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Year 5 Core Conditions > Reproductive system - Level 2.3 > Flashcards

Reproductive system - Level 2.3 Flashcards

1
Q

Epidemiology of cervical cancer?

A
  • 3rd most common gynaecological cancer after uterus and ovary
  • Most common cancer in women under 35
  • Age peaks 25-34
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2
Q

Definition of CIN?

A

• Cervical intraepithelial neoplasia (CIN) precursor lesion for carcinoma of the cervix
o CIN 1 – disease confined to lower third of epithelium
o CIN 2 – disease confined to lower and middle thirds of epithelium
o CIN 3 – affecting full thickness

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3
Q

Classes of cervical cancer?

A

o Breeches epithelial basement membrane
o If deepest part is <5mm from surface of epithelium – micro-invasive
o If it extends beyond 5mm or wider than 7mm – invasive carcinoma

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4
Q

Types of cervical cancer?

A
  • Squamous cell = 70%
  • Adenocarcinoma = 15%
  • Mixed = 15%
  • Neuroendocrine tumour, clear cell carcinoma, glassy cell carcinoma, sarcoma botryoides, lympohoma = <1%
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5
Q

Spread of cervical cancer?

A
  • Direct = Parametrium, vagina, bowel and bladder and then to the pelvic side wall.
  • Lymphatic = parametrial nodes, internal, external and common illiac nodes, obturator nodes, pre-sacral and para-aortic nodes
  • Ovarian spread is rare
  • Haematological = liver and lungs
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6
Q

Risk factors of cervical cancer?

A
  • Exposure to HPV (early first sexual experience, multiple partners, non-barrier contraception)
  • COCP
  • High parity
  • Smoking
  • Immunosuppression (esp. HIV and transplant patients)
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7
Q

Symptoms of cervical cancer?

A

Common symptoms
o Post-coital bleeding (PCB)
o Post-menopausal bleeding
o Vaginal discharge - blood stained, offensive, serous

Late Symptoms
•	Painless haematuria
•	Urinary frequency
•	Weight loss
•	Bowel disturbance
•	Fistula
•	Pain
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8
Q

Signs of cervical cancer?

A

o White or red patches on cervix
o Roughened hard cervix or ulcer +/- loss of fornices
o Fixed cervix if there is extension of the disease

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9
Q

When to refer of cervical cancer - postmenopausal?

A

o Refer all women urgently to gynaecology if suspicious, persistent vaginal discharge not explained
 2-week gynaecology clinic if not on HRT and vaginal bleeding or persistent or unexplained vaginal bleeding after stopping HRT for 6 weeks

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10
Q

When to refer of cervical cancer - premenopausal?

A

 Gynaecology clinic if persistent intermenstrual bleeding, post-coital bleeding, blood-stained discharge
 2-week if negative pelvic exam, not had smear, >3 months, new symptoms

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11
Q

Investigations of cervical cancer?

A

o Colposcopy
 Cervix visualised, transformation zone is identified and painted with acetic acid, taken up by neoplastic cells
 Aceto-white areas identify abnormal areas and enable punch biopsy to be taken to diagnose histologically
 Punch biopsies for histology (not LLETZ in cancer)
 Irregular cervical surface, abnormal vessels dense aceto-white changes.

o Bloods - FBC, U&Es, LFTs

o Fitness for surgery- CXR, U&E, FBC, IV pyelogram

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12
Q

Staging investigations of cervical cancer?

A 
o	CT abdomen and pelvis
o	MRI pelvis
o	EUA (bimanual vaginal examination, cystoscopy, hysteroscopy, PV/PR examination)
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13
Q

Staging of cervical cancer?

A

• FIGO Staging
o 0 – no primary tumour
o Tisb – carcinoma in-situ (pre-invasive)
o 1 – confined to uterus
o 2 – Extended locally to upper 2/3 of vagina
o 3 – Spread to lower 1/3 of vagina +/- hydronephrosis
4 – spread to blader or rectum

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14
Q

Vaccinations of cervical cancer?

A
  • Part of the NHS childhood vaccination programme – will include boys next academic year 2019/20
  • Gardasil (Merck) – HPV 16, 18 + 6, 11 (used)
  • Cervarix (GSK) – HPV 16, 18
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15
Q

Management of CIN1?

