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MSRA revision > Reproductive > Flashcards

Reproductive Flashcards

1
Q

What are the clinical features of endometriosis?

A
  • Usually asymptomatic
  • secondary dysmenorrhoea (very painful periods secondary to an underlying gynae issue)
  • dyspareunia
  • infertility
  • o/e fixed retroverted uterus
  • blood filled “chocolate” cysts on the ovary
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2
Q

What is the gold standard for diagnosing endometriosis?

A

Laparoscopy

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3
Q

What is a hydatidiform mole?

A
  • gestational trophoblastic disease
  • aka molar pregnancy
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4
Q

How does hydatidiform present?

A
  • painless vaginal bleeding in the first trimester
  • vomiting - may present similar to HG
  • uterus large for gestational age
  • HCG levels are very high
  • can get early onset pre-eclampsia with HTN and proteinuria
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5
Q

What is the management of hydatidiform mole?

A

urgent evacuation of retained products of conception and urgent histological examination of the tissue

Monitoring of HCG afterwards

If remains high may need chemotherapy to destroy remaining trophoblastic tissue

(increases risk of choriocarcinoma)

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6
Q

What are the risk factors for hyperemesis gravidarum?

A

associated with high HCG so more common in
- molar pregnancy
- multiple pregnancy
- obesity
- nulliparity

It can also cause hyperthyroidism

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7
Q

What is bacterial vaginosis?

A

disruption of the normal bacterial flora of the vaginal canal causing an increase in pH

  • thin white discharge
  • with a FISHY smell on alkalinisation
  • Clue cells seen on microscopy

Treatment: metronidazole

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8
Q

What sort of bacteria is gonorrhoea and what is the treatment?

A

gram negative diplococci
neisseria gonorrhoea

Treatment: IM Ceftriaxone
or Oral ciprofloxacin once only when sensitivities are known.

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9
Q

What is trichomonas vaginalis, what are the features and what is the treatment?

A
  • protozoal infection by “trichomonas vaginalis”
  • frothy, green discharge
  • foul smelling
  • dysuria
  • pain during sex
  • strawberry cervix on exam

Treatment: metronidazole

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10
Q

What antibiotic do you use to treat UTI in pregnancy?

A

Nitrofurantoin

But should be avoided at term - risk of neonatal haemolysis

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11
Q

What virus is associated with cervical cancer?

A

Human papilloma virus 16 and 18

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12
Q

What is placenta previa? How does it present

A

Placenta attaches over the internal cervical os

risk factors: previous C section, multiple pregnancy

PAINLESS vaginal bleeding in the 3rd trimester

Usually no fatal distress

Patient must deliver by C section

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13
Q

What is placenta accreta?

A

Placenta has attached to the myometrium

difficulty separating placenta from the uterus after fetal delivery

severe post party haemorrhage upon attempted manual removal - placenta often removed in pieces

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14
Q

Placental abruption

A

Premature separation of the placenta prior to fetal delivery

ABDO PAIN

ABRUPT, PAINFUL vaginal bleeding in the 3rd trimester

Fetal distress

Tetanic (constant maximal contractions) - UTERINE RIGIDITY - uterus is tense and tender

Risk of DIC and shock (due to haemorrhage)

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15
Q

Pre-eclampsia

A
  1. HYPERTENSION
  2. PROTEINURIA
  3. OEDEMA

RUQ pain due to liver capsule swelling

caused by placental artery vasoconstriction

occurs after 20 weeks gestation

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16
Q

eclampsia

A

pre-eclampsia untreated can progress to eclampsia which is characterised by SEIZURES

Needs urgent delivery regardless of gestational age

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17
Q

HELLP syndrome

A

severe pre-eclampsia

  1. haemolysis
  2. elevated liver enzymes
  3. Low platelets

Management: delivery if after 34 weeks

IV magnesium to prevent progression to eclampsia

If turns into eclampsia then delivery

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18
Q

What are symptoms of IV Magnesium toxicity?

