Reproductive Flashcards
What are the clinical features of endometriosis?
- 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
What is the gold standard for diagnosing endometriosis?
Laparoscopy
What is a hydatidiform mole?
- gestational trophoblastic disease
- aka molar pregnancy
How does hydatidiform present?
- 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
What is the management of hydatidiform mole?
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)
What are the risk factors for hyperemesis gravidarum?
associated with high HCG so more common in
- molar pregnancy
- multiple pregnancy
- obesity
- nulliparity
It can also cause hyperthyroidism
What is bacterial vaginosis?
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
What sort of bacteria is gonorrhoea and what is the treatment?
gram negative diplococci
neisseria gonorrhoea
Treatment: IM Ceftriaxone
or Oral ciprofloxacin once only when sensitivities are known.
What is trichomonas vaginalis, what are the features and what is the treatment?
- protozoal infection by “trichomonas vaginalis”
- frothy, green discharge
- foul smelling
- dysuria
- pain during sex
- strawberry cervix on exam
Treatment: metronidazole
What antibiotic do you use to treat UTI in pregnancy?
Nitrofurantoin
But should be avoided at term - risk of neonatal haemolysis
What virus is associated with cervical cancer?
Human papilloma virus 16 and 18
What is placenta previa? How does it present
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
What is placenta accreta?
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
Placental abruption
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)
Pre-eclampsia
- HYPERTENSION
- PROTEINURIA
- OEDEMA
RUQ pain due to liver capsule swelling
caused by placental artery vasoconstriction
occurs after 20 weeks gestation
eclampsia
pre-eclampsia untreated can progress to eclampsia which is characterised by SEIZURES
Needs urgent delivery regardless of gestational age
HELLP syndrome
severe pre-eclampsia
- haemolysis
- elevated liver enzymes
- Low platelets
Management: delivery if after 34 weeks
IV magnesium to prevent progression to eclampsia
If turns into eclampsia then delivery
What are symptoms of IV Magnesium toxicity?
loss of deep tendon reflexes
respiratory depression
cardiac arrest
azoospermia - no sperm in ejaculate
Asthenozoospermia - reduced sperm mobility
Oligospermia - low sperm count
Hypospermia - reduced semen volume
Teratospermia - poor sperm morphology
How is infertility defined?
Infertility is when a couple cannot get pregnant (conceive) despite having regular unprotected sex for at least 12 months
What is a side effect of the copper IUD?
Can cause prolonged, heavy and painful periods for the first 6 months
How long can you have the Progestogen only subdermal implant?
3 years
INHIBITS OVULATION
What is Asherman syndrome?
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
Polyhydraminos is associated with what conditions?
- maternal diabetes. Can lead to fetal hyperglycaemia and fetal polyuria
- duodenal atresia
- oesophageal atresia
Oligohydramnios
Reduced amniotic fluid
More common than polyhydramnios
- rupture of membranes
- fetal urinary tract blockages such as polycystic kidney disease or renal agenesis
What antibiotic normally uses to treat UTi is contraindicated in pregnancy
Trimethoprim
Because it is a folic acaid antagonist
So may inhibit DNA synthesis and affect fetal development
Also increases risk of miscarriages
What antibiotic normally uses to treat UTi is contraindicated in pregnancy
Trimethoprim
Because it is a folic acaid antagonist
So may inhibit DNA synthesis and affect fetal development
Also increases risk of miscarriages
What are the risk factors for ectopic pregnancy?
- pelvic inflammatory disease
- previous ectopic pregnancy
- tubal ligation
- adhesions due to previous abdominal surgery
What are the clinical features of ectopic pregnancy
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
How is ectopic pregnancy diagnosed?
- 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
Menstrual cycle
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
How does the COCP work?
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.
How does the progesterone only pill work?
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
How does the copper coil work?
- 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
How does Mirena coil work?
(IUD that secretes Levonorgestrel)
- changes to cervical mucous
- atrophy of endometrium
At how many days/weeks gestation can you detect HCG?
it is detectable in blood by 8- 11 days gestation
and in the urine by 9-14 days gestation.