A

o If HPV +ve offer 6-month colposcopy and LLETZ if persistent
 LLETZ – large loop excision of transformation zone, dine under LA with loop diathermy

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16
Q

Management of CIN2/3?

A

o Excised with LLETZ, smear at 6 months with high-risk HPV testing
o If negative, return to 3-year smears
o If abnormal, repeat assessment with colposcopy

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17
Q

Management of cervical cancer - Stage 1A1?

A

Stage 1A1 (<3mm depth)

o Local excision (radical trachelectomy, cervicectomy) or hysterectomy

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18
Q

Management of cervical cancer - Stage 1A2 & 1B1?

A

Stage 1A2 (<5mm depth) and 1B1 (<4cm diameter)

o Lymphadenectomy and if node negative, proceed to Wertheim’s hysterectomy
 Excision of primary tumour with 1cm margin and en bloc resection of main pelvic lymph node areas
 May involve – removing upper 1/3 of vagina and ligaments

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19
Q

Management of cervical cancer - Stage 1B2?

A 
o	Chemoradiotherapy (cisplatin)
	Involves external beam and brachytherapy
o	If negative lymph nodes, consider Wertheim’s hysterectomy
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20
Q

Management of cervical cancer - >Stage 2B?

A

o Combination chemoradiotherapy (cisplatin)

 Involves external beam and brachytherapy

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21
Q

Management of cervical cancer - Stage 4B?

A 
o	Chemoradiotherapy (cisplatin)
	Involves external beam and brachytherapy
o	Palliative radiotherapy to control bleeding
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22
Q

Complications of Weirthem’s hysterectomy?

A
  • Bleeding
  • Infection
  • DVT/PE
  • Ureteric fistula
  • Bladder dysfunction
  • Lymphoedema
  • Lymphocysts
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23
Q

Compications of radiotherapy for cervical cancer?

A
  • Acute bowel and bladder dysfunction (tenesmus, mucositis, bleeding)
  • 5% late bowel and bladder dysfunction (ulceration, strictures, bleeding, fistula formation)
  • Vaginal stenosis, shortening and dryness
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24
Q

Follow up of cervical cancer?

A
  • Patients are reviewed at 6 weeks post treatment, every 3-4 months for 1-2 years, annually for a total of 5 years
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25
Q

Survival of cervical cancer

A
  • 90% survival in women under 40 years of age
  • 1-year survival >80%
  • 5-year survival >65%
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26
Q

Epidemiology of endometrial cancer?

A
  • 4th most commonly diagnosed cancer in women in the UK
  • More than 9 in 10 cases are diagnosed in women aged 50 and over
  • North America 7:1 China
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27
Q

Pathology of endometrial cancer?

A
  • Endometrial hyperplasia with atypia (but not without) is a premalignant condition
  • Unopposed oestrogen leads to hyperplasia - predisposing to cytological atypia - precancerous
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28
Q

Types of endometrial cancer?

A
  • Adenocarcinomas (80%)
    o Main types: oestrogen-dependent endometrioid (Type 1) and oestrogen-independent non-endometrioid (Type 2)
  • Adenosquamous carcinoma
  • Clear cell or papillary serous carcinoma
  • Mixed mesodermal Mullerian tumours (MMMT)
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29
Q

Spread of endometrial cancer?

A
  • Direct = through myometrium to the cervix and upper vagina. The ovaries may be involved and the fallopian tubes. Surface of bowel and liver.
  • Lymphatic = to pelvic then para-aortic lymph nodes.
  • Haematological = occurs late  liver, lungs.
  • Recurrence is most common at the vaginal vault, normally in the first three years
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30
Q

Risk factors of endometrial cancer?

A 
o	Early/Late menopause
o	Nulliparity
o	PCOS
o	Breast cancer +/- Tamoxifen
o	Oestrogen-only HRT
o	Oestrogen-secreting ovarian tumours
o	Obesity
o	DM2
o	Hypothyroidism
o	HTN
o	HNPCC (Lynch 2 syndrome)
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31
Q

Aetiology of endometrial cancer?

A

UNOPPOSED OESTROGEN

Endogenous:
 Peripheral conversion in adipose tissue of androstenedione to oestrone.
 Oestrogen-producing tumour (granulosa cell tumour)
 PCOS or anovulatory cycles at menarche or during climacteric period (lack of progesterone as no luteal phase)

Exogenous:
 Oestrogen only HRT
 Tamoxifen (oestrogen agonist in the endometrial tissue)

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32
Q

Protective factors of endometrial cancer?

