Selected Notes obgyn 2 Flashcards
What group is urinary incontinence most common in?
Elederly females
Name some risk factors for developing urinary incontinence
Advancing age<br></br>Previous pregnancy/childbirth<br></br>High BMI<br></br>Hysterectomy<br></br>Family history
Name the reversible causes of urinary incontinence
DIAPPERS<br></br>D-delirium<br></br>I-Infection<br></br>A-atrophic vaginitis or urethritis<br></br>P-Pharmaceuticals-meds)<br></br>P-Psychiatric disorders<br></br>E-Endocrine disorders-diabetes etc<br></br>R-Restricted mobility<br></br>S-Stool impaction
What causes urge incontinence?
Detrusor overactivity
What is functional incontinence?
Comorbid physical conditions impair the patient’s ability to get to a bathroom in time<br></br>Causes: dementia, medications, injury/illness causing impaired mobility
What is a cystometry?
Investigation to measure bladder pressure whilst voiding
What is a cystogram?
Contrast instilled into the bladder and a radiological image is obtained to see if the contrast travels anywhere else
In the surgical management of stress incontinence, {{c1::colposuspension and fascial slings}} involve <span>s</span>{{c2::uspending the anterior vaginal wall}} <span>to the </span>{{c3::iliopectineal ligament of Cooper}}
What are the surgical management options for treating urge incontinence?
Bladder instillation->botox injection to paralyse detrusor muscle<br></br>Sacral neuromodulation->only int mtertiary centres where all other treatments have failed
What causes overflow incontinence?
Either:<br></br>1. Underactivity of the detrusor muscle e.g. from neurological damage OR<br></br>2. Urinary outlet pressures are too high e.g. constipation or prostatism
What is a genital or pelvic organ prolapse?
Descent of one or more pelvic structures from their normal anatomical position moving towards or through the vaginal opening
Name some risk factors for developing a genital prolapse
-Vaginal childbirth, especially with traumatic or complicated deliveries<br></br>-Increasing age<br></br>-Menopause<br></br>-Hysterectomy<br></br>-Obesity<br></br>-Chronic cough<br></br>-Heavy lifting<br></br>-Connective tissue disorders<br></br>-Spina bifida
What are the types of anterior vaginal wall prolapse?
Cystocele-bladder<br></br>Urethrocele-urethra<br></br>Cystourethrocele-both bladder and urethra
What is a cystocele? What condition can it lead to?
<ul><li>Bladder prolapse</li></ul>
Sterss incontinence<br></br>
Name the posterior wall prolapses
Enterocele-small intestine<br></br>Rectocele-rectum
Name the atypical vaginal wall prolapses?
Uterine prolapse-uterus<br></br>Vaginal vault prolapse-roof of the vagina
What are some differential diagnoses for a uterogential prolapse?
<ul><li>Gynecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain</li><li>Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain</li><li>Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass</li></ul>
Name some investigations to diagnose a genital prolapse
-Pelvic exam<br></br>Imaging if compolx or required for surgical planning<br></br>Urodynamic studies if co-existing urinary symptoms
What is a vaginal fistula?
Unusual opening that connects your vagina to another organ<br></br>Can link vagina to bladder, ureters, urethra, rectum, intestines
Name some of the causes of a vaginal fistula?
Childbirth<br></br>Abdominal surgery<br></br>Pelvic, cervical or colon cancer<br></br>Radiation teatment<br></br>Bowel disease-Crohn’s or diverticulitis<br></br>Infection
Name some complications of a vaginal fistula
Vaginal/urinary tract infections that keep returning<br></br>Stool or gas that leaks through the vagina<br></br>Irritated/swollen skin around vagina/anus<br></br>Abscesses<br></br>
What are fibroids?
Benign smooth muscle tumours <span>originating from the myometrium of the uterus.</span>
Uterine fibroids develop in response to {{c1::oestrogen}}. The incidence increases with age until {{c1::menopause}}
In which group of people are uterine fibroids most common?
More common in Afro-Caribbean women
The growth of fiborids is promoted by {{c1::oestrogen and progesterone.}} Fibroids contain more oestrogen and progesterone than {{c1::normal uterine muscle cells}}
Name some symptoms of uterine fibroids
-Asymptomatic<br></br>-Menorrhagia and dysmenorrhoea-.can cause iron deficiency anaemia<br></br>-Bloating<br></br>-Lower abdominal pain, cramps<br></br>-Urinary symptoms<br></br>-Subfertility<br></br>Rare: polycythaemia
Name some differential diagnoses for uterine fibroids
<ul><li>Endometrial polyps: Present with irregular menstrual bleeding and spotting</li><li>Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility</li></ul>
Name some complications of uterine fibroids
-Subfertility<br></br>-Iron deficiency anaemia<br></br>-Red degeneration-> haemorrhage into tumour-> commonly occurs during pregnancy
What are the types of uterine fibroids?
- Intramural<br></br>2. Subserosal<br></br>3. Submucosal<br></br>4. Pedunculated
Intramural fibroids grow {{c1::within the myometrium}}. As they grow they {{c1::distort the uterus}}
Subserosal fibroids develop {{c1::just below the outer layer}} of the uterus. They grow outwards and can become very large filling the {{c1::abdominal cavity}}
023196576665434d969a9a2ddb7f6c1b-oa-1
Types of fibroids
<img></img>
<img></img>
<img></img>
<img></img>
023196576665434d969a9a2ddb7f6c1b-oa-2
Types of fibroids
<img></img>
<img></img>
<img></img>
<img></img>
023196576665434d969a9a2ddb7f6c1b-oa-3
Types of fibroids
<img></img>
<img></img>
<img></img>
<img></img>
023196576665434d969a9a2ddb7f6c1b-oa-4
Types of fibroids
<img></img>
<img></img>
<img></img>
<img></img>
Red degeneration of fibroids refers to i{{c1::schaemia, infarction and necrosis}} of the fibroid due to disrupted blood supply. It is more likely to occur in larger fibroids during the {{c1::2nd and 3rd}} trimester of pergnancy. It may occur as the {{c1::fibroid rapidly enlarges during pregnancy,}} outrgrowing its blood supply and becoming ischamic or due to{{c1:: <span>kinking in the blood vessels</span>}}<span> as the uterus changes shape and expands during pregnancy.</span>
What is an ovarian cyst?
Fluid filled <span>sac that develops within or on the surface of an ovary.</span>
What are some differential diagnoses for ovarian cysts?
<ul><li>Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.</li><li>Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.</li><li>Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.</li></ul>
What investigations are done into a suspected ovarian cyst?
Pregnancy test to exclude ectopic<br></br>Diagnostgic laparoscopy-> especially if haemodynamically unstable<br></br>Ultrasound<br></br>Bloods: <br></br><ul><li>Ca125: tumour marker for ovarian cancer</li><li>LDH, aFP, HCG to assess for germ cfell tumour</li></ul>
What are the main possible complications of an ovarian cyst?
<ul><li>Torsion</li><li>Haemorrhage into the cyst</li><li>Rupture with bleeding into the peritoneum</li></ul>
What are the types of physiological/functional cysts?
<ol><li>Follicular cysts</li><li>Corpus luteum cysts</li></ol>
Serous cystadenoma are {{c1::benign}} tumours of the {{c1::epithelial cells}}
Mucinour cystadenomas mare also {{c1::benign tumours of the epithelial cells}} but these can {{c1::become huge,}} <span>taking up lots of space in the pelvis and abdomen.</span>
Sex cord stromal tumours are<span> rare tumours, that can be </span>{{c1::benign or malignant.}}<span> They arise from the </span>{{c1::stroma (connective tissue)}}<span> or </span>{{c2::sex cords (embryonic structures associated with the follicles).}}<span> There are several types, including </span>{{c2::Sertoli–Leydig cell tumours and granulosa cell tumours}}<span>.</span>
Name some risk factors for ovarian malignancy
<ul><li>Age</li><li>Postmenopause</li><li>Increased number of ovulations</li><li>Obesity</li><li>Hormone replacement therapy</li><li>Smoking</li><li>Breastfeeding (protective)</li><li>Family history and BRCA1 and BRCA2 genes</li></ul>
Name some protective factors for ovarian cancer
<ul><li>Anything that will reduce the number of ovulations:</li><li>Later onset of periods (menarche)</li><li>Early menopause</li><li>Any pregnancies</li><li>Use of the combined contraceptive pill</li></ul>
<div> </div>
Name some non-malignant causes of a raiserd CA125
<ul><li>Endometriosis</li><li>Fibroids</li><li>Adenomyosis</li><li>Pelvic infection</li><li>Liver disease</li><li>Pregnancy</li></ul>
In women under 40 with a complex ovarian mass what tests should be done?
