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Reproductive Health Workbook 1 Flashcards

1
Q

What examinations could you do for a patient with HMB?

A

Look for signs of anaemia (pallor, glossitis, angular stomatitis)
Assess BMI
Speculum examination
Bimanual examination

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2
Q

What can cause HMB?

A

PALM COEIN

Structural causes:
Polyps
Adenomyosis
Leiomyomas (fibroids)
Malignancy and hyperplasia

Non-structural causes:
Coagulopathy (e.g. von Willebrand’s)
Ovulatory dysfunction (e.g. PCOS)
Endometrial (e.g. endometriosis)
Iatrogenic (e.g. anticoagulant treatment)
Not otherwise classified (e.g. systemic causes such as hypothyroidism, liver or kidney disease)

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3
Q

How would you investigate HMB?

A

Pregnancy test

FBC: to exclude anaemia

Thyroid function test and coagulation screen

Imaging:
transvaginal US to exclude local structural causes (fibroids, polyps)

Further investigations:
* Hysteroscopy: for direct visualisation of the uterine cavity
* Endometrial biopsy (e.g. if abnormal endometrial thickness, intermenstrual bleeding or postmenopausal bleeding)
* Vaginal swabs (if considering STI)

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4
Q

Mx options for HMB?

A

Tranexamic acid (anti-fibrinolytic): used before or just before the period

Mefenamic acid (NSAID): used during or just before the period, useful if dysmenorrhoea is also present

COCP

IUS

Norethisterone

Surgery (depends on cause, could be fibroidectomy, endometrial ablation, myomectomy, hysterectomy)

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5
Q

Advantages and disadvantages of IUS and COCP for HMB management?

A

IUS- also helps with dysmenorrhea, provides contraception, has to be inserted in a small procedure which comes with risks like infection and perforation

COCP- can be taken continuously to stop periods, provides contraception, risks including VTE and breast cancer

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6
Q

MOA of tranexamic acid? Mefenamic acid?

A

Tranexamic acid = anti-fibrinolytic, inhibits the interaction of plasminogen with plasmin and fibrin

Mefenamic acid = NSAID, inhibits prostaglandin synthetase

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7
Q

Complications of surgical intervention for HMB?

A

bladder or bowel perforation
vesicovaginal fistula
haemorrhage
infection

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8
Q

how do primary and secondary dysmenorrhea present differently?

A

Primary dysmenorrhoea usually starts 6–12 months after the menarche
The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
Pelvic examination is normal

Secondary dysmenorrhoea often starts after several years of painless periods
The pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle
Other gynaecological symptoms (e.g. dyspareunia) are often present

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9
Q

Clinical features indicating a serious secondary cause of dysmenorrhoea include:

A

Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids)

Abnormal cervix on examination

Persistent intermenstrual or postcoital bleeding without associated features of PID

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10
Q

Differentials for secondary dysmenorrhea?

A

Endometriosis/adenomyosis —chronic pelvic pain frequently occurring prior to menstruation, accompanied by heavy menstrual bleeding and deep dyspareunia

Fibroids (myomas) — lower abdominal pain, menorrhagia, a pelvic mass may be identified on examination

PID — lower abdominal pain and tenderness that may be accompanied by dyspareunia, abnormal vaginal bleeding, and abnormal vaginal discharge

Ovarian cancer — pelvic or abdominal pain, abdo distension, early satiety/ loss of appetite, and urinary sxs

Cervical cancer — pelvic pain, dyspareunia, intermenstrual or postcoital bleeding, and blood-stained, mucoid, or purulent vaginal discharge

Recent IUD insertion

Non gynae e.g. IBS, lactose intolerance, appendicitis

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11
Q

Differentials for endometriosis?

A

Primary dysmenorrhoea
Uterine fibroids
Pelvic inflammatory disease
Ectopic pregnancy
Torsion of an ovarian cyst
Appendicitis
Irritable bowel syndrome

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12
Q

Investigations for endometriosis?