A

o Parity

o COCP

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33
Q

Symptoms of endometrial cancer?

A

• Post-Menopausal Bleeding (PMB)
- 1 in 10 women with PMB will have endometrial cancer or atypical hyperplasia.
- Atypical hyperplasia = abnormalities of the cellular or glandular architecture (premalignant).
- Most common cause of PMB is vaginal atrophy.
o Reassure, lubricants, E2 creams
• Irregular menstrual cycle
• Heavy or irregular periods (premenopausal women)
• PV discharge and pyometra (pus in the uterine cavity)

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34
Q

Investigations of endometrial cancer?

A

o Vulval, vagina and speculum examination

o Bloods – FBC, U&Es, LFTs

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35
Q

Referral within 2 weeks of endometrial cancer?

A

o >55 with PMB, consider if <55
o Direct access USS in >55 with:
 Unexplained vaginal discharge – new, thrombocytosis, haematuria
 Visible haematuria – low Hb, thrombocytosis, high glucose

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36
Q

Investigations of endometrial cancer?

A

Speculum and Bimanual to exclude other causes

TVUS
 <4mm endometrial thickness (ET) = very low risk - no need for endometrial sampling unless recurrent
 >4mm - biopsy

Biopsies
o Blind outpatient sampling (e.g. pipelle, vabra)
o Hysteroscopy (under LA as outpatient, or GA as in patient)

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37
Q

Staging investigations of endometrial cancer?

A

 CT/MRI pelvis

 CXR to exclude lung spread

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38
Q

Staging of endometrial cancer?

A

o Stage I – confined to body of uterus (corpus uteri)
o Stage II - involving the cervix
o Stage III - spread outside the uterus, but not beyond pelvis
o Stage IV - with bowel, bladder or distant organ involvement

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39
Q

Management of endometrial cancer - Stage 1?

A

 Total abdominal hysterectomy with bilateral salpingo-oophorectomy with peritoneal washings

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40
Q

Management of endometrial cancer - Stage 2?

A

 Radical hysterectomy with systematic pelvic node clearance

 Para-aortic lymphadenectomy

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41
Q

Management of endometrial cancer - Stage 3/4?

A

 Maximal de-bulking surgery

 Palliation – high-dose progesterone and external beam radiotherapy

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42
Q

Management of endometrial cancer - other treatments?

A

o Adjuvant radiotherapy used in low-grade disease with deep myometrial invasion and high-grade disease with superficial invasion
o Radiotherapy used in pelvic recurrence

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43
Q

Follow up of endometrial cancer?

A
  • 6 weeks post-surgery
  • Every 3-4 months for 2 years
  • Annually to 5 years
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44
Q

Epidemiology of ovarian cancer?

A
  • 2nd most common gynaecological cancer after uterus.
  • Most common cause of gynaecological cancer death.
  • Peak incidence = 75-84 years.
  • Lifetime risk 2% in UK
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45
Q

Types of ovarian cancer?

A

90% are epithelial ovarian cancers (EOC).

o Epithelial – derived from Mullerian epithelium (>50)
 Serous, endometrioid, clear cell, mucinous, Brenner

o Sex cord or stromal – derived from ovarian stroma, sex cord derivatives or both
 Fibroma, fibrosarcoma, Sertoli-Leydig tumour, Granulosa tumours

o Germ cell – derived from ovarian germ cells (<30)
 Dysgerminoma, endodermal sinus tumours, teratoma, choriocarcinoma, sarcoma

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46
Q

Spread of ovarian cancer?

A
  • Transcolemic spread = pelvis and abdomen
  • Lymphatic
  • Haematological
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47
Q

Risk factors of ovarian cancer?

A
  • Nulliparity
  • Early menarche and/or late menopause
  • Endometriosis
  • HRT
  • Difficulty conceiving
  • BRCA 1 and BRCA 2 mutations
  • HNPCC (Lynch II syndrome – bowel, ovarian and endometrial ca)
  • Age, smoking, obesity
48
Q

Protective factors of ovarian cancer?

A
  • COCP
  • Pregnancy
  • Female sterilisation
49
Q

Symptoms of ovarian cancer?

