Reproductive Health Tutorials Flashcards
Define partner notification
the process of contacting the sexual partners of an individual with a sexually transmitted infection including HIV, and
advising them that they have been exposed to infection
What is the value of contact slips / cards for partner notification?
Can provide anonymity and confidentiality for the index patient
* Enable sexual contacts to seek medical advice or treatment
* Inform the contact’s clinic of index patient’s diagnosis, and date of diagnosis.
* Enable cross-referencing and
evaluation of partner notification
Give infective causes of genital soreness / sores
Candida
Herpes simplex
Herpes zoster
Syphilis
Tropical diseases-
LGV, Granuloma inguinale, Chancroid
Give non-infective causes of genital soreness/ sores
A) Trauma
Physical
Chemical
B) Dermatological conditions
Fixed drug reactions
Beçhets
Apthosis
Lichen planus
Pemphigus
Malignancy
Differentials for penile ulcer?
Syphilis
Herpes simplex
Lymphogranuloma venereum
Aphthous ulceration
Trauma
How can syphilis be diagnosed?
From lesions:
Dark ground microscopy
Treponemal PCR
In blood:
Treponemal enzyme immunoassay (EIA)
Treponema pallidum particle agglutination assay
(TPPA)
Rapid plasma reagin test (RPR)
Always perform full STI screen
What is Condyloma acuminata?
genital warts
epidermal manifestation of the papilloma virus
(HPV)
How should genital warts be investigated?
All female patients presenting with external genital warts should have a speculum exam
And colposcopy referral if internal warts (Similarly consider proctoscopy if anal warts and rectal bleeding)
Give some normal anatomical variants that could be mistaken for genital warts?
Fordyce spots
Pearly papules
Skin tags
Tyson’s glands
Vestibular papillosis
Haemangiokeratoma
Sebaceous cysts
What infective and malignant conditions can be mistaken for genital warts?
Conylomata Lata (syphilis)
VIN, PIN or squamous cell carcinomas
Molluscum contagiosum
How can genital warts be managed?
No treatment (may spontaneously resolve)
Destruction (cryoRx)
Anti-mitotic agents (Podophyllotoxin)
Immune modifiers (Imiquimod cream)
Surgery
Questions to ask somebody with genital warts/ lumps?
How long?
Other symptoms?
– Itch, bleed, rectal symptoms
Change in size, number, appearance?
Any treatment tried? Medical reviews?
Had before?
It is common for genital warts to appear for the first time in pregnancy. How should this be managed?
reassure that v low risk of vertical transmission, watch and wait
What is chronic pelvic pain?
Intermittent or constant pain
In the lower abdomen or pelvis
At least 6 months in duration
Not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
how does chronic pelvic pain due to nerve entrapment present? mx?
A highly localised, sharp, stabbing or aching pain, exacerbated by particular movements and persisting beyond 5 weeks or occurring after a pain free interval
Treatment- Analgesia, Physiotherapy, Nerve modulation and Antidepressant
How does chronic pelvic pain due to MSK problems present? Tx?
May be:
Pain at joints in pelvis
Damage to the muscles in the abdominal wall or pelvic floor
Pelvic organ prolapse
Trigger points-localised areas of deep tenderness – chronic muscle contraction
Treatment- Analgesia, Physiotherapy, Nerve modulation and Antidepressant
What is the ROME III criteria for diganosis of IBS?
Continuous or recurrent abdominal pain or discomfort on at least 3 days a month in the last 3 months
Onset at least 6 months previously
Associated with at least two of the following:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in the form of stool.
How can you investigate chronic pelvic pain?
STI Screening
TV USS -identify and assess adnexal masses
TVUSS and MRI - useful tests to diagnose adenomyosis
Laparoscopy:
Now second line after therapeutic intervention
Not helpful for IBS, IC and adenomyosis diagnosis
Carries risk of death 1:10,000 and organ injury 2.4 : 1,000
Define oligomenorrhea
Infrequent periods
Cycle >35 days but less than 6 months in length
What can cause oligomenorrhea?
‘Constitutional’
Anovulation:
PCOS
Thyroid disease
Prolactinoma
CAH
Give some causes of primary amenorrhea
Delayed puberty
Imperforate hymen/transverse septum
Absent vagina
Mullerian agenesis
Gonadal dysgenesis (Turner)
PCOS (less common in primary)
CAH
Give some causes of secondary amenorrhea
Pregnancy
PCOS
Premature menopause
Prolactinoma
Thyroid disease
Cushing’s
Eating disorder
Exercise induced
Asherman Syndrome
Sheehan Syndrome
Differential diagnoses for PCOS?
Simple obesity
Premature ovarian failure
Thyroid disease
Hyperprolactinaemia
CAH
Androgen secreting tumours
Cushing’s syndrome
Blood tests to do in PCOS?
Sex Hormone Binding Globulin (SHBG)
Total testosterone
Free androgen index (FAI)
FSH, LH
TFT
Prolactin
Mx of PCOS in woman who wants to conceive?