A

loss of deep tendon reflexes
respiratory depression
cardiac arrest

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19
Q

azoospermia - no sperm in ejaculate

Asthenozoospermia - reduced sperm mobility

Oligospermia - low sperm count

Hypospermia - reduced semen volume

Teratospermia - poor sperm morphology

A
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20
Q

How is infertility defined?

A

Infertility is when a couple cannot get pregnant (conceive) despite having regular unprotected sex for at least 12 months

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21
Q

What is a side effect of the copper IUD?

A

Can cause prolonged, heavy and painful periods for the first 6 months

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22
Q

How long can you have the Progestogen only subdermal implant?

A

3 years

INHIBITS OVULATION

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23
Q

What is Asherman syndrome?

A

adhesions/fibrosis forms in the uterus and/or cervix

Most commonly due to previous surgery
most commonly following D&C of intrauterine pregnancy
(Can occur following surgical fibroid removal for example )

results in reduced fertility, recurrent miscarriages, secondary amenorrhoea

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24
Q

Polyhydraminos is associated with what conditions?

A
  • maternal diabetes. Can lead to fetal hyperglycaemia and fetal polyuria
  • duodenal atresia
  • oesophageal atresia
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25
Q

Oligohydramnios

A

Reduced amniotic fluid

More common than polyhydramnios

  • rupture of membranes
  • fetal urinary tract blockages such as polycystic kidney disease or renal agenesis
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26
Q

What antibiotic normally uses to treat UTi is contraindicated in pregnancy

A

Trimethoprim
Because it is a folic acaid antagonist
So may inhibit DNA synthesis and affect fetal development
Also increases risk of miscarriages

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27
Q

What antibiotic normally uses to treat UTi is contraindicated in pregnancy

A

Trimethoprim
Because it is a folic acaid antagonist
So may inhibit DNA synthesis and affect fetal development
Also increases risk of miscarriages

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28
Q

What are the risk factors for ectopic pregnancy?

A
  • pelvic inflammatory disease
  • previous ectopic pregnancy
  • tubal ligation
  • adhesions due to previous abdominal surgery
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29
Q

What are the clinical features of ectopic pregnancy

A

May be picked up on routine US scan. Can present with symptoms due to the stretching of the Fallopian tube. Can present as Fallopian tube rupture.
Typically presents in early pregnancy

Triad:
1. vaginal bleeding (mild to moderate)
2. Pelvic pain
3. adnexal mass

Can get referred shoulder pain due to irritation of the phrenic nerve by blood in the abdominal cavity

If rupture - signs of hypovolaemic shock

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30
Q

How is ectopic pregnancy diagnosed?

A
  • transvaginal US may show an empty uterus + adnexal mass
  • HCG levels may be raised but do not double in 48 hours as a normal pregnancy does

Treatment: methotrexate, sometimes surgical

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31
Q

Menstrual cycle

A

menstrual cycle
Gonadotropin releasing hormone is released by the hypothalamus and acts on the anterior pituitary - stimulating it to secrete FSH and LH

FSH and LH act on the ovaries - stimulating a few of the follicles to gorow and develop

The developing follicles release oestrogen + progesterone

As the levels of oestrogen + progesterone increase - they exert negative feedback on the AP - and inhibit release of FSH and LH

So at this point of the cycle, the oestrogen is the hormone that is predominantly increasing

Estrogen is causing proliferation of the endomaterila lining and also thinning of the cervical mucous to increase chances of fertilisation

Once the estrogen levels hit a critical point (which coincides with follicle maturation), the feedback switches to POSITIVE feedback and this triggers a sudden increase in the release of LH from AP - this is called the “LH surge”

The LH surge triggers the follicle to open and release the oocyte - THIS IS OVULATION

After ovulation, you are now in the LUTEAL PHASE of the cycle - due to presence of corpus luteum

The oocyte then becomes the corpus luteum - the theca cells of the corpus lured produce mainly progesterone and some estrogen

Progesterone maintains the endometrial lining and thickens the cervical mucous

so in the luteal phase - progesterone is the dominant hormone

if fertilisation does not occur, the corpus luteum degenerates and progesterone and estrogen levels drop - FSH and LH are suddenly inhibited and they are once again able to stimulate the follicles in the ovaries to grow - hence the cycle begins again

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32
Q

How does the COCP work?