A
  • Vague which may look like IBS or diverticular disease
  • Most present at Stage 3

o Abdominal distension (often described as persistent bloating).
o Abdominal pain.
o Weight loss, loss of appetite, early satiety
o Fatigue
o Urinary symptoms
o Change in bowel habit
o Vaginal bleeding

50
Q

Signs of ovarian cancer?

A 
o	Fixed pelvic mass
o	Ascites
o	Omental mass
o	Pleural effusion
o	Supraclavicular lymph node enlargement
51
Q

When to refer for clinical genetics in ovarian cancer?

A

 Two primary cancers in one 1st or 2nd degree relative
 Three 1st or 2nd degree relatives with breast/ovarian/stomach/endometrial cancers
 Two 1st or 2nd degree relatives, one having ovarian cancer at any age and the other with breast cancer <50
 Two 1st or 2nd degree relatives with ovarian cancer at any age

If gene mutation - yearly TVUS and Ca125
Offer BSO if BRCA positive

52
Q

When to refer in ovarian cancer?

A
  • Refer urgently in any woman with ascites and/or pelvic or abdominal mass which is not fibroids
53
Q

Tests performed in primary care in ovarian cancer?

A

Bloods – FBC, U&Es, LFTs (esp. albumin)

54
Q

Tumour markers of ovarian cancer?

A

CA125
• Raised in 80% of epithelial cancers (serous, endometrioid).
• Also raised in endometriosis, PID, pregnancy, torsion, rupture, other cancers, HF

CEA (carcinoembryonic antigen)
• Raised in colorectal cancers, normal in ovarian cancer.

CA19.9
• Raised in mucinous tumours

AFP, hCG, LDH
• If woman <40

55
Q

Tests to perform in secondary care of ovarian cancer?

A 
o	Ca125, TVUS and abdominal US
o	CT/MRI staging
o	Work out RMI, >250 needs MDT review
o	CXR
o	Ascites or pleural effusion sampled and sent for cytology
56
Q

Staging of ovarian cancer?

A

o Stage I – ovaries only
o Stage II – beyond ovaries and confined to pelvis
o Stage III – disease beyond pelvis, confined to abdomen (SI, omentum, peritoneum)
o Stage IV - distant metastases

57
Q

Management of ovarian cancer - of ascites and pleural effusion?

A
  • Drainage of massive tense ascites (Bonanno suprapubic catheter) or a pleural effusion pre-operatively.
  • Albumin may drop following ascitic draining
58
Q

Management of ovarian cancer - early stages?

A

Exploratory laparotomy - histological confirmation, staging and tumour debulking
o Total abdominal hysterectomy and bilateral salpingo-oophorectomy
o Omentectomy
o Para-aortic and pelvic lymph node sampling
o Peritoneal washings and biopsies

Adjuvant chemotherapy - Carboplatin with paclitaxel
o Everyone but low-grade stage 1A and 1B

59
Q

Management of ovarian cancer - stages 3/4?

A

Same as Stage 1/2 with:

  • Stage 3/4 – Neoadjuvant chemotherapy
60
Q

Management of ovarian cancer - follow up?

A
  • 6 weeks post-surgery.
  • Every 3-4 months for 1-2 years.
  • Annually to 5 years
  • Ca125 often used to monitor
61
Q

Epidemiology of vulval cancer?

A
  • Vulval carcinomas are uncommon.
  • Mostly occur in older women (~74 years)
  • Labia majorum most common site
62
Q

Types of vulval cancer?

A

o ~90% are squamous cell carcinomas.
o ~5% are primary vulval melanomas with basal cell, Bartholin’s gland carcinoma and rarely sarcomas accounting for the rest

63
Q

Spread of vulval cancer?

A

o Usually locally, slow metastases to groin nodes and then pelvic nodes
o Local to vagina, urethra and anus

64
Q

Risk factors of vulval cancer?

A 
o	Lichen sclerosis
o	VIN.(vulval intraepithelial neoplasia)
o	HPV
o	Psoriasis
o	Smoking
o	Pagets Disease of vulva (adenocarcinoma in situ)
65
Q

Management of VIN?

A

 Dysplastic lesion of squamous epithelium associated with persistent infection with HPV (esp. 16)
 Histological diagnosis so biopsies taken
 Types:
• Usual type – HPV related
• Differentiated type – chronic dermatological conditions
 Rx – Laser therapy, wide local excision, imiquimod

66
Q

Symptoms and signs of vulval cancer?

