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MSRA 2 > Reproductive > Flashcards

Reproductive Flashcards

1
Q

With regular intercourse, what percentage of couples will have a natural conception within one year?

A

84%

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2
Q

How many placenta praevia present?

A

The classic presentation of placenta praevia is painless vaginal bleeding with the amount of visible blood loss in keeping with
the physiological status of the patient.

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3
Q

What is placenta praevia associated with?

A
  • a large placenta (e.g. twins)
  • uterine abnormalities
  • fibroids
  • multiparity
  • former surgery (e.g. caesarean section)
  • previous infection
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4
Q

How does vasa previa present?

A

Antepartum haemorrhage immediately after artificial rupture of the membranes is highly suggestive of vasa praevia.

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5
Q

How do we treat hyperthyroidism in pregnancy?

A

Usually caused by Graves

Propylthiouracil (PTU) and carbimazole (CBZ) are both used in pregnancy. The choice of which depends on which trimester the patient is in (the patient in this vignette is in her 2nd trimester). PTU has a double action, blocking thyroxine synthesis and the conversion of T4 to T3. CBZ blocks thyroxine synthesis. Both may have an immunosuppressive effect. Both are associated with side effects in 2-3% of cases, including rash, fever, agranulocytosis (0.2%) and occasional gastrointestinal side effects. Both cross the placenta and can cause transient neonatal hypothyroidism. Because of a possible risk of teratogenicity with CBZ this is best avoided in the 1st trimester. There are no known long term developmental effects with PTU exposure in utero, but PTU is associated with an increased risk of maternal hepatotoxicity. It is currently recommended that patients seeking pregnancy and throughout the first trimester are treated preferentially with PTU. If they require ongoing treatment with an antithyroid drug, this may be switched to CBZ in the 2nd trimester. After initial stabilisation the dose is reduced as rapidly as possible (and is frequently withdrawn by the 2nd trimester) to achieve a free T4 at the upper limit of the normal range (this will be managed in the endocrinology clinc).

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6
Q

Postmenopausal bleeding is not normal. Most common dx?

A

Postmenopausal bleeding is endometrial carcinoma until proven otherwise.

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7
Q

How do we reduce N&V in pregnancy?

A

“Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms: Nonpharmacological (ginger, P6 wrist acupressure) & pharmacological (antihistamines & phenothiazines).”

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8
Q

What is the most common non-obstetric cause of surgical emergency in pregnancy?

A

Acute appendicitis - will likely present atypically

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9
Q

How does ectopic pregnancy present?

A

Be aware that ectopic pregnancy commonly presents atypically & presentation can resemble those of other more common conditions, including UTI & GI conditions, so consider the possibility in all women of reproductive age.
* The most common gestational age at diagnosis is 6 to 10 weeks.
* Most common symptoms:
* Abdominal pain
* Pelvic pain
* Missed period - note 30% of ectopics present before a period has been missed
* Vaginal bleeding (* clots)
* Common signs:
* Pelvic or abdominal tenderness
* Adnexal tenderness

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10
Q

What medication may we use to reduce the size of fibroids before surgical removal, and what is a key side effect?

A

GnRH agonist e.g. goserelin

Osteoporosis

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11
Q

When do we use emergency contraception with COCP use?

A

Emergency contraception is recommended if 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a
packet and unprotected intercourse has occurred since finishing the last packet.

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12
Q

How do we manage post-coital bleeding?

A

None had invasive cancer
Some had CIN (abnormal histology with normal smear)

Bleeding of three months or more, especially if heavy, will need further ix

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13
Q

What are the indications for rhesus negative mothers

A
  • Those having surgical or medical terminations of pregnancy unless they are already known to have anti-D antibodies.
  • Those where spontaneous miscarriage is followed by medical or surgical evacuation.
  • Those where spontaneous complete miscarriage occurs > 12 weeks gestation.
  • When significant TPH (transplacental haemorrhage) may occur (chorionic villous sampling, external cephalic version, antepartum haemorrhage, uterine procedures (amniocentesis, foetal blood sampling), abdominal trauma, intrauterine death
  • Ectopic pregnancy
  • With threatened miscarriage >12 weeks (if bleeding continues intermittently give anti-D 6 weekly until delivery) even if it was given prophylactically for a sensitising event earlier in the same pregnancy.
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14
Q

What is adenomyosis?

A

Adenomyosis refers to the extension of endometrial tissue and stroma into the uterine myometrium.

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15
Q

What are the risk factors for endometrial ca?

A
  • obesity
  • nulliparity
  • late menopause
    o family history of ovary, breast, colon cancer
  • tamoxifen
  • unopposed oestrogen therapy (HRT)
  • pelvic irradiation
  • diabetes
  • polycystic ovary syndrome
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16
Q

Which ca does HRT increase the risk of?

A

Breast ca

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17
Q

How does endometriosis present?