Tumour markers for a possibole germ cell tumour:<br></br><ul><li><b><i>Lactate dehydrogenase</i></b> (<b><i>LDH</i></b>)</li><li><b><i>Alpha-fetoprotein</i></b> (<b><i>α-FP</i></b>)</li><li><b><i>Human chorionic gonadotropin</i></b> (<b><i>HCG</i></b>)</li></ul>
Ovarian torsion is usually due to an {{c1::ovarian mass}} larger than {{c1::5cm.}} It is more likely to occur with {{c1::benign t}}umours. Also more likely to occur during {{c1::pregnancy}}
Name some risk factors for developing ovarian torsion?
Ovarian mass<br></br>Being of reproductive age<br></br>Pregnancy<br></br>Ovarian hyperstimulation syndrome
Name some complications of an ovarian torsion
Fertility not typically affected as other ovary can compensate<br></br>If only functioning ovary removed-> infertility and menopause<br></br><br></br>If necrotic ovary not removed:<br></br><ul><li>Infection</li><li>Abscess</li><li>Sepsis</li></ul><div>If it ruptures-> peritonitis and adhesions</div>
What is lichen sclerosus?
Inflammatory dermatological condition
What is Koebner phenomenon?
When the signs and symptoms worsen with friction to the skin
Name a few things that cane make lichen sclerosus worse
Friction to the skin<br></br>Tight underwear<br></br>Sex<br></br>Urinary incontinence<br></br>Scratching the affected area
Name some differential diagnoses for lichen sclerosus
<ul><li><div>Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.</div></li><li><div>Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.</div></li><li><div>Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.</div></li></ul>
Name some complications of lichen sclerosus
<ul><li>5% risk of developing squamous cell carcinoma of the vulva</li><li>Pain and discomfort</li><li>Sexual dysfunction</li><li>Bleeding</li><li>Narrowing of vaginal/urethral openings</li></ul>
Name some risk factors for developing cervical cancer
<ul><li>HPV 16 and 18 infection or anything that increases the risk of this (early sexual activity, not suing condoms, increased number of sexual partners)</li><li>Smoking</li><li>Immunosuppression</li><li>Non engagementwith cervical screening</li><li>Using COCP for >5yrs</li></ul>
Name some differential diagnoses of cervical cancer
<ul><li>Vaginitis: itching, burning, pain, and abnormal discharge</li><li>Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding</li><li>Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss</li><li>Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse</li></ul>
What characteristics of a cervix would be worrying and prompt an urgen colposcopy?
Ulceration<br></br>Inflammation<br></br>Bleeding<br></br>Visible tumour
What does cervical screening involve?
<ul><li>Speculum exam</li><li>Collection of cells from the cervix</li><li>Cells examined for precancerous changes(dyskaryosis)</li><li>Transporting the cells: liquid based cytology</li></ul>
Name some exceptions to the usual cervical screening programme
<ul><li>Women with HIV are screened annually</li><li>Women over 65 may request a smear if they have not had one since aged 50</li><li>Women with previous CIN may require additional tests (e.g. test of cure after treatment)</li><li>Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)</li><li>Pregnant women due a routine smear should wait until 12 weeks post-partum</li></ul>
Name 3 infections that can be identified from smear testing for cervical cancer
<ul><li>Bacterial vaginosis</li><li>Candidiasis</li><li>Trichomoniasis</li></ul>
Management of smear results:<br></br><ul><li>Inadequate sample – {{c1::repeat the smear after at least three months}}</li><li>HPV negative – {{c2::continue routine screening}}</li><li>HPV positive with normal cytology – {{c3::repeat the HPV test after 12 months}}</li><li>HPV positive with abnormal cytology – {{c4::refer for colposcopy}}</li></ul>
What is a colposcopy?
Inserting a speculum and using a colposcope to magnify the cervix.<br></br>Allows epithelial lining of cervix to be examined
Tests used in a colposcopy:<br></br><div><ol><li><b><i>Acetic acid</i></b> causes abnormal cells to appear {{c1::white.}} This appearance is described as <b><i>acetowhite</i></b>. This occurs in cells with an increased {{c1::<b><i>nuclear to cytoplasmic ratio</i></b> (more <b><i>nuclear material</i></b>),}} such as {{c1::<b><i>cervical intraepithelial neoplasia</i></b> and <b><i>cervical cancer</i></b> }}cells.</li><li><b><i>Schiller’s iodine test</i></b> involves using an {{c1::<b><i>iodine solution</i></b> }}to stain the cells of the cervix. Iodine will stain {{c1::healthy cells a brown colour.}} Abnormal areas {{c1::will not stain.}}</li><li>A <b><i>punch biopsy</i></b> or <b><i>large loop excision of the transformational zone</i></b> can be performed during the colposcopy procedure to get a tissue sample.</li></ol></div>
<h3><b>Large Loop Excision of the Transformation Zone (LLETZ)</b></h3>
<div>A large loop excision of the transformation zone (<b><i>LLETZ</i></b>) procedure is also called a {{c1::<b><i>loop biopsy</i></b>.}} It can be performed with a {{c1::<b><i>local anaesthetic</i></b> d}}uring a {{c1::colposcopy procedure.}} It involves using a loop of wire with electrical current (<b><i>diathermy</i></b>) to {{c1::remove abnormal epithelial tissue on the cervix.}} The electrical current <b><i>cauterises</i></b> the tissue and stops bleeding.</div>
<div>{{c1::Bleeding and abnormal discharge}} can occur for several weeks following a LLETZ procedure. This varies between women. {{c1::Intercourse and tampon use should be avoided}} after the procedure to reduce the risk of infection. Depending on the depth of the tissue removed from the cervix, the procedure may increase the risk of {{c1::<b><i>preterm labour</i></b>.}}</div>
<div> </div>
What are the main risks associated with a cone biopsy?
<ul><li>Pain</li><li>Bleeding</li><li>Infection</li><li>Scar formation with stenosis of the cervix</li><li>Increased risk of miscarriage and premature labour</li></ul>
<h3><b>Staging of cervical cancer<br></br></b></h3>
<div>The{{c1:: <b><i>International Federation of Gynaecology and Obstetrics</i></b> (<b><i>FIGO</i></b>)}} staging system is used to stage cervical cancer:</div>
<ul><li>Stage 1: {{c2::Confined to the cervix}}</li><li>Stage 2: {{c3::Invades the uterus or upper 2/3 of the vagina}}</li><li>Stage 3: {{c4::Invades the pelvic wall or lower 1/3 of the vagina}}</li><li>Stage 4: {{c5::Invades the bladder, rectum or beyond the pelvis}}</li></ul>
<h3><b>Management of cervical cancer</b></h3>
<div><br></br></div>
<ul><li><b><i>Cervical intraepithelial neoplasia</i></b> and <b><i>early-stage 1A</i></b>: {{c1::LLETZ or cone biopsy}}</li><li><b><i>Stage 1B – 2A</i></b>: {{c2::Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy}}</li><li><b><i>Stage 2B – 4A</i></b>: {{c3::Chemotherapy and radiotherapy}}</li><li><b><i>Stage 4B</i></b>: M{{c4::anagement may involve a combination of surgery, radiotherapy, chemotherapy and palliative care}}</li></ul>
What do HPV strains 6 and 11 cause?
Genital warts
Name some risk factors for developing endometrial cancer
<ul><li>Nulliparity</li><li>Obesity</li><li>Early menarche</li><li>Late menopause</li><li>Polycystic ovary syndrome</li><li>Oestrogen-only hormone replacement therapy</li><li>Tamoxifen</li></ul>
Name some protective factors against endometrial cancer
<ul><li>multiparity</li><li>combined oral contraceptive pill</li><li>smoking (the reasons for this are unclear)</li></ul>
Name some symptoms of endometrial cancer
<ul><li><strong>Postmenopausal bleeding(usually slight and intermittent then becomes heavier)</strong></li><li>Abnormal vaginal bleeding, such as intermenstrual bleeding</li><li>Dyspareunia</li><li>Pelvic pain-uncommon apart from in later stages</li><li>Abdominal discomfort or bloating</li><li>Weight loss</li><li>Anaemia</li></ul>
Name some differentials for endometrial cancer
<ul><li>Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.</li><li>Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.</li><li>Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.</li></ul>
What is endometrial hyperplasia?
Precancerous thickening of the endometrium
What are the 2 types of endometrial hyperplasia
<ul><li>Hyperplasia without atypia</li><li>Atypical hyperplasia</li></ul>
<b><i>Type 2 diabetes</i></b><span> may increase the risk of endometrial cancer due to the increased production of</span>{{c1::<span> </span><b><i>insulin</i></b><span>. </span>}} which<span> may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer. </span>
<b><i>Tamoxifen</i></b><span> has an </span>{{c1::anti-oestrogenic effec}}<span>t on breast tissue, but an </span>{{c1::oestrogenic}} <span>effect on the endometrium. This </span>{{c1::increase}}<span> the risk of endometrial cancer.</span>
What are the NICE suspected cancer referral guidelines concerning endometrial cancer?