A
  • Lump
  • Pain
  • Irritation
  • Bleeding
  • Ulceration
  • Pruritus
  • Palpable groin lymph nodes – enlarged, hard, immobile
67
Q

Diagnosis of vulval cancer?

A

o Examination and biopsy (wedge)

68
Q

Other investigations of vulval cancer?

A

o Cystoscopy
o Proctoscopy
o MRI (staging)
o CXR (staging and preoperative)

69
Q

Staging of vulval cancer?

A

o 1 – confined to vulva
o 2 – extension to adjacent perineal structures (lower 1/3 urethra, lower 1/3 lower vagina, anus) with negative nodes
o 3 – with or without extension to adjacent perineal structures (lower 1/3 urethra, lower 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes
o 4 – Invades regional (Upper 2/3 vagina, upper 2/3 urethra) or distant

70
Q

Referral of vulval cancer?

A

o Women with unexplained vaginal lump, vulval bleeding or ulceration
o Women with pruritus or pain which has been treated and still persists

71
Q

Management of vulval cancer - local disease?

A
  • All patients with >1mm deep, triple incision surgery
    o Wide local excision + ipsilateral groin node biopsy (lymphadectomy) + sample contralateral side
    o If tumour <2cm width and <1mm deep, LN excision is not needed
72
Q

Management of vulval cancer - advanced disease?

A

o Radical vulvectomy (wide excision of vulva + removal of inguinal glands)
o Radiotherapy used pre-op to shrink tumours
- Chemoradiation used if unsuitable for surgery, to shrink tumours pre-operatively or for relapses

73
Q

Definition of recurrent miscarriages?

A

• Three or more miscarriages occurring in succession before 24 weeks gestation (1% of couples)

74
Q

Aetiology of recurrent miscarriages?

A

Antiphospholipid antibodies can cause recurrent miscarriage

Chromosomal defects (4% of couples) 
	Usually balanced reciprocal or Robertsonian translocation

Uterine abnormalities are common with late miscarriage.
 Cervical incompetence, polycystic ovary syndrome, adhesions etc.

Thrombophilia
 Factor V leiden, prothrombin gene and protein C and S deficiency

Bacterial vaginosis – associated with 2nd trimester loss

75
Q

Definition of antiphospholipid syndrome?

A

 Defined as presence of antibodies on 2 occasions plus 3 or more consecutive miscarriages <10 weeks, 1 foetal loss 10 weeks or older or 1 or more births of normal foetus >34/40 with severe pre-eclampsia or growth restriction

76
Q

Investigations of recurrent miscarriages?

A

 Antiphospholipid antibodies (positive if 2 tests +ve, 12 weeks apart)
 Thrombophilia screening
 Pelvic US to assess uterus
 Karyotype foetal products
• If abnormal chromosome – karyotype parental blood
 High cervical swab for bacterial vaginosis

77
Q

Management of recurrent miscarriages?

A

Referral to specialist recurrent miscarriage clinic

o Antiphospholipid syndrome
 Aspirin 75mg PO from day of positive pregnancy test
 Enoxaparin 40mg SC as soon as foetal heart seen

o Thrombophilia
 LMWH (Enoxaparin)

o Bacterial vaginosis
 Treat infection

78
Q

Definition of miscarriage, early and late?

A
  • Loss of a pregnancy before 24 weeks gestation
  • Early miscarriage, if it occurs before 13 weeks of gestation.
  • Late miscarriage, if it occurs between 13 and 24 weeks of gestation
79
Q

Epidemiology of miscarriage?

A
  • 15-20% of pregnancies miscarry, mostly in 1st trimester

- Rate increases with maternal age

80
Q

Definition of threatened miscarriage?

A

o There is bleeding but the foetus still alive, the uterus is the size expected from the dates and the OS is closed.
o Only 25% will go on to miscarry

81
Q

Definition of inevitable miscarriage?

A

o Bleeding is usually heavier.
o Although the fetus may still be alive, the cervical OS is open.
o Miscarriage is about to occur

82
Q

Definition of incomplete miscarriage?

A

o Some fetal parts have been passed, but the os is usually open

83
Q

Definition of complete miscarriage?

A

o All fetal tissue has been passed.

o Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed

84
Q

Definition of septic miscarriage?