A

Commonest presentation is otherwise secondary dysmenorrhoea - usually worsening from the late twenties onwards.
* Other presentations include:
* deep dyspareunia - mainly with lesions in the pouch of Douglas, uterosacral ligaments, and posterior vaginal fornix.
* infertility
* present in 30-40% of infertile couples - but pregnancy rates are the same with and without treatment if there is minimal disease, i.e. endometriosis is not the cause of infertility if the patient only has minimal disease
* premenstrual or postmenstrual spotting
* menorrhagia (adenomyosis)
* bowel symptoms from involvement of the uterosacral ligaments, pouch of Douglas &/or rectosigmoid colon may result in - e.g. cyclical pain passing motions, rectal bleeding, stricture, constipation
* cyclical haematuria from bladder involvement is rare
* In addition to pain, patients present with nonspecific symptoms of fatigue, generalized malaise, and sleep disturbances.

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18
Q

Give the risks of smoking with pregnancy?

A
  1. reduction in ovulations
  2. abnormal sperm production
  3. 2x rates of miscarriage
  4. preterm labour
  5. lighter-for-dates babies
  6. reduced reading ability in smokers’ children up to 11 years old
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19
Q

How does listeriosis present?

A

Ingestion of Listeria by pregnant women can result in nausea, vomiting, diarrhoea, fever, malaise, back pain, and headache.
stillbirth.
* Maternal infection with Listeria can result in chorioamnionitis, premature labour, spontaneous abortion, or stillbirth.

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20
Q

How do we treat listeriosis

A

Amox + gent

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21
Q

How do we treat syphilis?

A

Benzathine benzylpenicillin

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22
Q

How do we treat congenital toxoplasmosis?

A

Spiramycin

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23
Q

What is the most common cause of heavy menstrual bleeding?

A

Dysfunctional uterine bleeding

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24
Q

What is gravida?

A

total no. of times a woman has been pregnant including the current one. Note that each pregnancy is only counted one time, even if the pregnancy was a multiple gestation, such as twins or triplets.

25
Q

What is para X + Y?

A

X = No. of pregnancies beyond 24wks (twins count as one and a still birth after 24wks also count as one).
* Y = No. of losses before 24wks (e.g. terminations, spontaneous abortions, ectopic pregnancies).

26
Q

How does uterine prolapse present?

A
  • Typically, symptoms are worse after prolonged standing & relieved by lying down.
  • Common features include complaint of a lump or mass within the vagina or the patient may say that there is
    “fullness down below” which may become a “lump between the thighs” in the case of procidentia.
  • Urinary frequency, urgency, incontinence and rarely, retention, may occur in patients with anterior vaginal wall prolapse, difficulty in defaecation may indicate a rectocoele.
  • Neglected cases may be complicated by excessive purulent discharge, decubitus ulceration & bleeding.
  • Not uncommonly, prolapse is an incidental finding. Many patients cope by pushing the prolapse back into the vagina.
27
Q

How does a Bartholin’s cyst present?

A
  • The most common age of presentation is in the 20’s and they usually occur in women who are nulliparous or of low parity.
    hard.
  • There is initially labial oedema before swelling forms and onset of swelling is rapid over a matter of days or even hours.
  • The swelling may be very painful and there is superficial dyspareunia.
  • Small cysts may be asymptomatic and discovered incidentally - e.g. when performing a routine cervical smear.
  • On examination, the patient’s gait may be a wide-legged swagger.
  • There is usually usually a unilateral labial mass that may be as large as a hen’s egg - it may be soft & fluctuant, or tense & hard.
28
Q

What is asthenozoospermia?

A

Reduced sperm motility

29
Q

What is azoospermia?

A

No sperm in ejaculate

30
Q

What is oligospermia?

A

Low sperm count

31
Q

What is hypospermia?

A

Reduced semen volume

32
Q

What is teratospermia?

A

Poor sperm morphology

33
Q

Which pregnancies are considering postterm?

A

42w

34
Q

How does rectal herpes infection present?

A

This patient is complaining of pain with defecation but without any associated abdominal or bowel symptoms. Grouped ulcers are characteristic of a herpetic infection.
* The ulcers begin as vesicular lesions and then painfully ulcerate.
* The perineal region is frequently involved, and the lesions may spread into the anal canal but do not usually cause any proctosigmoiditis.
* Often accompanied by neuropathic symptoms, as herpes resides in the dorsal ganglia.

35
Q

What is a missed miscarriage?

A

this is when the fetus has died before 24 weeks gestation, is small for dates but has not been lost from the uterus.

36
Q

What does haemophilus ducreyi form?

A

causes chancroid (actually rare in UK - found primarily in developing countries) - painful genital ulcer(s)
and tender inguinal lymphadenopathy.

37
Q

How do we assess cervical ripeness?

A

Bishop score
PEDSS

Position of cervix
* Effacement (or length) of cervix
* Dilation of cervix
* Softness (or consistency) of cervix
* Station of the foetus

38
Q

How do we score the Bishop score?

A

The maximum score is 10.
* A score of ≤5 suggests that labour is unlikely to start without induction.
* A score of ≥9 indicates that labour will most likely commence spontaneously.
* A low Bishop’s score often indicates that induction is unlikely to be successful.