Urgent 2 week wait: women with postmenopausal bleeding<br></br><br></br>Transvaginal US in women >55yrs with:<br></br><ul><li>Unexplained vaginal discharge</li><li>Visible haematuria+raised platelets, anaemia or elevated glucose levels</li></ul>
<div>The {{c1::<b><i>International Federation of Gynaecology and Obstetrics</i></b> (<b><i>FIGO</i></b>)}} staging system is used to stage endometrial cancer:</div>
<ul><li>Stage 1: {{c2::Confined to the uterus}}</li><li>Stage 2: {{c3::Invades the cervix}}</li><li>Stage 3: {{c4::Invades the ovaries, fallopian tubes, vagina or lymph nodes}}</li><li>Stage 4: {{c5::Invades bladder, rectum or beyond the pelvis}}</li></ul>
What are the different types of ovarian cancers?
<ol><li>Epithelial </li><li>Germ cell</li><li>Sex cord</li></ol>
What group of people do ovarian germ cell tumours typically arise from?
Young women-> atypical for most cases of ovarian cancer
What are the tumour markers for ovarian germ cell tumours?
Alpha fetoprotein and B-HCG
What is a Krukenbery tumour?
‘Signet ring’ sub-type of tumour typically GI in origin whcih has metastasised to the ovary
Name some risk factors for developing ovarian cancer
<ul><li>Advanced age</li><li>Smoking</li><li>Increased numbr of ovulations(early menarche, late menopause)</li><li>Obesity</li><li>HRT</li><li>Genetics: BRCA1&2</li></ul>
Name some protective factors against ovarian cancer
<ul><li>Childbearong</li><li>Breastfeeding</li><li>Early menopause</li><li>Use of COCP</li></ul>
Name some differentials for developing ovarian cancer
<div><div><div><div><div><div><ul><li>Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits</li><li>Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation</li><li>Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating</li><li>Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms</li></ul></div></div></div></div></div></div>
<div><div><div><div><div><br></br></div></div></div></div></div>
What investigations are done to diagnose ovarian cancer?
<ol><li>CA125 blood test</li><li>Pelvic and abdominal US scan</li><li>CT scans for staging</li><li>AFP and B-HCG in younger women-germ cell tumours</li><li>Laparotomy for tissue biopsy</li></ol>
Name some conditions aside from ovarian cancer that can raise the CA125 level
<ul><li>Endometriosis</li><li>Menstruation</li><li>Benign ovarian cysts</li></ul>
<ul><li><div>Ovarian cancer staging:</div></li><li><div>Stage I ({{c1::limited to the ovaries):}}</div></li><li><div>Stage II {{c2::involving one or both ovaries with pelvic extension and/or implants:}}</div></li><li><div>Stage III {{c3::involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:}}</div></li><li><div>Stage IV ovarian cancer is {{c4::tumour involving one or both ovaries with distant metastasis.}}</div></li></ul>
What are the NICE suspected cancer guidelines relating to ovarian cancer?
2 week wait if:<br></br><ul><li>Ascites</li><li>Pelvic mass</li><li>Abdominal mass</li></ul><div>Further investigations includng CA125 if:</div><div><ul><li>New symptoms of IBS/change in bowel habit</li><li>Abdominal bloating</li><li>Early satiety</li><li>Pelvic pain</li><li>Urinary frequency/urgency</li><li>Weight loss</li></ul></div>
What does the risk of malignancy index relating to ovarian cancer take into account?
<div>Estimates the risk of an ovarian mass being malignant</div>
<ul><li>Menopausal status</li><li>Ultrasound findings</li><li>CA125 level</li></ul>
Name some risk factors for developing vulval cancer
<ul><li>Advancing age</li><li>HPV infeciton</li><li>Vulval intraepithelial neoplasia(VIN)</li><li>Immunosuppression</li><li>Lichen sclerosus</li></ul>
Name some differential diagnoses for vulval cancer
<div><div><div><div><div><div><ul><li>Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.</li><li>Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.</li><li>Bartholin's cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.</li></ul></div></div></div></div></div></div>
<div><div><div><div><div><br></br></div></div></div></div></div>
What investigations might be done to diagnose vulval cancer?
<ul><li>Torough exam of vulva</li><li>Biopsy</li><li>Imaging/blood tests to a\ssess extent of disease and staging</li></ul>
What are the treatment options for VIN
<ul><li><b><i>Watch and wait</i></b> with close followup</li><li><b><i>Wide local excision</i></b> (surgery) to remove the lesion</li><li><b><i>Imiquimod</i></b> cream</li><li><b><i>Laser ablation</i></b></li></ul>
<br></br>
What age group(s) are most at risk of developing a molar pregnancy?
Extreme ends of the fertility age range: <br></br><ul><li><16yrs</li><li>>45yrs</li></ul>
What is a complete molar pregnancy?
<ul><li>Formation from a single sperm and empty egg with no genetic material</li><li>Sperm replicates to provide a normal number of chromosomes-all paternal origin</li><li>No foetal tissue, only proligeration of swollen chorionic villi</li></ul>
What is a partial molar paregnancy?
<ul><li>Formed from 2 sperm and a normal egg</li><li>Both paternal and maternal genetic materials present</li><li>Variable evidence of foetal parts</li></ul>
Name some differential diagnoses for a molar pregnancy
<ul><li>Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.</li><li>Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.</li><li>Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.</li></ul>
Name 2 complications of molar pregnancies
Choriocarcinoma<br></br>Mole can metastasise-> patient may require systemic chemotherapy
What is endometriosis?
Growth of ectopic endometrial tissue outside of the uterine cavity
Name some theories thought to explain the cause of endometriosis
<ul><li>Retrograde menstruation</li><li>Coelomic metaplasia</li><li>Lymphatic/vascular dissemination of endometrial cells</li></ul>
Name some differential diagnoses for endometriosis
<ul><li>Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.</li><li>Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.</li><li>Adhesions: pelvic pain and possible bowel obstruction.</li><li>Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.</li></ul>
What investigations are used to diagnose endometriosis?
<ul><li>Transvaginal US-> Often normal but may ID an ovarian endometrioma</li><li>GS: Diagnositc laparoscopy</li></ul>
Name a complication of endometriosis
<ul><li>Infertility</li><li>Poor quality of life due to chronic pain</li></ul>
<div>The {{c1::<b><i>American Society of Reproductive Medicine</i></b> (<b><i>ASRM</i></b>)}} has a staging system for endometriosis.</div>
<ul><li>Stage 1: {{c2::Small superficial lesions}}</li><li>Stage 2: {{c3::Mild, but deeper lesions than stage 1}}</li><li>Stage 3: {{c4::Deeper lesions, with lesions on the ovaries and mild adhesions}}</li><li>Stage 4: {{c5::Deep and large lesions affecting the ovaries with extensive adhesions}}</li></ul>
What is adenomyosis?
Presence of endometrial tissue within the myometrium
In which group of people is adenomyosis most common in?
Multiparous women towards the end of their reproductive years
What conditions can adenomyosis occur with?
<ul><li>Endometriosis</li><li>Fibroids</li></ul>
What investigations are done to diagnose adenomyosis?
1st line: transvaginal US of pelvis<br></br>If unsuitable: MRI and transabdominal US<br></br>GS: Histological exam of the uterus after a hysterectomy(mostly unsuitable)
What complications relating to pregnancy can adenomyosis cause?
<ul><li>Infertility</li><li>Miscarriage</li><li>Preterm birth</li><li>Small for gestational age</li><li>Preterm rupture of membranes</li><li>Malpresentation</li><li>Need for C section</li><li>Postpartum haemorrhage</li></ul>
What is atrophic vaginitis?
Inflammation and thinning of the geniatl tissues due to a decrease in oestrogen levels
What causes atophic vaginitis?
Decline in oestrogen levels, typically post-menopause
On examination, what might you find in a patient with atrophic vaginitis?
Pale and dry vagina<br></br><ul><li>Loss of pubic hair</li><li>Thinning of vaginal mucosa</li><li>Narrowed introitus</li><li>Loss of vaginal rugae</li></ul>
Name some differentials for atrophic vaginitis
<ul><li>For postmenopausal bleeding: <strong>malignancy</strong>, endometrial hyperplasia</li><li>For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes</li><li>For narrowed introitus: female genital mutilation</li><li>For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis</li><li>For dyspareunia: malignancy, vaginismus</li></ul>
What investigations should be done in a patient presenting with likely atrophic vaginitis?
<ul><li>Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy</li><li>Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer</li><li>An infection screen if itching or discharge is present</li><li>A biopsy of any abnormal skin lesions, if needed</li></ul>
What is a miscarriage?