A

o The contents of the uterus are infected causing endometritis.
o Vaginal loss is offensive and the uterus is tender.
o A fever can be absent.
o If pelvic infection occurs there is abdominal pain and peritonism

85
Q

Definition of missed miscarriage?

A

o The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or USS is performed
o The uterus is smaller than expected for dates and the OS is closed

86
Q

Aetiology of miscarriage?

A
  • Isolated non-recurring chromosomal abnormalities – 60% of one off miscarriages
  • Exercise, intercourse and emotional trauma DO NOT cause miscarriage
87
Q

Symptoms of miscarriage??

A
  • Bleeding PV in first 24 weeks
  • Pain
  • Enquire about: nausea, vomiting, dizziness, fainting, shoulder tip pain, urinary symptoms, passage of tissue
  • Need to assess state of os and uterine size
88
Q

Investigations of miscarriage?

A
  • Urine pregnancy test
  • TVUS
  • Bloods: FBC, Rh group
  • Blood culture (if indicated)
89
Q

Management of early pregnancy bleeding - initial management?

A

o If >6 weeks and no pain, tenderness, cerical motion tenderness – refer for EPAU services

o If <6 weeks and no pain
 Return if bleeding continue or pain develops
 Repeat urine PT in 7 days and return if positive
 Negative pregnancy test means pregnancy has miscarried

90
Q

Management of early pregnancy bleeding - findings on TVUS?

A

Foetal heartbeat
• If bleeding gets worse or persists >14 days, return
• If bleeding stops, start or continue antenatal care

Crown-rump length
• If <7mm and no visible heartbeat –2nd scan after 7 days
• If >7mm and no visible heartbeat -2nd scan after 7 days or 2nd opinion

Gestational sac diameter
• If <25mm and no visible fetal pole – 2nd scan after 7 days
• If >25mm and no visible fetal pole - 2nd scan after 7 days or 2nd opinion

91
Q

Management of early pregnancy bleeding - diagnosing miscarriage?

A

 Diagnosis cannot be 100% accurate from 1 US scan, particularly at early stages

92
Q

Management of early pregnancy bleeding - if confirmed miscarriage?

A

o If unacceptable pain or bleeding – surgical management of miscarriage
 Evacuation of retained products of conception (ERPC)

o Immediate admission if haemodynamically unstable
 IV fluids
 If bleeding profuse – ergometrine 0.5mg IM
 If there is a fever, swabs for bacterial culture are taken and IV abx are given

93
Q

Management of early pregnancy bleeding - uncertain viability?

A

o Arrange rescan in 10-14 days

94
Q

Management of early pregnancy bleeding - miscarriage couselling?

A

o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o There is a likelihood of bleeding, but foetal tissue usually absorbed
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages

95
Q

Management of early pregnancy bleeding - non-viable miscarriage - expectant management?

A

 If scan confirms 1st trimester miscarriage (incomplete or missed)
 Offer for 7-14 days when confirmed miscarriage
 Offer rescan in 2 weeks to ensure complete if no significant bleeding or persistent/increasing bleeding/pain
 Repeat pregnancy test at 3 weeks and return if positive

96
Q

Management of early pregnancy bleeding - non-viable miscarriage - when to explore other managements?

A

 Risk of haemorrhage (last 1st trimester), previous traumatic pregnancy, infection

97
Q

Management of early pregnancy bleeding - non-viable miscarriage - medical management?

A

 Offered when failed expectant treatment
 Give analgesia and anti-emetic
 Misoprostol either orally/vaginally for missed (800mcg) or incomplete miscarriage (600mcg)
 Bleeding should start within 24 hours and may continue for 3 weeks
 Pregnancy test after 3 weeks and return if positive

98
Q

Management of early pregnancy bleeding - non-viable miscarriage - surgical management?

A

 If heavy or persistent bleeding > 2 weeks, infected retained tissue or patient choice
 Manual vacuum aspiration under LA OR Suction evacuation under GA and <13 weeks

99
Q

Management of early pregnancy bleeding - non-viable miscarriage - anti-D prophylaxis?

A

o Anti-D immunoglobulin 250IU given to all surgical patients who are Rhesus negative
 Do not offer to medical management, threatened miscarriage, complete miscarriage, unknown location

100
Q

Aetiology of mid-trimester miscarriage?