A

By keeping oestrogen + progesterone levels raised - you have negative feedback on the hypothalamus and anterior pituitary - inhibition of GnRH, and therefore FSH and LH
If FSH and LH are low - follicles don’t develop and ovulation does not occur (you need an LH surge for follicle to be released)

primarily by PREVENTING OVULATION

Progesterone maintains the endometrial lining

When the pill is stopped (for the 7 days off) the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“. This is not classed as a menstrual period as ovulation has not occurred.

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33
Q

How does the progesterone only pill work?

A

like the COCP, it primarily INHIBITS OVULATION

If progesterone levels remain raised - they have a negative feedback affect - inhibiting FSH and LH release from anterior pituitary - thus follicles don’t develop and ovulation does not occur (you need an LH surge for follicle to be released)

also:
- thickening of cervical mucous

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34
Q

How does the copper coil work?

A
  • prevents fertilisation due to direct toxic effect on sperm cells and ovum
  • changes to cervical mucous that prevent implantation
  • localised inflammatory action preventing implantation in endometrium

can also be used as emergency contraception

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35
Q

How does Mirena coil work?
(IUD that secretes Levonorgestrel)

A
  • changes to cervical mucous
  • atrophy of endometrium
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36
Q

At how many days/weeks gestation can you detect HCG?

A

it is detectable in blood by 8- 11 days gestation

and in the urine by 9-14 days gestation.

37
Q

How do you diagnose ovarian failure

A

amenorrhoea + FSH levels very high in a woman <40

38
Q

symptoms of breast cysts

A
  • benign
  • breast pain and tenderness
  • varies in size and tenderness with menstrual cycle
  • regresses with menopause
39
Q

what are the symptoms of breast fibroadenoma

A
  • most common benign breast lesion
  • typically occurs in pre-menopausal women
  • firm, solid, NON-TENDER, WELL CIRCUMSCRIBED and MOBILE mass
  • Fibroadenomas tend to grow during pregnancy, when estrogen levels are higher. They tend to shrink during menopause, when estrogen levels are lower.

(unlike breast cysts they are solid, while the breast cysts are fluid filled)

40
Q

Breast fat necrosis

A

can occur following a blow or injury to a women with very large breasts

can occur following breast surgery, biopsy, radiotherapy to the breasts.

Presents as a lump - Usually painless but they do get skin changes - erythema, bruising, dimpling of the skin

41
Q

Adenomyosis

A

ectopic endometrial tissue in the myometrium

affects mostly pre-menopausal, multiparous women

Presents as heavy/painful menstruation

Boggy enlarged uterus

42
Q

Leiomyoma

A

benign tumour arising from the smooth muscle of the uterus
aka FIBROID

These tumors are responsive to estrogen and commonly become larger during pregnancy and shrink in size after menopause.

Can present as heavy menstrual bleeding

also bladder and bowel symptoms due to compressive effects

O/e enlarged, irregular uterus

(both adenomyoma + leiomyoma present with enlarged uterus)

43
Q

Postcoital bleeding should make you suspicious for what?

A

cervical cancer

44
Q

post menopausal bleeding should make you suspicious for what?

A

endometrial cancer

post menopausal bleeding is not normal and is endometrial cancer UNTIL PROVEN OTHERWISE

45
Q

Sx of cevrical cancer

A

Abnormal vaginal bleeding
- post coital bleeding - the most common symptom
- intermenstrual

offensive persistent vaginal discharge

46
Q

vasa previa

A

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

typically presents as vaginal bleeding immediately after the waters break
+ signs of fetal distress

Blood loss is from the fetal blood supply so risk of severe haemorrhage to the baby - high fetal mortality

47
Q

How do you define a missed miscarriage?

A

A missed (or silent) miscarriage is one where the baby has died or is too small for the gestational age (bc it has stopped developing), but has not been physically miscarried, <24 weeks

Can be managed expectantly - the body may expel the tissue by itself

Or medication can be given

If moree than 12 weeks gestation D&C may be required

48
Q

How do you define TORCH infections

A

T - Toxoplasmosis
O- Other - syphilis, hepatitis B
R- rubella
C- CMV
H- Herpex simplex

49
Q

What are some normal physiological changes of pregnancy?