Loss of pregnancy <24 weeks gestation
Name some risk factors for having a miscarriage
<ul><li>Maternal age >30</li><li>Previous miscarriage</li><li>Obesity</li><li>Smoking</li><li>APS</li><li>Uterina abnormalities</li><li>Coagulopathies</li><li>Previous uterine surgeries</li><li>Chromosomal abnormalities</li></ul>
Name some symptoms of a miscarriage
<ul><li>Often found incidentally on US</li><li>Vaginal bleeding->clots/conception products</li><li>If lots of bleeding: signs of haemodynamic instability: pallor, dizziness, SOB</li><li>Suprapubic, cramping pain</li></ul>
<b>Signs a patient is having a miscarriage:</b><br></br><br></br><ul><li>Haemodynamic instability: {{c1::tachycardia, hypotension, tachypnoea}}<br></br></li><li>Abdominal exam: {{c2::distended, local areas of tenderness}}</li><li>Speculum exam: {{c3::diameter of cervical os, products of conception, bleeding}}</li><li>Bimanual exam: {{c4::uterine tenderness, adnexal masses/collections}}</li></ul>
Name some differentials for a miscarriage
<ul><li>Ectopic pregnancy</li><li>Hydatidiform mole</li><li>Cervical/uterine cancer</li></ul>
What blood might be done in a patient suspected of having a miscarriage?
b-HCG-important to also assess the possibility of an ectopic pregnancy
What are the different kinds of miscarriage?
<ul><li>Threatened</li><li>Inevitable</li><li>Missed/delayed</li><li>Incomplete</li><li>Complete</li><li>Septic</li></ul>
What is an ectopic pregnancy?
<ul><li>Embryo implants and beigns to grow outside fo the uterine cavity, usually in the fallopian tuubes</li></ul>
Name some of the causes/risk factors for having an ectopic pregnancy
<ul><li>Pelvic inflammatory disease</li><li>Endometriosis</li><li>Genital infections</li><li>Previous ectopic pregnancies</li><li>Having an IUD/coil in situ</li><li>Assissted reproduciton like IVF</li></ul>
Name some differentials for an ectopic pregnancy
<ul><li>Miscarriage</li><li>UTI</li><li>Appendicitis</li><li>Diverticulitis</li><li>PID</li><li>Ovarian accident</li></ul>
What investigations should be done in a patient with a suspected ectopic pregnancy?
<ol><li>B-HCG-POSITIVE</li><li>Pelvic US</li><li>Transvaginal US</li></ol>
<div>Can't find evidence of pregnancy on any scans</div>
<div><br></br></div>
<div><ul><li>Serum B-HCG</li></ul></div>
<b>Serum B-HCG in suspected ectopic pregnancy:<br></br></b><br></br><ul><li>Initial >1500iU: {{c1::ectopic-diagnostic laparoscopy}}</li><li>Initial <1500iU {{c2::and stable: repeat in 48 hours}}</li></ul><div><br></br></div><div><br></br></div>
Using B-HCG monitoring how can you tell if a patient is having a miscarriage or has a viable pregnancy?
<ul><li>Viable pregnancy: will double every 48 hours</li><li>Miscarriage: halves every 48 hours</li></ul>
What complications can arise from an ectopic pregnancy
<ul><li>Fallopian tube rupture-> hypovolaemic shock->organ failure-> death</li></ul>
Name some causes of oligohydramnios
<ul><li>Pre-term rupture of membranea</li><li>Non-functional kidneys</li><li>Renal agenesis(Potter's)</li><li>Obstructive uropathy</li><li>Placental insufficiency</li><li>Chromosomal abnormalities</li><li>Viral infections</li></ul>
What are the most common causes of oligohydramnios?
<ul><li>Pre-term rupture of membranes</li><li>Placental insufficiency </li></ul>
What causes symptoms in patients with oligohydramnios?
<ul><li>Decreased space around fetus</li><li>Lack of amniotic fluid for fetal growth and development</li></ul>
What investigations are typically done to diagnose oligohydramnios?
USS:<br></br><ul><li>Reduced amniotic fluid index</li><li>Reduced max pool depth(MPD) or single deepest pocket(SDP)</li></ul><div>To ID underlying cause:</div><div><ul><li>Meernal bloods</li><li>Karyotyping</li></ul><div>If membrane rup[ture suspecteD:</div></div><div><ul><li>IGFBP-1 or PAMG-1(usually in amniotic fluid)</li></ul></div>
What is important to remember if delivering a baby early via C-section due to oligohydramnios?
Give a course of steroids for fetal lung development and antibtiotics to lower risk of infection
What complications can arise from oligohydramnios and why?
<ul><li>Amniotic fluid allows fetus to move in utero</li><li>No fluid-> no exercise-> muscle contracures-> disability after birth</li></ul>
What investigations might be done in a patient with polyhydramnios?
USS-diagnostic<br></br>To look for cause:<br></br><ul><li>Maternal glucose tolerance test</li><li>Fetal anaemia</li><li>Karyotyping</li><li>Fetal anatomy for structural cause</li><li>Viral screen(TORCH)</li></ul>
<b>Viral screen: TORCH</b><br></br><ul><li>T{{c1::oxoplasmosis}}<br></br></li><li>P{{c2::arvovirus}}</li><li>R{{c3::ubella}}</li><li>C{{c4::MV}}</li><li>H{{c5::epatitis}}</li></ul>
What are the 2 stages of labour?
<ul><li>Latent phase: 0-3cm cervical dilation</li><li>Active phase: 3-10cm cervical dilation</li></ul>
Name some differentials for the first stage of labour
<ul><li>Braxton Hicks</li><li>Preterm labour</li></ul>
What investigations might be done if a woman is in the first stage of labour?
<ul><li>Regular assessment of maternal and foetal vital signs</li><li>Frequent exam to determine cervical dilation and effacement</li><li>Palpation to assess position and descent of foetus</li></ul>
Name some signs and symptoms of the second stage of labour
<ul><li>Foetal head flexion, descent and ngagement into the pelvis</li><li>Foetal internal rotation to face maternal back</li><li>Foetal head extension to deliver head</li><li>Foetal external rotation after delivery of head, positioning of shoulders in AP position</li><li>Delivery of anterior shoulder first then rest of foetus</li><li>Maternal desure to push</li></ul>
Name some signs indicative of the 3rd stage of labour
<ul><li>Gush of blood from vagina</li><li>Lengthening of umbilical cord</li><li>Ascension of uterus in abdomen</li></ul>
Name some indications for inducing labour
<ul><li>Post dates: >41 weeks gestation</li><li>Preterm prelabour rupture of membranes</li><li>Intrauterine foetal death</li><li>Abnormal CTG</li><li>Maternal conditions like pre-eclampsia, diabetes, cholestasis</li></ul>
Name some contrainidctaions for inducing labour
<ul><li>Previous classica/vertical incision during C-section</li><li>Multiple lower uterine segment C-sections</li><li>Transmissable infections </li><li>Placenta praevia</li><li>Malpresentations</li><li>Severe fetal compromise</li><li>Cord prolapse</li><li>Vasa previa</li></ul>
What investigations might be carried out prior to starting inductino of labour?
<ul><li>US: confirm gestational age, foetal position and placental location</li><li>Bloods: Check mother's health status-pre-eclampsia/diabetes</li></ul>
Name some differentials for pre-term labour
<ul><li>Braxton Hicks</li><li>UTI</li><li>Placental abruption</li><li>Uterine rupture</li></ul>
What investigations might be done in a patient presentign with pre term labour
<ul><li>Foetal fibroenctin tes(fFN)- assesss risk of pre term elivery after onset of pre-term labour</li></ul>
What age does menopause usually happen?
<ul><li>45-55</li><li>Average in UK: 52yrs</li></ul>
Name some symptoms of menopause
<ul><li>Vasomotor: hot flushes, night sweats</li><li>Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm</li><li>Psychological: depression, anxiety, brain fog</li></ul>
Name some differentials for menopause
<ul><li>Hyperthyroidism</li><li>Depression</li><li>premature ovarian insufficiency</li></ul>
What are the types of HRT
<ul><li>Oestrogens-can be oral, transdermal or topical</li><li>Progestogens-oral, transdermal, intrauterine</li></ul>
Name some benefits of HRT
<ul><li>Relief of vasomotor sx</li><li>Relief of urogential sc</li><li>Reduced risk of osteoporosis</li></ul>
Name some things HRT can increase the risk of?