Reduce BMI to <30
Start Folic acid
Baseline fertility assessment, including semen analysis on partner
Refer to fertility services
May require ovulation induction e.g. clomiphene citrate
Metformin controversial
Mx of patient with PCOS who wants regular periods?
COCP
Cyclical progestogens
Fetal movements are usually perceived from 18-20 weeks gestation and most women should be aware of them by 20/40, They are defined as any discrete kick, flutter, swish or roll.
What can affect fetal movements?
Prior to 28/40 an anteriorly placed placenta may reduce the woman’s perception of fetal movements
Sedating drugs which cross the placenta such as alcohol, benzodiazepines, methadone and other opioids can have a transient effect on fetal movements
Normal or excessive fetal activity has been reported in anencaphalic fetuses.
A lack of vigorous motion may relate to abnormalities of the CNS, muscular dysfunction or skeletal abnormalities
Fetal position can have an effect – if the fetal spine lies anterior the woman may be less likely to perceive fetal movements
What is important to ask in a patient experiencing RFM?
assess the woman’s risk factors for stillbirth and fetal growth restriction
What is normal for her baby and what are they like now? Reduced or completely absent?
Diabetes, smoking, obesity, extremes of maternal age (<20 and >40), language barriers, SGA, recurrent episodes
What investigations can be done for RFM?
Assess viability:
Sonicaide / Handheld doppler
CTG monitoring
Assessment of fetal growth – may be SFH or referral for growth scan
BP and urine dip - raised BP/PET are known to increase the risk
What is USS helpful for in twin pregnancies?
Number of babies
Chorionicity and No of placentae
Dividing membrane – present / absent/ how thick
Determining sex of each baby
Best done at 11-14 weeks
What advice should be given to patients with multiple pregnancy?
Enhanced scan schedule/hospital visits
pre-eclampsia sxs - e.g. epigastric pain, headache, swelling
Sudden increase in abdominal girth or breathlessness - ? TTTS
Symptoms of preterm labour
By 28 weeks discuss a plan for labour, delivery in consultant led unit
Discuss if any objections to blood transfusion
What is the risk of prematurity with twin pregnancy?
60%
What can cause one twin to die in utero? What should be done if one twin dies in utero?
Cause:
Maybe due to – no reason / growth restriction / TTTS
Hypo-perfusion/hypotension related injury
Mx:
Screen for fetal anaemia- DV/ MCA doppler
Fetal brain MRI in 4 wks
MDT decision whether to deliver
When should additional scans be offered in twin pregnancy?
Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome:
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
How can twin pregnancies be delivered?
Monoamniotic twins:
Elective caesarean section between 32 and 33+ 6 weeks.
Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks):
* Vaginal delivery is possible when first baby has a cephalic presentation
* Caesarean section may be required for the second baby after successful birth of the first baby
* Elective caesarean is advised when the presenting twin is not cephalic presentation
Potential complications during labour for twin pregnancy?
Malpresentation
Stuck twin / interlocked heads
Cord prolapse
Abruption
Fetal hypoxia
TTTS
Operative delivery
PPH
PET
When should women with HMB be referred for hysteroscopy?
Red flag signs/symptoms/ Risk factors
women taking tamoxifen
women for whom treatment for HMB has been unsuccessful
When should women with HMB be referred for USS?
their uterus is palpable abdominally
history or examination suggests a pelvic mass
examination is inconclusive or difficult, for example in women who are obese
What is dysfunctional uterine bleeding?
primary menorrhagia
Heavy menstrual bleeding with no recognisable pelvic pathology, pregnancy or general bleeding disorders.
What can be used in the short term for emergency control of menorrhagia?
Norethisterone: 5mg tds for up to 7 days. Can be used in a 3-weeks-on, 1-week-off pattern for 3-4 months to temporise, for example where patient is on waiting list for treatment.
GnRH analogues: Monthly (or quarterly, depending on preparation) injection to downregulate the cycle and induce temporary ‘medical menopause’
Questions to ask a woman presenting with infertility?
Age
Duration of fertility
Type of infertility
Menstrual cycle – ovulating?
Tubal surgery/ PID
Menorrhagia/dysmenorrhoea/pelvic pain
Pelvic surgery
Examination features of a woman with infertility?
BMI
Body hair distribution
Galactorrhoea
Secondary sexual characteristics
Pelvic – structural abnormalities
fixed or tender uterus
What might you see on laparoscopy for endometriosis ?
Active endometriosis – “powder-burn” spots, chocolate cysts
Inactive endometriosis – “scars”
Advnatges of breastfeeding?
Promotes bonding
Improves uterine involution
? Reduced risk of breast cancer
Contraception
Safe and cheap
Disadvantages of breastfeeding?
Nipple inversion: correct by Waller shields in late pregnancy
Maternal fatigue
Emotional stress