A

o May be due to mechanical causes (cervical weakness), uterine abnormalities, chronic maternal disease (DM, SLE), infection or no cause identified

101
Q

Management of mid-trimester miscarriage?

A

o Cervical cerclage at 14 weeks of pregnancy – removed prior to labour
o Investigate to ensure any treatable cause is treated next time

102
Q

Management of pregnancy of unknown location - investigation?

A

• Measure hCG – 2 samples 48 hours apart

103
Q

Management of pregnancy of unknown location - if decreased hCG >50%?

A

o Pregnancy unlikely to continue but not confirmed
o Take urine pregnancy test 14 days after 2nd serum hCG and if negative, no action needed, if positive then return to EPAU

104
Q

Management of pregnancy of unknown location - if decrease in hCG <50% or increase <63%?

A

o Refer for review in EPAU withint 24 hours

105
Q

Management of pregnancy of unknown location - if increased hCG >63%?

A

o Likely a developing intrauterine pregnancy (although may be ectopic)
o Offer TVUS to determine location between 7-14 days later
 If viable intrauterine pregnancy confirmed – offer routine antenatal care
 If viable intrauterine pregnancy not confirmed – refer for review by gynaecologist

106
Q

Definition of premenstrual syndrome?

A

o Distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease
o Recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation

107
Q

Pathology of premenstrual syndrome?

A
  • Suggestion abnormal response to normal progesterone excursions
  • Affects GABA receptors
  • Neurons in PMS preferentially metabolise progesterone into pregnenolone (heightens anxiety) rather than allopregnanolone (anxiolytic)
108
Q

Risk factors of premenstrual syndrome?

A

o FHx of PMS
o High BMI
o Stress
o Traumatic events

109
Q

Symptoms of premenstrual syndrome?

A
  • Mood swings
  • Irritability
  • Depression
  • Stress/Tension
  • Bloating and breast tenderness
  • Headache
  • GI upset
110
Q

Diagnosis of moderate premenstrual syndrome?

A

o Severe PMS involves disruption of interpersonal/work relationships or interference with normal activities

111
Q

Diagnosis of severe premenstrual syndrome?

A

o >5 symptoms present for most of the luteal phase and absence of symptoms post menses (at least one symptom must be from the first 4):
 Markedly depressed mood, feelings of hopelessness or self-deprecation.
 Marked anxiety, tension (being ‘on edge’)
 Marked affective lability (e.g. feeling suddenly sad or tearful)
 Persistent and marked anger/irritability/increased conflicts.
 Decreased interest in usual activities.
 Subjective sense of difficulty in concentrating.
 Lethargy, easy fatigability/lack of energy.
 Marked change in appetite, overeating or specific food cravings.
 Hypersomnia or insomnia
 Subjective sense of being overwhelmed or out of control.
 Other physical symptoms (breast tenderness or swelling, headaches, joint or muscle pain, a sense of ;bloating;, weight gain).

112
Q

Investigations of premenstrual syndrome?

A

• Exclude underlying organic/psychiatric causes
o BP, pulse, thyroid and breast examination
• Symptoms diary filled in over 2 cycles (2-3 months)

113
Q

Management of premenstrual syndrome - general measures?

A

• Improve Healthy Diet
o Less fat, sugar, salt, caffeine and alcohol.
o Regular, frequent small balanced meals rich in complex carbohydrates
• Increase exercise
• Stop smoking
• Schedule stressful tasks to better half of month if needed
• Stress reduction
o Relaxation techniques
o Yoga
o Meditation
o Breathing techniques

114
Q

Management of premenstrual syndrome - 1st line moderate?

A

• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed

115
Q

Management of premenstrual syndrome - 1st line severe?

A

• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
• SSRI (fluoxetine/sertraline/citalopram)
o Continuous or just for luteal phase of menstruation
o Give 3 months, if benefit then continue for 6-12 months

116
Q

Management of premenstrual syndrome - secondary care options?

A
  • Progesterone or progestogens used alone.
  • Antidepressants other than SSRIs
  • Alprazolam.
  • Diuretics
  • Danazol
  • Transdermal oestrogen
  • GnRH analogues +/- addback HRT
117
Q

Management of premenstrual syndrome - surgery?

A
  • Hysterectomy including oophorectomy with oestrogen-only HRT, last resort for severe PMS

Year 5 Core Conditions (55 decks)

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