<ul><li>Breast cancer</li><li>Endometrial cancer(especially if given alone)</li><li>VTE</li></ul>
Name some contraindications for prescribing HRT
<ul><li>Breast cancer</li><li>Oestrogen dependednt cancer</li><li>Vaginal bleeding of unknown cause</li><li>Pregnancy</li><li>Untreated endometrial hyperplasia</li><li>VTE</li><li>Liver disease with abnormal LFTs</li></ul>
Name some complications of menopause
<ul><li>Osteoporosis</li><li>Cardiovascular disease</li><li>Dyspareunia</li><li>Urinary incontinence</li></ul>
What does GnRH do for the menstrual cycle?
<ul><li>Released from the hypothalamus and stimulates LH and FSH release from anterior pituitary</li></ul>
What are the phases of the ovarian cycle?
<ul><li>Follicular </li><li>Ovulation</li><li>Luteal</li></ul>
What happens during the follicular phase of the ovarian cycle?
<ul><li>Follicles begin to mature and prepare to release an oocyte</li></ul>
<div>At the start: low ovarian hormoen profuction: little negative feedback at HPG axis so increase in FSH and LH</div>
<div>Only 1 follicle can reach maturity, other follicles form polar bodies</div>
<div>Oestrogen becomes high enough to initiate positive feedback, increases everything, especially LH but increased inhibin means FSH doesn't surge(inhibin selectively inhibits FSH)</div>
<div>Granulosa cells express LH receptors</div>
<div><img></img><br></br></div>
What happens during the ovulaton stage of the ovarian cycle
<ul><li>Response to LH surge: follicle ruptures and oocyte assissted to fallopiani tube by fimbria-> viable for fertilisaton for 24 hours</li><li>After ovulation, follicel remains luteinised, secreting oestrogen and progesterone</li></ul>
<div><img></img><br></br></div>
What happens in the luteal phase of the ovarian cycle?
<ul><li>In absence of fertilisation: corpus luteum regresses after 14 days, fall in hormones relieving negative feedback</li></ul>
<div><img></img><br></br></div>
What happens to the corpus luteum if fertilisation occurs?
<ul><li>HCG is produced exerting a leuteningin effect to maintain the corpus luteum</li></ul>
What are the stages of the uterine cycle?
<ul><li>Proliferative </li><li>Secretory</li><li>Menses</li></ul>
<div><br></br></div>
<div><img></img><br></br></div>
What happens in the proliferative phase of the uterine cycle?
<ul><li>Runs alongside follicular phase</li><li>Prepares reproductive tract for fertilisation and implantation</li><li>Oestrogen initiates fallopian tube formation-> endometrium thickening-> increased growth and motility o fmyometrium and productive of thin alkaline cervical mucus</li></ul>
<div><br></br></div>
<div><img></img><br></br></div>
What happens during the secretory phase of the uterine cycle?
<ul><li>Runs alongside luteal phase</li><li>Progesterone stimulates thickening of endometrium into glandular secretory form, thickening of myometrium, reduction of motility in myometrium, thick acidic cervical mucus production(prevent polyspermy)</li></ul>
<div><img></img><br></br></div>
What are the main hormones involved in:<br></br>a)proliferative phase<br></br>b)secretory phase?
a)oestrogen<br></br>b)progesterone
Name some differentials for PCOS
<ul><li>Menopause</li><li>Congenital adrenal hyperplasia</li><li>Hyperprolactinaemia</li><li>Androgen secreting tumour</li><li>Cushing's</li></ul>
What investigations might be done to diagnose PCOS?
<ul><li>Bedside: clinical exam to look for features of hyperandrogenism/insulin resistance</li><li>Bloods: LH:FSH ratio, total testosterone, fasting/oral glucose tolerance, TFT, prolactin, cortisol</li><li>Imaging: transabdominal/transvaginal USS</li></ul>
What diagnostic criteria is used for PCOS?
<ul><li>Rotterdam diagnostic criteria</li></ul>
Name some complications of PCOS
<ul><li>Infertility</li><li>Metabolic syndrome and dyslipidaemia</li><li>T2DM</li><li>CVD</li><li>Hypertension</li><li>Obstructive sleep apnoea</li></ul>
What is Asherman’s syndrome?
<ul><li>Adhesions(synechiae) form within uterus following damage to the uterus</li></ul>
Name some common causes of Asherman’s syndrome
<ul><li>Pregnancy related dilatation and curettage procedure</li><li>Post uterine surgery</li><li>Pelvic infections</li></ul>
Name some complications of Asherman’s syndrome
<ul><li>Menstruation abnormalities</li><li>Infertility</li><li>Recurrent miscarriages</li></ul>
What are congenital malformations of the female genital tract?
<ul><li>Deviations form normal anatomy resulting from embryonic maldevelopment of Mullerian or paramesonephric ducts</li></ul>
What are the most common types of congenital uterine abnormalities caused by?
<ul><li>Incomplete fusion of mullerian or paramesonephric ducts</li></ul>
Name some complications of congenital uteirne abnormalities
<ul><li>Dysmenorrhoea</li><li>Haematoemtra</li><li>Complicaitons during pregnancy and labour</li><li>Congenital renal abnormalities often co-exist</li></ul>
What are endometrial polyps?
<ul><li>Benign growths of endometrial lining of the uterus, consisting of glandular epithelium, stroma and blood vessels</li></ul>
What age groups are endometrial polyps found in?
<ul><li>Reproductive age women</li><li>Can occur post menopausal</li></ul>
Name some risk factors for polyps
<ul><li>Obesity</li><li>Htn</li><li>Tamoxifen</li><li>HRT</li></ul>
Name some differentials for a polyp
<ul><li>Fibroid</li><li>Adenomyoma</li><li>Endometrial carcinoma</li><li>Gestation trophoblastic disease</li></ul>
Name some complications fo endometrial polyps
<ul><li>Small percentage may have atypical hyperplasia/endometrial carcinoma</li><li>Anaemia due to chronic blood loss in those with heavy menstrual bleeding</li></ul>
Name the causative organisms of PID
<ul><li>Chlamydia trachomatis-most common cause</li><li>Gonnorhoea</li><li>Mycoplasma genitalium</li><li>Mycoplasma hominis</li><li>Sometiems no pathogen isolates</li></ul>
What is Fitz Hugh Curtis syndrome?
<ul><li>Adhesions form between anterior liver capsule and anterior wall/diaphragm in context of PIC</li></ul>
Name some differential diagnoses for PID
<ul><li>Appendicitis</li><li>Ectopic</li><li>Endometriosis</li><li>Ovarian cyst</li><li>UTI</li></ul>
What investigations are used to diagnose PID
<ul><li>Pregnancy test to exclude ectopic</li><li>Swabs for gonorrhoea and chlamydia or urine NAAT </li><li>Bimanual exam: cervical motion tenderness</li></ul>
<div>Bloods: FBC+WCC+CRP</div>
<div><br></br></div>
<div>Imaging: TV USS</div>
Name some complications of PID
<ul><li>Chornic pelvic pain-tubal damage from inflammation</li><li>Infertility</li><li>Ectopic pregnancy</li><li>Fitz-High Curtis syndrome</li></ul>
What condition might Fitz Hugh Curtis syndrome be confused with?
<ul><li>Cholecystitis</li></ul>
Name some risk factors for developing renal stones
<ul><li>Obesity</li><li>Dehydration</li><li>Diet rich in oxalate foods like fruit, nuts, cocoa</li><li>Previous stones</li><li>Anatomical abnormalities</li><li>FHx</li></ul>
Name some differentials for urinary tract calculi
<ul><li>Pyelonephritis</li><li>Appendicits</li><li>Diverticulitis</li><li>Ovarian torsion</li><li>Ectopic pregnancy</li><li>AAA</li></ul>
What investigaitons might be done to diagnose renal stones?
<ul><li>Urinalysis</li><li>Uirne mc+s</li><li>Observations to check for sepsis</li><li>FBC, UE, calcium and uric acid</li><li><b>GS: non contrast helical CT KUB</b></li><li><br></br></li></ul>
What is a prolactinoma?
<ul><li>Benign tumour of the pituitary gland-secretes excessive prolactin</li></ul>
What does the aerola contain and how do they change during pregnancy?
<ul><li>Contain sebaceous glands</li><li>Enlarge during pregnancy and secrete an oily substance that acts as a protective lubricant</li></ul>
What are the 3 main parts that make up the anatomical structure of the breast
<ul><li>Mammary glands</li><li>Connective tissue stroma</li><li>Pectoral fascia</li></ul>
What are the groups of lymph nodes that receive lymph from breast tissues?
<ul><li>Axillary nodes(75%)</li><li>Parasternal nodes(20%)</li><li>Posterior intercosta nodes(5%)</li></ul>
What is a fibroadenoma?
<ul><li>Benign tumour consisting of a mixture of fibrous and epithelial tissue</li></ul>
Name some differentials for fibroadenomas
<ul><li>Breast cyst</li><li>Invasive breast cancer</li><li>Intraductal papilloma</li><li>Lipoma</li></ul>
What investigations might be done in a patient presenting with a likely fibroadenoma?
