abx. prophylaxis
482
Rx for episiotomy and tears in general
Analgesia
high fibre diet to prevent constipation and straining
Arrange physio/pelvic floor exercises
483
Complications of episiotomy and perineal tears
```
Painful intercourse
Pain
Faecal incontinence
Infection
Scar tissue
```
484
What is a C-section
Delivery of fetus through incision in the abdomen wall and uterus
485
Indications for C-section
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
Describe category 1 C-section
Crash
Immediate threat to life of mother or fetus
Aim <30mins
487
Describe category 2 C-section
Is for maternal or fetal compromise
Not immediately life threatening
Aim 30-60 minutes
488
Describe Category 3 C-section
Semi-elective
| E.g pre-eclampsia or failed induction of labour
489
Describe category 4 c-section
Elective
E.g term Singleton breech
Should be carried out >39 weeks
490
Intraoperative complications of C-section
```
Blood loss
Uterine lacerations
Bladder laceration
Bowel injury
Ureteral injury
```
491
Post-operative complications of C-section
```
Wound
Infection
Endometritis
UTI
Venous thromboembolism
```
492
What are the 2 main types of instruments used in vaginal delivery
Forceps
| Ventouse
493
Pros and cons of forceps
Safer for baby
| But can cause serious maternal genital tract trauma
494
Pros and cons of ventouse
```
Associated with decreased maternal genital tract trauma
But fetal complications:
Cephalohaematoma
Retinal haemorrhage
More likely to fail
```
495
Maternal indications for C-section
Prolonged 2nd stage
Maternal exhaustion
Medical avoidance of pushing (severe cardiac disease)
Pushing not possible e.g tetraplegia, paraplegia
496
Criteria for instrumentation assisted vaginal delivery
```
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
Fetal reasons for instrumented vaginal delivery
Suspected fetal distress
498
Complications of instrumented vaginal delivery for mother
Maternal genital tract trauma
499
Fetal complications of forceps operative vaginal delivery
Facial nerve palsy
Skull fractures
Orbital injury
Intracranial haemorrhage
500
Fetal complications of ventouse operative vaginal delivery
```
Cephalohaematoma
Subgaleal haematoma
Retinal haemorrhage
Scalp lacerations
Scalp avulsions
```
501
Absolute CI to operative vaginal delivery
```
Unengaged fetal head in singleton
Incompletely dilated cervix
True cephalo-pelvis disproportion
breech and face presentation
Preterm gestation
```
502
Risk factors for uterine rupture
```
Dehiscence of scars
Obstructed labour in multiparous
Pervious uterine surgery or cervical surgery
Internal version
Breech extraction
```
503
Reasons to offer induction of labour
Gestational DM
Overdue (7-12 days)
Fetal reasons
504
Commonest cause uterine rupture UK
Dehiscence of CS scars
505
Risks associated with induction of labour
```
Increased risk regional anaesthetic
Increased risk fetal distress
Increased risk hyperstimulation of uterus
Increased risk C-section
Increased risk infection
Increased risk bleeding
```
506
Which score is used to asses the cervix
Bishops Score
507
What does being overdue increase the risk of
Stillbirth
508
Ix for induced labour
Continous fetal monitoring
CTG
Partogram
509
Steps of induction of labour
Vaginal sweep
Vaginal prostaglandins pessaries or IV medication
Cook balloon
Amniotomy (once cervix have dilated and effaced)
IV oxytocin to stimulate contractions
510
Define induction of labour
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
What is an amnitomy
Artifical rupture of fetal membranes
512
What does a higher Bishops score indicate
Indication to perform an amnitomy
513
CI for induction of labour
```
Malpresentation
Fetal distress
Placenta praevia
Vasa praevia
Pelvic tumours
```
514
what is the role of oxytocin in induction of labour
To induce contractions
515
Define stillbirth
Babies born dead that were alive >24 week
516
Causes of stillbirth
```
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
Is the risk of stillbirth increased or decreased in multiples
Increased
518
Clinical features of stillbirth
Absent of fetal movements
Absence of fetal HR
Dx by USS
519
Ix for suspected stillbirth
Dx by absent fetal HR on USS
520
What is Lichen Sclerosis
Chronic inflammatory skin disease of the anogenital region in women
521
Where does Lichen Scleroris affect
Anogenital region
522
Who does Lichen Sclerosis affect
Women
523
Describe the bimodal incidence of Lichen Sclerosis sin females
Peaking in:
Prepubescent women
Post menopausal women
524
What is the main clinical significance/risk of Lichen Sclerosis
Has the potential to progress to Squamous cell carcinoma
525
Rx for Lichen Sclerosis