A

Pregnancy test
Baseline blood tests (FBC, U&Es, CRP): white cells may be raised in appendicitis or pelvis inflammatory disease
transvaginal ultrasound scan
Diagnostic laparoscopy

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13
Q

Describe the mechanism of action of three different hormonal therapeutics you might use to manage endometriosis related pain, their mode of administration, and their side effects

A

implant (Nexplanon) - inhibits ovulation and thickens cervical mucus, implant in the arm , ADRS = menstrual irregularities, complications with insertion and removal, decreased sex drive, mood swings and depression

injectable (Depot-provera) - high dose progesterone, inhibits ovulation, IM injections every 12 weeks, ADRS = menstrual irregularities and weight gain

levonorgestrel IUS (Mirena) - prevents implantation and reduces endometrial proliferation, thickens cervical mucus, ADRS= headaches, acne, breast tenderness

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14
Q

What are the constituents of HRT?

A

Oestrogen alone
Oestrogen and progesterone
Tibilone = synthetic, mimics oestrogen, progestogen and testosterone

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15
Q

Which women should take combined HRT?

A

women who have not had a hysterectomy

Oestrogen-alone HRT can stimulate the lining of the womb (endometrium), leading to thickening and possibly cancer

progesterone or a progestogen is added to counteract the effects of oestrogen

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16
Q

Risks v benefits of HRT?

A

+ relief of menopausal symptoms
+ prevention of osteoporosis
+ protection against heart disease

  • increased risk of breast cancer
  • increased risk of ovarian cancer
  • increased risk of endometrial cancer
  • increased risk of VTE (unless transdermal)
  • increased risk of stroke
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17
Q

What is endometrial hyperplasia?

A

irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio, may progress to cancer if left untreated

The most common presentation of endometrial hyperplasia is abnormal uterine bleeding

This includes HMB, intermenstrual bleeding, unscheduled bleeding on HRT and postmenopausal bleeding

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18
Q

What causes endometrial hyperplasia?

A

unopposed oestrogen exposure (relatively high oestrogen and low progesterone levels)

Increased age, nulliparity
Anovulatory cycles- PCOS, perimenopause
Obesity
Diabetes Mellitus
Ovarian tumors- granulosa cell tumors
HRT
HNPCC or Lynch syndrome

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19
Q

Describe normal physiology of urinary continence

A

micturition is made up of the storage/continence phase, when urine is stored in the bladder and the voiding phase, where urine is released through the urethra

storage requires relaxation of the detrusor muscle of the bladder, and simultaneous contraction of both the internal urethral sphincters (IUS) and external urethral sphincters (EUS)

detrusor relaxation and IUS contraction are under autonomic control: pontine continence centre = sympathetic innervation of detrusor muscle and IUS via spinal cord and hypogastric nerve (nerve roots T10-L2)

EUS contraction is under voluntary somatic control : pudendal nerve (nerve roots S2-S4) = contraction

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20
Q

What should you look for on examination of a patient with urinary incontinence?

A

General examination: weight, gait, and indicators of neurological disease

Examine the abdomen for a palpable bladder or a mass

Perform a pelvic examination:
Ask the woman to cough and observe external urethral meatus for leakage (stress)
Assess pelvic muscle tone and contraction during bimanual examination

While performing the pelvic examination, also look for:
Evidence of pelvic organ prolapse
Urethral diverticulum — sac-like protrusion between the periurethral tissues and the anterior vaginal wall
Pelvic mass
Atrophic vaginitis

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21
Q

How should you investigate urinary incontinence?

A

vaginal examination

urine dipstick and culture - to test for blood, glucose, protein, leucocytes, and nitrites

bladder diaries should be completed for a minimum of 3 days

urodynamic studies

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22
Q

Lifestyle advice for women with incontinence?

A

reduce caffeine intake
avoid excessive / reduced fluid intake
smoking cessation
weight loss

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23
Q

What is duloxetine? ADRs?

A

SNRI

increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction of EUS

nausea, dry mouth, fatigue, constipation

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24
Q

Give 2 options that are available for surgical mx of stress incontinence?