<div>Triple assessment:</div>
<div><ul><li>Clinical exam</li><li>Imaging: US/Mammogram</li><li>Needle biopsy-fine needle aspiration/core biopsy</li></ul></div>
What is fibrocytic breast disease?
<ul><li>Benign condition-> presence of fibrous tissue and cysts in the breast</li><li>Considered a variation of normal breast tissue</li></ul>
Name some differentials for fibrocystic breast disease
<ul><li>Breast cancer</li><li>Cysts</li><li>Fibroadenoma</li><li>Mastitis/abscess</li></ul>
What investigations might be used to diagnose fibrocystic breast disease
<ul><li>Clinical exam</li><li>Mammogram and US</li><li>Biopsy: exclude malignancy if suspicious findings</li></ul>
What genetic mutations are implicated in breast cancer?
<ul><li>BRCA1/2</li></ul>
Name some risk factors for developing breast cancer
High hormone exposure:<br></br><ul><li>Endogenous oestrogen: early menarche, nulliparity, late menopause</li><li>Exogenous oestrogen and progestin: COCP, HRT</li></ul><div>Inherited gene mutations: BRCA1/2</div><div>Increasing age</div><div>F history/personal history of breast cancer</div><div>Alcohol/tobacco use</div>
What are the subtypes of breast cancer?
Pre-invasive:<br></br><ul><li>Ductal carcinoma in situ</li><li>Lobular carcinomaa in situ</li></ul><div>Invasive:</div><div><ul><li>Invasive ductal carcinoma</li><li>Invasive lobular carcinoma</li><li>Medullary carcinoma</li></ul><div>Others:</div></div><div><ul><li>Inflammatory</li><li>Mucinous</li><li>Tubular</li><li>HER2 positive breast cancer</li><li>Triple negative breast cancer</li></ul></div>
Name some differentials for breast cancer
<ul><li>Fibroadenoma</li><li>Cysts</li><li>Mastitis</li><li>Lipoma</li></ul>
Name 2 methods for staging breast cancer
<ul><li>TNM staging(tumour node metastasis)</li><li>Stage 1A/B/2A/B/ETC</li></ul>
What are some methods used to treat breast cancer?
<ul><li>Surgery</li><li>Radiotherapy</li><li>Hormone therapy</li><li>Biological therapy</li><li>Chemotherapy</li></ul>
What are some features that wwould favour a mastectomy instead of awide local excision?
<ul><li>Multifocal tumour rather than solitary lesion</li><li>Central tumour rather than peripheral</li><li>Large lesion in small breast rather than small lesion in large breast</li><li>DCIS >4CM rather than <4cm</li></ul>
Name a biological therapy that might be used in breast cancer treatment and when it might be used?
<ul><li>Trastuzumab(Herceptin)-used in HER2 positive tumours</li><li>Can't be used in patients with heart disorders</li></ul>
Name some examples of hormonal therapies that might be used in patients with breast cancer
<ul><li>Tamoxifen: pre/peri menopausal women</li><li>Anastrozole: aromatose inhibitors: post-menopausal women</li></ul>
Name some side effects of tamoxifen
<ul><li>Increased risk of endometrial cancer</li><li>VTE</li><li>Menopausal symptoms</li></ul>
<b>Symptoms of benign breast disease</b><br></br><ul><li>Fibroadenoma: {{c1::highly mobile, encapsulated breast masses}}<br></br></li><li>Mastitis: {{c2::breast redness, mastalgia, malaise, fever}}</li><li>Intraductal papilloma: {{c3::bloody discharge from nipple, no mass}}</li><li>Radial scar: {{c4::mammogram-stellite pattern-central scanning and glandular tissue}}</li><li>Fat necrosis: {{c5::painless breast mass, skin thickening}}</li><li>Fibrocystic breast disease: {{c6::breast lumps, pain, tenderness}}</li><li>Mammry duct ectasia: {{c7::palpable peri-areolar breast mass, nipple discharge}}</li></ul>
Name some differentials for Paget’s disease of the nipple
<ul><li>Atopic dermatitis/contact dermatitis/psoriasis</li><li>Intraductal papilloma</li><li>Mastitis/abscess</li></ul>
What is cervical effecement?
<ul><li>Also called cervical ripening</li><li>Thinning of the cervix</li><li>Before: shaped like a bottleneck and up to 4cm</li><li>Through pregnancy: cervix tightly closed and protected by mucus plug</li></ul>
<div><img></img><br></br></div>
What are the 7 mechanisms of labour?
<ul><li>Descent</li><li>Flexion</li><li>Internal rotation</li><li>Extension</li><li>Restitution</li><li>External rotation</li><li>Delivery of body</li></ul>
What happens during the ‘descent’ stage of labour?
<ul><li>Fetus descends into pelvis</li></ul>
<div><img></img><br></br></div>
What encourages the ‘descent’ stage of labour?
<ul><li>Increased abdominal muscle tone</li><li>Increased frequency and strength of contractions</li></ul>
What happens during the ‘flexion’ stage of labour?
<ul><li>Fetus descends through pelvis-> uterine contractions exert pressure down fetal spine towards occiput forcing the occiput to come into contact with pelvic floor</li><li>Fetal neck flexes allowing the circumference of the head to reduce-easier to pass through pelvis</li><li><img></img><br></br></li></ul>
What happens during the internal rotation stage of labour?
<ul><li>With each contraction, fetal head is pushed onto pelvic floor, supporting a small degree of rotation</li><li>Regular contractions eventually lead to head completing 90 degree turn</li></ul>
<div><img></img><br></br></div>
What happens during the ‘extension’ phase of labour?
<ul><li>Fetal occiput slips beneath suprapubic arch allowing the head to extend-fetal head born and usually facing maternal back</li></ul>
<div><img></img><br></br></div>
What happens during the ‘restitution/external rotation’ stage of labour?
<ul><li>fetus naturally aligns head with shoulders</li><li>Visually head may be seen to externally rotate face to right or left</li></ul>
<div><img></img><br></br></div>
What is delayed cord clamping?
<ul><li>Umbilical cord not immediately clamped and cut at point of birth but allowed >1 minute to transfuse blood to baby</li><li>Baby can receive up to 214g of blood </li></ul>
Name some benefits of delayed cord clamping
<ul><li>Allows baby time to transition to extra-uterine life</li><li>Increase in RBC, irone and stem cells</li><li>Reduced need for inotropic support</li></ul>
What are some benefits of an upright birth?
<ul><li>Increases diameter of pelvic inlet</li><li>Less risk of compressing mother's aorta</li><li>Encourages stronger and longer contractions</li><li>Gravity</li></ul>
What are the advantages of using entotox as pain relief in labour?
<ul><li>Fast actnig-20-30 seconds</li><li>Can eb used alongside analgesia</li><li>Does not require further fetal monitoring</li></ul>
What is an epidural?
<ul><li>Mix of bupivacaine and fentanyl</li><li>Epidural catheter inserted by anaesthetist and drugs administered through pump</li></ul>
<div><img></img><br></br></div>
Name some pros and cons of using an epidural
Pros:<br></br><ul><li>Total pain relief in 90% of cases</li><li>Effect will last until baby is born</li></ul><div>Cons:</div><div><ul><li>Reduced mobility</li><li>Cant take up to an hour to take effect</li><li>Will need urinary catheter</li><li>Can slow donw labour if not already established</li></ul></div>
What is an operative vaginal delivery?
<ul><li>Use of an instrument to aid delivery of the fetus</li></ul>
What are the 2 main instruments used in operative deliveries?
<ul><li>Ventouse</li><li>Forceps</li></ul>
What are ventouse deliveries associated with?
<ul><li>Lower success rate</li><li>Less maternal perineal injuries</li><li>Less pain</li><li>More cephalhaematoma</li><li>More subgaleal haematoma</li><li>More fetal retinal haemorrhage</li></ul>
What are forceps and how are they used for delivery?
<ul><li>Double bladed instruments</li><li>Inserted into pelvis, applied round sides of fetal head with blades locked together</li><li>Gentle traction applied during uterine contractions</li></ul>
<div><img></img><br></br></div>
What are forceps associated with?
<ul><li>Higher rate of 3rd/4th degree tears</li><li>Less often used to rotate</li><li>Doesn't require maternal effort</li></ul>
Name some indications for performing an assisted vaginal delivery
Maternal:<br></br><ul><li>Maternal exhaustion</li><li>Maternal medical conditions that mean active pushing should be avoided(intracranial pathologies, severe heart disease/htn)</li></ul><div><br></br></div><div>Fetal:</div><div><ul><li>Suspected fetal compromise in 2nd stage of labour0CTG monitoring/abnormal fetal blood sample</li><li>Cinical concerns like significant antepartum haemorrhage</li></ul></div>
Name some absolute contraindications to an instrumental delivery
<ul><li>Unengaged fetal head</li><li>Incompletely dilated cervix</li><li>True cephalo pelvic disproportion</li><li>Breech and face presentation</li><li>Preterm gestation(<34 weeks)</li></ul>
What are the pre-requisites for intstrumental delivery?