A
  • increased heart rate
  • reduced blood pressure due to peripheral vasodilation
  • increased plasma volume - leading to decreased Hb concentration - dilutional anaemia
  • can develop a bounding/collapsing pulse or ejection systolic murmur
  • reduction in plats but remains in normal range
  • hypercoagulability
  • lungs - increase in tidal volume
  • increase in basal metabolic rate
50
Q

pelvic inflammatory disease

A
  • Abdo/pelvic pain and tenderness
  • Fever
  • Nausea/anorexia
  • purulent cervical discharge
  • Cervical motion tenderness
51
Q

What is a threatened miscarriage?

A
  • any vaginal bleeding <24 weeks is a threatened miscarriage
  • risk of proceeding to miscarriage - does not mean it will definitely happen
  • cervical os is closed
52
Q

How can you check female fertility?

A

You check progesterone levels 1 week before the period is expected - i.e. mid luteal progesterone levels

This tells you if ovulation is occurring because the corpus leteum (the ovulated egg from the follicle) secretes progesterone

53
Q

PCOS lab findings

A
  • high LH, FSH normal
  • So you get a high LH:FSH ratio of at least 2:1
  • Increased LH leads to increases testosterone secretion which is converted to oestrogen in adipose tissue. Increased oestrogen increases risk of endometrial hyperplasia and can increase risk of endometrial cancer
54
Q

What is Sheehan syndrome?

A

severe post partum haemorrhage –> post partum necrosis of anterior pituitary cells –> hypopituitarism of one or more/all hormone
prolactin especially affected

  • absence of lactation
  • amenorrhoea (periods don’t return after pregnancy)
  • hypothyroidism - fatigue
  • loss of axillary and pubic hair
  • can get secondary adrenal insufficiency
55
Q

What is the first line treatment for menorrhagia?

A

Mirena coil
- levonorgestrel intra-uterine system

56
Q

How does haemophilia ducreyi present?

A
  • STI - causes a “chancroid”
  • rare in developed countries
  • PAINFUL genital ulcer + PAINFUL lymphadenopathy in groin
57
Q

What is the cause of lymphogranuloma venereum?

A

Caused less common serotypes of Chlamydia Trachomatis infection

PAINLESS genital ulcers AND PAINFUL lymphadenopathy that ulcerate (form abscesses “buboes”)

58
Q

How does Syphilis present?

A

initially presents as a single PAINLESS ulcer (chancre)

59
Q

How does chlamydia infection affect the newborn?

A

Can cause:
- conjunctivitis
- pneumonia

60
Q

Patient in early pregnancy presents with vaginal spotting and lower abdominal pain. What is the first line investigation?

A

Transvaginal ultrasound
Can differentiate between miscarriage and ectopic pregnancy

61
Q

What are risk factors for endometrial hyperplasia

A

Endometrial hyperplasia is abnormal proliferative endometrium related to prolonged estrogen expo sure – and increases risk of endometrial ca.
- nulliparity (pregnancy reduces oestrogen exposure)
- early menarche and late menopause - longer exposure to oestrogen
- anovulatory cycles
- PCOS (increased testosterone to oestrogen conversion in adipose tissue)
- hormone replacement therapy
- obesity.

62
Q

risk factors for Ovarian cancer

A
  • BRCA1 gene mutation
  • positive family history
  • higher lifetime ovulation (early menarche, late menopause, nulliparity)
  • white ethnicity

**OCPs are protective (fewer lifetime ovulations).

63
Q

Contraceptive pill decreases the risk of which cancers?

A

reduces the risk of ovarian, endometrial and colorectal cancer

64
Q

What form of contraception would you offer to a woman who has previously been treated for breast cancer?

A

avoid any hormonal contraceptives including COCP, POP and Progesterone IUD

Copper coil would be a suitable choice

65
Q

COCP increases the risk of which cancers?

A

Increases the risk of breast cance rmainly

There is some evidence it increases the risk of cervical cancer

66
Q

The POP increases the risk of breast cancer?