A

Colposuspension: lifting up the tissue around the neck of the
bladder, and suspending it in this lifted position using synthetic stitches

Rectus fascial sling: sling made from abdominal fascia is placed behind the urethra to support it

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25
Complications of surgery for urinary incontinence?
infection bleeding / needing a transfusion damage to bladder and bowel nerve damage retention
26
What ligaments are in place to support the uterus?
Broad Ligament: double layer of peritoneum attaching the sides of the uterus to the pelvis (mesometrium, mesosalpinx, mesovarium) Round Ligament: A remnant of the gubernaculum, maintains the anteverted position of the uterus Ovarian Ligament: Joins the ovaries to the uterus Cardinal Ligament: Located at the base of the broad ligament, extends from the cervix to the lateral pelvic walls, contains the uterine artery and vein Uterosacral Ligament: Extends from the cervix to the sacrum
27
Define cystocele, rectocele and enterocele
cystocele = bladder bulges into vaginal space rectocele = bulging of the anterior wall of the rectum into the posterior wall of the vagina enterocele= small intestine prolapses into vaginal space
28
outline the different degrees of uterine prolapse
First degree: The cervix drops into the vagina Second degree: The cervix drops to the level just inside the opening of the vagina Third degree: The cervix is outside the vagina Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia
29
How may urogenital prolapse present?
feeling of pressure or heaviness in the pelvis, urinary incontinence, difficulty emptying the bladder or bowel, lower back pain, and pain during sex
30
How can urogenital prolapse be managed?
physiotherapy, particularly directed pelvic floor muscle training (PFMT) pessaries surgery: anterior or posterior colporrhaphy surgical mesh placement
31
What are the risks of surgery for urogential prolapse?
Surgery done through vagina = quicker procedure and recovery, risk of pain during sex afterwards Surgery done with an abdominal incision may result in less pain during sex, but there is a risk of damage to the intestines and adhesions and also a longer recovery time Vaginally placed mesh has a significant risk of complications, including mesh erosion, pain, infection, and bladder or bowel injury
32
What is an adenexal mass? Causes?
a growth that develops around the uterus in the adenexa Ovarian cysts Noncancerous ovarian tumors Ovarian cancer Ectopic pregnancy Broad ligament leiomyoma Hydrosalpinx
33
Chronic pelvic pain is any pain in the lower abdomen or pelvis that lasts for more than 6 months. What can cause it?
endometriosis PID interstitial cystitis (bladder inflammation) adhesions trapped or damaged nerves in the pelvic area pelvic organ prolapse musculoskeletal pain irritable bowel syndrome (IBS) depression, including postnatal depression traumatic experiences, such as sexual and/or physical abuse
34
What is surgical menopause? What are the potential risks?
acute onset of menopause due to oophorectomy risks: osteoporosis cardiovascular disease low libido vaginal dryness infertility
35
Describe the journey of the zygote from fertilisation until a urinary pregnancy test becomes positive.
the zygote travels down the fallopian tube, where it becomes a morula once it reaches the uterus, the morula becomes a blastocyst the blastocyst implants into the endometrium human chorionic gonadotrophin (hCG), which starts to be produced around 6 days after fertilisation by the syncytiotrophoblastic cells of the placenta
36
At what gestation does the uterus become palpable?
12 weeks, just above the pubic symphysis
37
Causes of large-for-date uterus?
Incorrect due date Multiple pregnancy, polyhydramnios, molar pregnancy A large-for-gestational-age foetus (foetal macrosomia).
38
What investigations should you offer a newly pregnant mum?
weight and height measurement blood pressure urine dip screening for Down's syndrome, Edwards' syndrome and Patau's syndrome around the time of dating scan (11-14 weeks) blood tests for infectious diseases e.g. HIV
39
How can you differentiate between an ectopic pregnancy and miscarriage as cause of an apparent pregnancy with an empty uterus?
hCG - slowly rising in ectopic, decreasing after miscarriage Transvaginal ultrasonography (TVUS) laprascopy
40
Recurrent miscarriage means having three or more miscarriages in a row. What can cause this?
sometimes no known cause , higher risk when older or obese Antiphospholipid syndrome (APS) other coagulation disorders: factor V Leiden, prothromobin, and protein S deficiency abnormal chromosomes incompetent cervix abnormally shaped uterus PCOS uncontrolled diabetes / thyroid disease
41
What investigations can be done for couples presenting with recurrent miscarriages?
blood tests for APS and other clotting disorders genetic testing pelvic USS, hysteroscopy and laparascopy for uterine abnormalities
42
Define infertility. Differentiate between primary and secondary infertility
Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse Primary infertility is when a pregnancy has never been achieved, and secondary infertility is when at least one prior pregnancy has been achieved.
43
In the female reproductive system, infertility may be caused by:
tubal disorders such as blocked fallopian tubes (untreated STIs, complications of unsafe abortion, postpartum sepsis or abdominal/pelvic surgery) uterine disorders which could be inflammatory in nature (such as endometriosis), congenital in nature (such as septate uterus), or benign in nature (such as fibroids) disorders of the ovaries, such as PCOS disorders of the endocrine system
44
What are the WHO reference values for normal semen analysis?
semen volume: 1.5 ml or more pH: 7.2 or more sperm concentration: 15 million spermatozoa per ml or more total sperm number: 39 million spermatozoa per ejaculate or more total motility (percentage of progressive motility and non‑progressive motility): 40% or more motile or 32% or more with progressive motility vitality: 58% or more live spermatozoa sperm morphology (percentage of normal forms): 4% or more
45
What information obtainable through history would be helpful if you suspected tubal factor infertility?
PMH of STIs and PID? REVIEW
46
How can you induce ovulation in a patient with an anovulatory disorder like PCOS?
Exercise and weight loss Letrozole Clomiphene citrate
47
Give some risks of a high BMI for pregnancy and delivery
increased risk of: thrombosis gestational diabetes hypertension, pre-eclampsia induction of labour caesarean birth anaesthetic complications and wound infections
48
How should patients with FGM be managed?
health professional should explain the UK law on FGM documentation and risk assessment all women and girls with recent FGM require police and social services referral referral to hopsital FGM service All women should be offered referral for psychological assessment, testing for HIV, Hep B and C and sexual health screening pregnant women with FGM require consultant led care
49
Complications of FGM?
short term: haemorrhage, urinary retention and genital swelling long term: genital scarring, urinary tract damage, dyspareunia, PID, infertility, psychological issues
50
what is the reporting system for FGM in the UK?
must be documented in clinical records must be referred to police if under 18
51
Challenges facing refugees and asylum seekers in accessing healthcare in European countries?
language barriers/ communication issues financial issues discrimination lack of access to personal health records
52
How should you present an obstetric case?
1. Patient’s name 2. Age 3. Gravidity and Parity Gravidity = number of pregnancies a woman has had, including current pregnancy Parity = number of deliveries of 24 weeks or more plus those ending before 24 weeks where there was a sign of life 4. Maturity of pregnancy, expressed in weeks gestation 5. The presenting problem(s)
53
What is Naguele's formula for calculating an expected due date?
first day of last menstrual period - 3 months + 1 year and 7 days = EDD
54
Physiological changes in the cardiovascular system in pregnancy?
increased cardiac output, expanded blood volume, and reduced systemic vascular resistance and blood pressure
55
Complications of preterm prelabour rupture of membranes?
fetal: prematurity, infection, pulmonary hypoplasia maternal: chorioamnionitis
56
What foetal monitoring is available during labour?
foetal heart rate auscultation - Pinard stethoscope or doppler USS immediately after contractions Offer cardiotocography (CTG) if intermittent auscultation indicates possible fetal heart rate abnormalities or if high risk delivery
57
Progress in labour is influenced by the three P’s:
Power (uterine contractions) Passenger (size, presentation and position of the baby) Passage (the shape and size of the pelvis and soft tissues)
58
What are the 3 phases of the first stage of labour?
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
59
Delay in the first stage of labour is considered when there is either:
Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women
60
How is progress monitored in the first stage of labour?
a partogram recorded : Cervical dilatation (measured by a 4-hourly vaginal examination) Descent of the fetal head Maternal pulse, bp, temp and urine output Fetal heart rate Frequency of contractions Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium Drugs and fluids that have been given The dilation of the cervix is plotted against the duration of labour (time). When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines. Crossing the alert line is an indication for amniotomy (artificially rupturing the membranes) and a repeat examination in 2 hours. Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.
61
Delay in the second stage is when the active second stage (pushing) lasts over:
2 hours in a nulliparous woman 1 hour in a multiparous woman
62
The main options for managing failure to progress are:
Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section
63
What causes delay in the first stage of labour?
slow effacement due to inefficient uterine contractions can be managed with an oxytocin infusion
64