<ul><li>Fully dilated</li><li>Ruptured membranes</li><li>Cephalic presentation</li><li>Defined fetal position</li><li>Fetal head at least at level of ischial spines and no more than 1/5 palpable per abdomen</li><li>Empty bladder</li><li>Adequate pain relief</li><li>Adequate maternal pelvis</li></ul>
Name some fetal complications from an instrumental deliver
<ul><li>Neonatal jaundice</li><li>Scalp lacerations</li><li>Cephalohaematoma</li><li>Subgaleal haematoma</li><li>Retinal heamorrhage</li><li>Skull fractures</li></ul>
Name some maternal complications of instrumental deliveries
<ul><li>Vaginal tears: 3rd/4th degree</li><li>VTE</li><li>Incontinence</li><li>PPH</li><li>Shoulder dystocia</li><li>Infection</li></ul>
<b>Results of quadruple test indicative of higher Down’s risk</b><br></br><ul><li>AFP: {{c1::Low}}<br></br></li><li>hCG: {{c2::high}}</li><li>Inhibin A: {{c3::high}}</li><li>Unconjugated oestriol: {{c4::low}}</li></ul>
What are the 2 types of invasive prenatal diagnostic testing?
<ul><li>Chorionic villus testing(CVS)</li><li>Amniocentesis</li></ul>
What is CVS?
<ul><li>US guided smapling of placental tissue by insterting a fine needle through abdomen and into uterus</li><li>Rules out mosaicism-if positive will need amniocentesis</li></ul>
What is amniocentesis?
<ul><li>US guided insertion of fine needle through abdomen into uterus to take a sample of amniotic fluid-contains abby's cells so is a true reflection of baby's DNA</li></ul>
Name some risks of invasive prenatal testing
<ul><li>Miscarriage</li><li>Infection</li></ul>
What does the anomaly scan screen for?
<ul><li>11 physical confitions</li><li>Some associated with Down's-congenital heart disease, abdominal wall defects</li></ul>
Name some risk factors for mastitis
<ul><li>Poor breastfeeding technique</li><li>Nipple damage</li><li>Maternal stress</li><li>Previous hx of mastitis</li></ul>
Name some differentials for mastitis
<ul><li>Breast abscess</li><li>Breast cancer</li><li>Breast engorgement-> bilateral, ssociated with milk stasis and tense breasts</li></ul>
Name a complication of mastitis
<ul><li>Breast abscess</li></ul>
What is a breast abscess?
<ul><li>Accumulation of pus within an area of breast tissue, often a complication of infectious mastitis</li></ul>
What is bacterial vaginosis?
<ul><li>Bacterial imblaance of the vagina cuased by an overgrowth of anaerobic bacteria and loss of lactobacilli</li></ul>
What are the features of lactobacilli bacteria?
<ul><li>Rod-shaped</li><li>Produce hydrogen peroxide-> keeps vaginal pH >4.5 which inhibits growth of other organisms</li></ul>
Name some risk factors for bacterial vagnosis
<ul><li>Sexual activity</li><li>Receptive oral sex</li><li>Presence of an STI</li><li>Smoking</li><li>Recent antibiotic use</li><li>Ethnicity(higher in black women)</li><li>Vaginal douching/use of scented soaps/vaginal deoderants</li></ul>
Name some differentials for bacterial vaginosis
<ul><li>Vulvovaginal candidiasis</li><li>Trichomonas vaginalis infection</li><li>Chlamydia/gonorrhoea</li><li>Atrophic vaginitis</li></ul>
What investigations are done to diagnose bacterial vaginosis?
Ansel criteria: 3/4 of:<br></br><ul><li>pH>4.5</li><li>grey/milky discharge</li><li>clue cells on wet mount(vaginal epithelial cells studded with gram variable coccobacilli)</li><li>KOH whiff test</li></ul><div>Microscopy: high vaginal smear: clue cells, decreased lactobacilli and no pus cells</div>
Name some complications for bacterial vaginosis
<ul><li>Pregnancy related-> premature birth, miscarriage, chorioamnionitis risks</li></ul>
<div><br></br></div>
Name some risk factors for vulvovaginal candidiasis
<ul><li>Pregnancy</li><li>Diabetes</li><li>Antibiotic use</li><li>Corticosteroid use/immunosuppression</li></ul>
Name some signs of vulvovaginal candidiasis
<ul><li>Erythema/swelling of vulva</li><li>Discharge</li><li>Satellite lesions-red, pustular lesions with superficial white/creamy pseudomembranous plaques</li></ul>
What is chlamydia?
<ul><li>STD caused by obligate intracellular bacteria chlamydia trachomatis</li></ul>
What are the different serotypes of chlamydia and what infections do they cause?
<ul><li>A-C: Ocular infection: chlamydial conjunctivitis</li><li>D-K: classical GU infection</li><li>L1-L3: Lymphogrannuloma venereum(LGV), MSM, proctitis</li></ul>
What group of people is L1-L3 chalmydial infections found in most commonly?
<ul><li>MSM</li></ul>
Name some risk factors for chlamydia
<ul><li><25yrs</li><li>Recent change in sexual partner/infected partner</li><li>Co-infection with other STIs</li><li>Non-barrier contraception</li></ul>
What does chlamydia in rpegnancy increase the risk of?
<ul><li>Low birth weight</li><li>Miscarriage</li></ul>
What contact tracing should be done in patient with chlamydia?
<ul><li>Men with urethral sx: all partners 4 weeks prior to sx onset</li><li>asx men and women: last 6 months r most recent partner</li></ul>
Name some complicatons of chlamydia
<div><ul><li>Reactive arthritis</li><li>Infertility</li><li>Epididymitis</li><li>PID</li><li>Endometritis</li><li>Increased incidence of ectopics</li><li>Perihepatitis</li></ul></div>
<br></br>
Name some risk facotrs for gonorrhoea
<ul><li><225yrs</li><li>MSM</li><li>High density urban areas</li><li>Previous gonorrhoea infections</li><li>Multiple sexual partners</li></ul>
Name some complications of gonorrhoea
<ul><li>PID</li><li>Epididdymo-orchitis.prostatitis</li><li>Dissminated gonococcal infection</li></ul>
Name some complications of disseminated gonococcal infection
<ul><li>Septic arthriits: mc cause of septic arthritis in young people</li><li>Endocarditis</li><li>Perihepatitis</li></ul>
<div>Fitz-Hugh-Curtis syndrome</div>
What is gonorrhoea in pregnancy associated with?
<ul><li>Perinatal mortality</li><li>Spontaneous abortion</li><li>Premature labour</li><li>fetal membrane rupture</li><li>Vertical transmission-> gonococcal conjunctivitis</li></ul>
What are gential herpes?
<ul><li>Infectious disease that causes painful sores/ulceers on the genitals</li><li>HSV1/2</li></ul>
What does HSV1 cause?
<ul><li>Oral/genital herpes-coldsores</li></ul>
What does HSV2 cause?
<ul><li>Anogenital herpes</li></ul>
Name some risk factors for developing gential herpes
<ul><li>Multiple sexual partners</li><li>Oral sex with partner with cold sores</li></ul>
What are genital warts?
<ul><li>Benign epithelial/mucosal outgrowths caused by HPV</li></ul>
Name some risk factors for developing genital warts
<ul><li>Early age at 1st sex</li><li>Multiple partnes</li><li>Smoking</li><li>Immunosuppression</li><li>Diabetes-> persistence of warts</li></ul>
Name some differentials for genital warts
<ul><li>Molluscum contagiosum</li><li>Condyloma lata(secondary syphilis)</li><li>Genital herpes</li><li>Skin tags</li></ul>
What is a risk of gential warts in pregnancy?
<ul><li>Very low risk of transmission during birth-can cause respiraotry papillomatosis</li></ul>
What is HIV?
<ul><li>Single stranded RNA retrovirus that infects and replicates in CD4(T helper) cells</li></ul>
Name some risk factors for developing HIV
<ul><li>MSM</li><li>IVDU</li><li>High prevalence areas</li><li>Other STDs, breaks in skin</li></ul>
What are the different stages of HIV infection?
<ol><li>Seroconversion illness</li><li>Symptomatic HIV</li><li>AIDS defining illness</li></ol>
Name some AIDS defining illnesses/infections/malignancies
<ul><li>Pneumocystis jiroveci</li><li>Non-Hodgkin's lymphoma</li><li>TB</li></ul>
What are NRTI’s?