Topical steroids
526
Ix for Lichen Sclerosis
Usually clinical O/E
| Biopsy: when unsure or suspecting malignancy
527
Clinical features of Lichen Sclerosis
```
White atrophic patches (anogenital region)
Itching
Pain
Fusion of parts of anogenital region
Pain during sex/toilet
```
528
Which organism causes Trichomoniasis
Parasite
| Trichomonas Vaginalis
529
what is the main symptoms of Trichomoniasis
Majority asymptomatic
530
Potential symptoms of Trichomoniasis
Discharge
Dysuria
Itching/burning genitals
531
Complications of Trichomoniasis in pregnancy
Miscarriage
| Preterm labour
532
Rx Trichomoniasis
Metronidazole
533
Which type of organism causes Trichomoniasis
Parasitic STI
534
What is Hypermesis Gravidarum
Persistent/severe vomiting in pregnancy
535
Risk factors for Hypermesis Gravidarum
Multiple pregnancy
Molar pregnancy
Previous HG pregnancy
536
Rx for Hypermesis Gravidarum
```
Admit if severe enough
Anti-emetics
IV fluid replacement
Daily U&Es measurement
High dose Folic acid
```
537
Ix for Hypermesis Gravidarum
U&Es
Urine dipstick
FBC
538
Clinical features of Hyperemesis Gravidarum
Dehydration
Persistent vomiting
Hypovolaemia
Electrolyte disturbance
539
What is a stillbirth
Babies born dead that were alive >24 weeks
540
Causes of stilbirth
```
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
Clinical features of stillbirth
No fetal heart sounds
| Absent fetal movements
542
Dx for stillbirth
Absent fetal HR on USS
| Repeat if mother requests
543
Rx to induce labour in stillborn
Mifeprostune
Prostaglandins
Oxytocin
544
Which support group can help support parents of still born
SANDs
545
When would you advise delivery in stillbirth
```
Pre-eclampsia
Abruption
Sepsis
Membrane rupture
Coagulopathy
```
546
What do you need before carrying out a post mortem on a fetus
Written consent
547
Which infections can cause stillbirth
```
Rubella
Flu
Cytomegalovirus
Herpes simplex
Lyme disease
Toxoplasmosis
Q fever
Malaria
```
548
Risk factors for stillbirth
```
Twins/multiple
>35yrs
Smoking, drinking, drug use
Obesity
Pre-existing health conditions e.g epilepsy
```
549
By law do stillbirths have to be registered?
Yes
550
What is the main risk with retained placenta
Haemorrhage
551
When is the placenta considered delayed
Not delivered within 30 mins of active management
| Not delivered within 60 mins of physiological management
552
Associations with retained placenta
```
Previous RP
Preterm delivery
Maternal age >35yrs
Placental weight <600g
Partity>5
Induced labour
Pethidine used in labour
```
553
Complications of retained placenta
Haemorrhage
| Infection
554
Management of retained placenta
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
What should you avoid doing in retained placenta and why
Avoid excessive cord traction
| As the cord may snap or uterus may invert
556
What can cause inverted uterus
Mismanagement of 3rd stage labour
| e.g with cord traction
557
Management of inverted uterus
```
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
Compare the risk of venous thrombo-embolis in pregnant vs non-pregnant women
Increased risk in pregnancy
559
RF for venous thromboembolism in pregnancy
```
Age
BMI
Smoking
IV drug abuse
PET
Dehydration
mobility
Infections
Operative delivery
Prolonged labour
Haemorrhage
Previous VTE
Sickle cell disease
```
560
Why are pregnant ladies in a hypercoaguable state
to protect mothers against haemorrhage post-delivery
561
Prophylaxis of venous thrombosis-embolism in pregnancy
TED stockings
Increased mobility
Anti-coagulation - LMWH
562
Rx for venous thrombosis-embolism in pregnancy
Appropriate Rx with anti-coagulation
563
Ix for venous thromboembolism
```
ECg
ABG
Doppler
V/Q scan
CTPA
```
564
Which test used normally in venous thromboembolism disease in considered unhelpful in pregnancy
D-dimer
565
Clinical features of venous thromboembolism disease in pregnancy
```
DVT:
Calf pain
Tenderness
Swelling
Warmth
Discolouration
Tachycardia
```
```
PE:
SOB
Chest pain
Haemoptysis
Tachycardia
Collapse
```
566
What are the 2 main manifestations of thromboembolic disease in pregnancy
DVT
| PE
567
What is the leading direct cause of maternal death
Thrombosis and thromboembolism
568
Why is LMWH used in pregnancy
Does not cross the placenta
| not secreted into breast milk
569
Which blood changes occur in pregnancy
fibrinogen
platelets
anti-coagulants
fibrinolysis
570
Define gestational diabetes
Women without diabetes suffers high blood sugar levels during pregnancy
Abnormal glc. tolerance reverts to normal after delivery
571
2 classes of diabetes in pregnancy
Pre-existing (can be type I or type II)
Gestational DM
572