What causes delay in the second stage of labour?
Baby is too large Birth canal is too small Pelvis is too small for baby to move down Uterine contractions aren’t strong enough
65
Oxytocin mechanism of action? ARDs?
Increases intracellular calcium in uterine smooth muscle, which causes uterine muscle contraction Arrhythmias; headache; nausea; vomiting
66
What intrapartum analgesia is available? Advantages and disadvantages?
Entonox ('gas and air') - gives some relief, although it may make patients feel sick and light‑headed Diamorphine and pethidine can be given as injections for pain relief may make patients feel or be sick and drowsy patients will not be able to get into water for 2 hours after an injection (water birth) baby's breathing may be affected and they may be drowsy (which could affect breastfeeding) epidural (local anaesthetic) it is better at relieving pain than opioids patient and baby will need careful monitoring so can't move around as much it is linked to a longer second stage of labour and an increased chance of a forceps birth/ ventouse birth
67
Differentiate between active and physiological mx of the third stage of labour
Active management of the third stage of labour involves giving IM oxytocin, early cord clamping and controlled cord traction to deliver the placenta = quicker with reduced risk of bleeding but risk of N+V With physiological management, the placenta is delivered spontaneously by maternal effort
68
Define zygosity and chorionicity.
Zygosity refers to the type of conception and the genetic makeup of the twins, while chorionicity refers to the type of placentation
69
Give some antenatal complications of multiple pregnancy
polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage
70
Give some fetal complications of multiple pregnancy
prematurity light-for date babies malformation
71
Give some labour complications of multiple pregnancy
PPH increased malpresentation cord prolapse, entanglement
72
How should twin pregnancies be managed?
ultrasound for diagnosis + monthly checks additional iron + folate more antenatal care (e.g. weekly > 30 weeks) precautions at labour (e.g. 2 obstetricians present) 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
73
Causes of antepartum haemorrhage?
placental abruption and placenta praevia
74
Outline the risks of C section deliveries
wound infection endometrial infection bleeding, DVT damage to bladder cuts to babies skin breathing difficulties in the baby
75
Benefits of C section?
reduced risk of: pain during the birth injury to the vagina pelvic organ prolapse
76
What drug is used for thromboprophylaxis in pregnancy?
LMWH DOACs and warfarin should be avoided in pregnancy.
77
Advice for epileptic pregnant women?
risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus aim for monotherapy there is no indication to monitor antiepileptic drug levels
78
Risks of anaemia in pregnancy?
Mother: breathing difficulties, fainting, tiredness, palpitations, and sleep difficulties increased risk of developing perinatal infection, pre-eclampsia, and bleeding baby: intrauterine growth retardation, prematurity, and low birth weight
79
Impact of domestic violence on pregnancy?
increases the risk of miscarriage, infection, premature birth, and injury or death to the baby emotional and mental health problems, such as stress and anxiety, which can affect the development of the baby
80
What drugs are used to treat hypertension in pregnancy ? Give their mechanism, contraindications and ADRs
oral labetalol is now first-line beta blocker, contraindicated in asthma, ADRs= abdo discomfort, bradycardia, confusion, depression, diarrhoea, dizziness, dry eye, fatigue oral nifedipine (e.g. if asthmatic) CCB, avoid before week 20 ARDs= abdo pain; dizziness; drowsiness; flushing; headache; nausea; palpitations; peripheral oedema; skin reactions; tachycardia; vomiting hydralazine vasodilator risk of neonatal thrombocytopenia
81
How can obstetric cholestasis be investigated?
LFTs and serum bile salts ALT is typically elevated e.g. 500 u/l blood glucose may show hypogylcaemia
82
What are the differentials for obstetric cholestasis?
other causes of liver disease: Pre-eclampsia and HELLP syndrome (= haemolysis, elevated liver enzymes, low platelet count) Acute fatty liver of pregnancy Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis,Wilson's disease, and viral hepatitis may also be seen in pregnancy other causes of pruritus: Pemphigoid gestationis Pruritis gravidarum Atopic dermatitis Allergic reactions
83
Give some risk factors for puerperal psychosis
family history personal history of postpartum psychosis, bipolar disorder or schizophrenia complications with labour and delivery / traumatic birth
84
What is the incubation period of varicella zoster virus?
10 to 21 days
85
What are the risks and benefits of external cephalic version (ECV)?
+ if successful then no need for a cesarean section +relatively low complication rate - slightly uncomfortable pressure on abdomen - risk of bleeding from the placenta - risk of change to foetal heart rate

Y4 Reproductive Health (13 decks)

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