39
Q

What are melasma?

A

Melasma or Chloasma usually affects women (only 1:20 affected individuals are male).
* It generally starts between the age of 30 and 40.
* It is more common in people that tan well or have naturally dark skin compared with those who have fair skin.
* Melasma affects the forehead, cheeks & upper lips resulting in macules (freckle-like spots) & larger patches.
* Occasionally it spreads to involve the sides of the neck, and a similar condition may affect the shoulders and upper arms.

40
Q

What is the UK breast screening programme for women?

A

3 yearly mammograms from aged 50 - 70.

41
Q

How does the combined hormonal pill work?

A

Primary mechanism of action is prevention of ovulation.
* CHC acts on the hypothalamo-pituitary-ovarian axis to suppress luteinising hormone (LH) & follicle-stimulating
hormone (FSH) and thus inhibit ovulation.
* Changes to cervical mucus, endometrium & tubal motility that result from progestogen exposure may also contribute to the contraceptive effect.

42
Q

How does the Mirena coil work as contraception?

A

Foreign body effect may be a contributing factor of the LNG-IUS.
* Changes to cervical mucus - progestogenic effects have been demonstrated but it is not fully understood how
quickly such changes are established.
* Endometrial changes - prevention of implantation occurs via a progestogenic effect.
* Within a month of insertion, high intrauterine concentrations of LNG induce endometrial atrophy.
* In addition, changes in the intercellular junctions between the endometrial epithelial & stromal cells and an 1 in endometrial phagocytic cells may contribute to the contraceptive effect.

43
Q

How does ulipristal acetate work as emergency contraception?

A

UPA-EC is a selective progesterone receptor modulator and acts by delaying ovulation for at least 5 days, until sperm from UPSI are no longer viable.

44
Q

What is first-line for heavy menstrual bleeding?

A

Mirena

45
Q

A 24-year-old woman has been trying for a baby with her partner for one year but is unable to conceive. She reports regular periods with a 35 day cycle. Her partner has undergone fertility testing which has come back normal. Which of the following is the
NEXT MOST appropriate investigation?

A

In a woman, the most important investigation into subfertility is to check whether ovulation is occurring. This can be done via a mid-luteal cycle progesterone. Progesterone is produced mainly in the ovaries by the corpus luteum (what the follicle turns into after it releases the egg). Progesterone helps prepare the uterus for the implantation of a fertilized egg and maintains the endometrial lining after implantation. Mid-luteal phase progesterone is tested one week before a period is expected (i.e. day 21 of 28 day cycle or day 28 of 35 day cycle - always read the question carefully):

46
Q

How do breast cysts present?

A

The variation in size of the lump with her periods is suggestive of a breast cyst.
* These are actually commoner in peri-menopausal women, and they present as smooth discrete lumps which may be painful.
* They tend to increase in size before the period, decrease after it, and disappear altogether after the menopause.

47
Q

When may we perform an abortion?

A

Up to 24w, or at any point if major risk

48
Q

How does uterine fibroid present?

A

Uterine fibroids are the most common benign uterine tumour and most common pelvic tumour in women. Most are asymptomatic; however, can present with excessive uterine bleeding, symptoms secondary to pressure on bladder and rectum, and, less often, distortion of the uterine cavity, leading to miscarriage or infertility. An enlarged irregular uterus may be found on examination and the woman may be anaemic because of heavy menstrual bleeding.

49
Q

What is Asherman’s syndrome?

A

Asherman’s syndrome or intrauterine adhesions refers to the occurrence of adhesions within the uterus such that the cavity
becomes partly obliterated.

50
Q

Which methods of contraception should be used for pts with hx of breast ca?

A

Non-hormonal methods

51
Q

What is the most common bacterial STI in the UK?

A

Chlamydia

52
Q

How do we detect neural tube defects?

A

Ultrasound is recommended for all at-risk women (positive serum alpha-fetoprotein, previously affected child).

Amniocentesis is only used when unable to obtain adequate ultrasound images and is used to measure alpha-fetoprotein and
neuronal acetylcholinesterase.

53
Q

When do we do the combined test?

A

The combined test is used between 10-13 weeks to screen for Down’s syndrome and includes nuchal translucency, free B-HCG, pregnancy associated plasma protein & the woman’s age to provide an estimate of the chance that the fetus is trisomy-21. If the chance is greater than 1:200 then woman is offered diagnostic testing using either chorionic villus sampling (if <13 weeks’ gestation)
or amniocentesis (if >15 weeks’ gestation).

54
Q

A 43-year-old woman presents to her GP having recently found a small, hard lump in her right breast. It is not painful. On examination, the lump is tethered to the skin with some skin puckering. Dx?

A

Breast ca

55
Q

When is serum hCG noticable?

A

After D11 post contraception in 95% pts

56
Q

How do we mx pre-eclampsia?

A

Terminate the pregnancy and deliver the placenta despite the risk to the foetus

57
Q

When would pregnancy testing pick up a conception?

A

9 days post conception up to 20w

58
Q
A

MSRA 2 (12 decks)

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