How do you diagnose ovarian failure
amenorrhoea + FSH levels very high in a woman <40
symptoms of breast cysts
- benign
- breast pain and tenderness
- varies in size and tenderness with menstrual cycle
- regresses with menopause
what are the symptoms of breast fibroadenoma
- 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)
Breast fat necrosis
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
Adenomyosis
ectopic endometrial tissue in the myometrium
affects mostly pre-menopausal, multiparous women
Presents as heavy/painful menstruation
Boggy enlarged uterus
Leiomyoma
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)
Postcoital bleeding should make you suspicious for what?
cervical cancer
post menopausal bleeding should make you suspicious for what?
endometrial cancer
post menopausal bleeding is not normal and is endometrial cancer UNTIL PROVEN OTHERWISE
Sx of cevrical cancer
Abnormal vaginal bleeding
- post coital bleeding - the most common symptom
- intermenstrual
offensive persistent vaginal discharge
vasa previa
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
How do you define a missed miscarriage?
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
How do you define TORCH infections
T - Toxoplasmosis
O- Other - syphilis, hepatitis B
R- rubella
C- CMV
H- Herpex simplex
What are some normal physiological changes of pregnancy?
- 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
pelvic inflammatory disease
- Abdo/pelvic pain and tenderness
- Fever
- Nausea/anorexia
- purulent cervical discharge
- Cervical motion tenderness
What is a threatened miscarriage?
- 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
How can you check female fertility?
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
PCOS lab findings
- 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
What is Sheehan syndrome?
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
What is the first line treatment for menorrhagia?
Mirena coil
- levonorgestrel intra-uterine system
How does haemophilia ducreyi present?
- STI - causes a “chancroid”
- rare in developed countries
- PAINFUL genital ulcer + PAINFUL lymphadenopathy in groin
What is the cause of lymphogranuloma venereum?
Caused less common serotypes of Chlamydia Trachomatis infection
PAINLESS genital ulcers AND PAINFUL lymphadenopathy that ulcerate (form abscesses “buboes”)
How does Syphilis present?
initially presents as a single PAINLESS ulcer (chancre)
How does chlamydia infection affect the newborn?
Can cause:
- conjunctivitis
- pneumonia
Patient in early pregnancy presents with vaginal spotting and lower abdominal pain. What is the first line investigation?
Transvaginal ultrasound
Can differentiate between miscarriage and ectopic pregnancy
What are risk factors for endometrial hyperplasia
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.
risk factors for Ovarian cancer
- BRCA1 gene mutation
- positive family history
- higher lifetime ovulation (early menarche, late menopause, nulliparity)
- white ethnicity
**OCPs are protective (fewer lifetime ovulations).
Contraceptive pill decreases the risk of which cancers?
reduces the risk of ovarian, endometrial and colorectal cancer
What form of contraception would you offer to a woman who has previously been treated for breast cancer?
avoid any hormonal contraceptives including COCP, POP and Progesterone IUD
Copper coil would be a suitable choice
COCP increases the risk of which cancers?
Increases the risk of breast cance rmainly
There is some evidence it increases the risk of cervical cancer
The POP increases the risk of breast cancer?
Breast cancer mainly
Risk factors for cervical cancer?
- intercourse at an early age
- multiple sexual partners
- smoking
- history of STIs
- Using OCPs for > 5 years
Combined HRT increases the risk of which cancers?
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)
Oestrogen only HRT increases the risk of which cancer?
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
What is the management of hyperthyroidism in pregnancy?
1st trimester - propylthiouracil
2nd trimester - carbimazole
note hyperthyroidism in pregnancy can present as hyperemesis gravidarum
What blood test must you check in patients with hyperemesis gravidarum?
TFTs
what is the most effective form of emergency contraception?
copper coil
what is the most common side effect of the POP?
irregular periods
Does not regulate the menstrual cycle as well the COCP
how does Uterine rupture present
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
What is the most common cause of post partum haemorrhage?
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
What is the karyotype of androgen insensitivity syndrome?
46, XY
What is androgen insensitivity syndrome?
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.
What are the symptoms of uterine prolapse?
- 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
What is the first line treatment for uterine prolapse?
Pelvic floor therapy
What is the second most common cause of post Partum haemorrhage?
Retained placental tissue which prevents the uterus from contracting.
This can occur for example in placenta accreta
What is the first line treatment for post partum haemorrhage ?
Oxytocin - a uterotonic medication - helps the uterus to contract
Uterine massage
2nd line: Ergometrine, Carboprost, Misoprostol
What is the Karyotype of Turner Syndrome?
45XO
What condition gives you the karyotype 47 XXX
Triple X syndrome
Females with an additional X chromosome
What the karyotype of Klinefelter syndrome?
47 XXY
Male with an extra X chromosome
Karyotype 45XO is indicative of what condition?
Turner syndrome
Only one X chromosome
What sort of genes are BRCA1 and BRCA2?
tumour supressor genes
Ovarian cancer is most likely to spread to which lymph nodes initially?
Para-aortic nodes