What happens to maternal insulin requirements during pregnancy
Insulin requirements of mother increase
| Due to production of anti-insulin hormones in pregnancy (many of which produced by placenta)
573
Why can fetal hyperinsulinaemia occur in pregnancy
Maternal glucose crosses the placenta and induces insulin production in the fetus
Fetal hyperinsulinemia promotes fetal growth
Causes macrosomia
574
What can fetal hyper-insulinaemia cause
Macrosomia
575
What does gestational diabetes increase the risk for mothers in later life
Type II DM
576
What is the foetus at risk of after delivery if it suffers from hyper-insulinaemia
More risk for neonatal hypoglycaemia
577
Maternal complications of gestational DM
Increased risk pre-eclampsia
Increased risk infections
Increased risk LSCS delivery
Increased risk miscarriage
578
Fetal complications of maternal DM
```
Macrosomia (operative delivery, shoulder dystocia)
Erb’s Palsy
Malformation rates
Polyhydramnios
Preterm labour
Still birth
PN mortality
```
579
Preconception Rx for DM and pregnancy
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
During pregnancy management of pre-existing DM
```
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
Delivery for pregnancy and pre-existing DM
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
Risk factors for gestational DM
```
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
Which has the higher risk of complications pre-existing DM or gestational DM
Pre-existing
584
Screening for gestational DM
Risk factor present
Offer HbA1c at booking
75mh OGTT to be done
If normal repeat OGTT at 24-28 weeks
585
Management of gestational DM
Control sugars
Diet
Metformin
Insulin (in some cases)
586
Post-Delivery management of gestational DM
Check OGTT 6-8 weeks PN
| Yearly check HbA1C as risk developing type II DM later
587
Post delivery management of pre-existing DM in pregnancy
Can go back to pre-pregnancy regiment of insulin post delivery
588
Why does gestational DM require a yearly HbA1C
Cause of increased risk of Type II DM after having gestational DM
589
What can babies suffer from if mother was diabetic during the pregnancy
Hypoglycaemia
590
Which 2 tablets are given to induce TOP
Mifepristone
| Misoprostol
591
What is the action of Misoprostol in TOP
Prostaglandin that acts to innate contractions of the uterus
592
What is the action of Mifepristone in TOP
Primes the cervix
593
When can an abortion be carried out until
Up to 24 weeks
594
How long is the gap between the two tablets in medical abortion
24-48hrs
595
What are the two types of abortion
Medical
| Surgical
596
Complications of Abortion
```
Failed TOP
Infection
Haemorrhage
Uterine perforation
Uterine rupture
Cervical trauma
```
597
What are the 2 broad categories of pregnancy termination
Medical
| Surgical
598
What type of tumour is a choriocarcinoma
Germ cell tumour
599
What can choriocarcinoma occur after
```
Normal birth
Miscarriage
Ectopic pregnancy
Molar pregnancy
Abortion
```
600
Clinical features of choriocarcinoma
Persistent high hCG
| Persistent vaginal bleeding
601
Where does choriocarcinoma most commonly spread to
Lungs
602
What is choriocarcinoma a type of
Gestational Trophoblastic disease
603
What is the main Rx for choriocarcinoma
Methotrexate combination chemotherapy
604
What does choriocarcinoma have a very good Rx response to
Chemotherapy
605
Ix for choriocarcinoma
CXR hCG
| CT
606
What type of disease is a molar pregnancy
Gestational Trophoblastic disease
607
In a small proportion of molar pregnancies what can occur
Tissue from the molar pregnancy can remain and transform into choriocarcinoma
608
Clinical features of molar pregnancy
```
Very high hCG
Missed periods
Positive pregnancy test
Severe nausea/vomiting
Vaginal bleeding
```
609
Ix to Dx molar pregnancy
After miscarriage:
Histology for Dx
During pregnancy:
USS
hCG levels
Histology after evacuation
610
Rx for molar pregnancy
Suction removal
Methotrexate
Give Anti-D if woman is rhesus -ve
611
What must you not do after Rx of molar pregnancy
Get pregnancy for 6 months - 1 year
612
Describe a partial mole pregnancy
2 sperm fertilise the egg instead of one
75-80%
613
Describe complete mole pregnancy
One sperm (or even 2) fertilise an egg/ovum containing no genetic material (empty ovum)
20-25%
614
Describe transverse malpresentation
Shoulder presentation
| When baby is lying transversely
615
Describe face malpresentation
When the face presents at the birth canal
616
What is brow presentation
When the babies head is between full flexion and full extension
617
Rx for transverse malpresentation
ECV
If this fails
Fails at 37 weeks C/section