A

Breast cancer mainly

67
Q

Risk factors for cervical cancer?

A
  • intercourse at an early age
  • multiple sexual partners
  • smoking
  • history of STIs
  • Using OCPs for > 5 years
68
Q

Combined HRT increases the risk of which cancers?

A

Increased risk of breast and ovarian cancer

Combined HRT increases risk of breast cancer more than oestrogen only

(does not increase risk of endometrial ca)

69
Q

Oestrogen only HRT increases the risk of which cancer?

A

increases risk of endometrial cancer primarily due to unopposed oestrogen

therefore only given to women who have had a hysterectomy

Also, like the combined, there is slightly increases risk of breast cancer and ovarian cancer

70
Q

What is the management of hyperthyroidism in pregnancy?

A

1st trimester - propylthiouracil
2nd trimester - carbimazole

note hyperthyroidism in pregnancy can present as hyperemesis gravidarum

71
Q

What blood test must you check in patients with hyperemesis gravidarum?

A

TFTs

72
Q

what is the most effective form of emergency contraception?

A

copper coil

73
Q

what is the most common side effect of the POP?

A

irregular periods

Does not regulate the menstrual cycle as well the COCP

74
Q

how does Uterine rupture present

A

Causes:
- Previous C section increases risk
- Too much oxytocin given - can lead to uterine hyperstimulation

Presentation:
- sudden uterine pain/contractions go away
- symptoms of shock
- referred shoulder pain due to bleeding in abdominal cavity
- signs of fetal distress
- inability to detect uterine contractions
-typically presents in the 3rd trimester

75
Q

What is the most common cause of post partum haemorrhage?

A

Uterine atony (90%) of PPH

which can be caused by:
- very prolonged labour
- over stretched uterus due to large baby or twins

Uterus feels soft instead of hard/tense

Management:
- uterine massage to encourage contractions and expelling of placenta
- Administering oxytocin

76
Q
A
77
Q

What is the karyotype of androgen insensitivity syndrome?

A

46, XY

78
Q

What is androgen insensitivity syndrome?

A

Testosterone is present but the receptors cannot respond to androgen (non-functional androgen receptor)
testosterone is converted to estrogen peripherally
Therefore they are XY but have female appearing genitalia

The upper vagina, cervix, uterus, and fallopian tubes are absent because Müllerian inhibiting hormone is still produced by the testes.

tetses are located in the labia majora and are removed surgically prevent malignancy

Labs:
LH high
testosterone high

testosterone cannot feed back negatively on the anterior pituitary to regulate LH levels because the testosterone receptors on the anterior pituitary are similarly defective. High LH levels thus stimulate even more testosterone production.

79
Q

What are the symptoms of uterine prolapse?

A
  • feeling of heaviness of dragging sensation
  • feeling a lump coming down into the vagina especially after stand-ing/walking/exercise
  • urinary symptoms such as frequency
  • stress incontinence

caused by weakness of pelvic floor muscles

80
Q

What is the first line treatment for uterine prolapse?

A

Pelvic floor therapy

81
Q

What is the second most common cause of post Partum haemorrhage?

A

Retained placental tissue which prevents the uterus from contracting.

This can occur for example in placenta accreta

82
Q

What is the first line treatment for post partum haemorrhage ?

A

Oxytocin - a uterotonic medication - helps the uterus to contract

Uterine massage

2nd line: Ergometrine, Carboprost, Misoprostol

83
Q

What is the Karyotype of Turner Syndrome?

A

45XO

84
Q

What condition gives you the karyotype 47 XXX

A

Triple X syndrome
Females with an additional X chromosome

85
Q

What the karyotype of Klinefelter syndrome?

A

47 XXY
Male with an extra X chromosome

86
Q

Karyotype 45XO is indicative of what condition?

A

Turner syndrome
Only one X chromosome

87
Q

What sort of genes are BRCA1 and BRCA2?

A

tumour supressor genes

88
Q

Ovarian cancer is most likely to spread to which lymph nodes initially?

A

Para-aortic nodes

MSRA revision (25 decks)

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