<ul><li>nuceloside analogue reverse transcriptase inhibitors</li><li>E.g. zidovudine, abacavir etc</li><li>General SE: peripheral neuropathy</li></ul>
Is the cervical os open or closed in a threatened miscarriage?
<ul><li>Closed</li></ul>
What are the surgical options for miscarriage management?
<ul><li><12 weeks: manual vacuum aspiration</li><li>>12 weeks: evacuation of retained products of conception(ERPC)</li></ul>
Name some causes of polyhydramnios
Idiopathic: 50-60% of cases<br></br><br></br>Excess production due to increased fetal urination:<br></br><ul><li>Maternal diabetes mellitus</li><li>Fetal renal disorders</li><li>Fetal anaemia</li><li>Twin to twin transfusion syndrome</li></ul><div>Insufficiency removal due to decreased fetal swallowing:</div><div><ul><li>Oeosphageal.duodenal atresia</li><li>Diaphragmatic disorders</li><li>Anencephaly</li><li>Chromosomal disorders</li></ul></div>
What are some risks of amnioreduction in patients with polyhydramnios?
<ul><li>Infection</li><li>Placental abruption-> sudden increase in intrauterine pressure</li></ul>
What are the risks of indomethacin for polyhydramnios?
<ul><li>Associated with premature closure of ductus arteriosus(<32 weeks only)</li></ul>
Name some complications of polyhydramnios
<ul><li>Higher incidence of preterm labour</li><li>Malpresentation-fetus has more space to move within uterus</li><li>Higher risk fo cord prolapse</li><li>postpartum haemorrhage</li></ul>
What is a prolonged pregnancy?
<ul><li>5-10% of pregnancies that persist after 42 weeks gestation</li></ul>
Name some risk factors for a prolonged pregnancy
<ul><li>Nulliparity</li><li>Maternal age >40yrs</li><li>Previous prolonged pregnancy/fhx</li><li>High BMI</li></ul>
Name some symptoms patient with a prolonged pregnancy might experience
<ul><li>Static growth/macrosomia</li><li>Oligohydramnios</li><li>Decreased fetal movements</li><li>Presence of meconium</li><li>Dry/flaky skin with reduced vernix</li></ul>
What investigations might be done in a patient with a prolonged pregnancy?
<ul><li>Datig between 11+0 and 13+6 wk gestation during 1st triemster scan</li><li>US scanning to check growth and liquor volume-> poor prognostic value in determining placental functino and predicting fetal distress </li></ul>
What are the 2 main types of placenta praevia?
<ul><li>Minor placenta praevia: placenta is low but not coverig cervical s</li><li>Major placenta praevia: placenta lies over internal cervical os</li></ul>
What are the risks associated with placenta praevia?
<ul><li>Defective attachment to uterine wall-> increased risk of haemorrhage</li><li>Bleeding can be spontaneous or from mild trauma</li><li>Placenta can be damaged as fetus moves into lower uterine segment</li></ul>
Name some risk factors for placenta praevia
<ul><li>High parity</li><li>Age >40yrs</li><li>Previous hx</li><li>Hx of endometritis</li><li>Curettage to endometrium post miscarriage</li></ul>
What investigations might be done for a patient with suspected placenta praevia?
<ul><li>TV USS-> short distance between lower edge of placenta and internal os</li><li>Further USS at 37 weeks to reassess placental position</li><li>Kleihour testl if RH negative doe anti D for feto-maternal haemorrhage</li><li>>26 weeks: CTG to assess fetal wellbeing</li></ul>
What are the 2 kinds of placental abruption
<ol><li>Revealed: bleeding tracks down and drains through cervix-> vaginal bleeding</li><li>Concealed: Bleeding stays in uterus and forms clot retroplacentally-> not visible-> can cause systemic shock</li></ol>
Name some risk factors for placental abruption
ABRUPTION<br></br><ul><li>Abruption previously</li><li>B: BP-hypertension/pre-eclampsia</li><li>R: ruptured membranes-preamture/prolonged</li><li>Uterine injury</li><li>Polyhydramnios</li><li>Twins/multiple gestation</li><li>Infection-chorioamnionitis</li><li>Older age: >35yrs</li><li>Narcotic use +smoking</li></ul>
Name some differentials for placental abruption
<ul><li>Placenta praevia</li><li>Vasa praevia</li><li>Marginal placental bleeed</li><li>Uterine rupture</li><li>Local genital causes</li></ul>
What investigations might be used in a patient with suspected placental abruption?
<ul><li>CTG</li><li>US-retroplacental haematoma-> poor negative preedictive value(shouldn't be used to exclude abruption)</li></ul>
What are the different kinds of breech presentation?
<ul><li>Complete(flexed)-cross legged</li><li>Frank(extended): legs flexed at hip and extended at knees-mc</li><li>Footling: Atl eeast one leg extended at hip so foot is presenting part</li></ul>
<div><img></img><br></br></div>
Name some risk factors for breech presentation
Uterine:<br></br><ul><li>Multiparity</li><li>Fibroids</li><li>Placenta praevia</li><li>Uterine malformations</li></ul><div>Fetal:</div><div><ul><li>Prematurity</li><li>Macrosomia</li><li>Polyhydramnios</li><li>Twins</li></ul></div>
Name some differentials for breech presentation
<ul><li>Oblique lie</li><li>Transverse lie</li><li>Unstable lie(position changes)</li></ul>
Name some complications of external cephalic version
<ul><li>Transient/persistent heart rate abnormalities</li><li>Placental abruption</li></ul>
Name some specific manouvers used during a vaginal breech birth
<ul><li>Flexing fetal knees</li><li>Lovsett's manoeuver(rotate body and deliver shoulders)</li><li>Mauriceau-Smellie-Veit(MSV) manoeuver</li></ul>
<div>If fails: forceps</div>
<div>'hands off': no tractions: fetal head would extend and get trapped</div>
Name some complications of a breech presentation
<ul><li>Cord prolapse</li><li>Fetal head entrapment</li><li>Birth asphyxia-> usually secondary from delay in delivery</li><li>Premature rupture of membranes</li><li>Intracranial haemorrhage-> rapid head compression during delivery</li><li>Developmental dysplasia of the hip</li></ul>
What are the different kinds of fetal lies
<ul><li>Longitudinal</li><li>Transverse </li><li>Oblique</li></ul>
What are the different kinds of fetal presentation?
<ul><li>Cephalic-mc and safest</li><li>Shoulder</li><li>face</li><li>brow</li><li>breech</li></ul>
What are the different kinds of fetal position?
<ul><li>Occipito-anterior: mc and ideal</li><li>Occipito posterior</li><li>Occipito transverse</li></ul>
Name some risk factors for abnormal fetal lie/malpresentation/rotation
<ul><li>Prematurity</li><li>Multiple pregnancy</li><li>Fetal abnormalities</li><li>Placenta praevia</li><li>Primiparity</li><li>Uterine abnormalities(fibroids, partial septate uterus)</li></ul>
Name some contraindications for external cephalic version
<ul><li>Recent APH</li><li>Rutpured membranes</li><li>Uterine abnormaliites</li><li>Prior C section</li></ul>
Name some moderate risk factors for pre-eclampsia
<ul><li>Nulliparity</li><li>>40yrs</li><li>High BMI</li><li>Multiple pregnancy</li></ul>
Name some high risk factors for pre-eclampsia
<ul><li>Chronic hypertension</li><li>Previous eclampsia/pre-eclampsia</li><li>Diabetes</li><li>CKD</li><li>AI diseases: SLE, APS</li></ul>
Name some differentials for pre-eclampsia
<ul><li>Essential hypertension</li><li>Pregnancy induced hypertension</li><li>Eclampsia</li></ul>
What investigations might be done in a patient with suspected pre-eclampsia?
<ul><li>BP and proteinuria measurements</li><li>FBC: low Hb, low platelets</li><li>U&Es: high urea, high creatinine, low urine output</li><li>LFTs: high ALT, high AST</li></ul>
Name some maternal complications of pre-eclampsia
<ul><li>Eclampsia</li><li>Organ failure</li><li>DIC</li><li>HELLP syndrome</li></ul>
Name some fetal complications of pre-eclampsia
<ul><li>Intrauterine growth restriction</li><li>Pre-term delivery</li><li>Placental abruption</li><li>Neonatal hypoxia</li></ul>
What is eclampsia?
<ul><li>Occurence of one or more seizure in a pre-eclamptic women in the absence of another cause</li></ul>
What investigations might be done in a patient with eclampsia?
<ul><li>Exclude other reversible causes of seizure and assess for complications: blood glucose, neuro workup</li><li>Abdo USS-> rule out placental abruption</li></ul>
Name some signs of magnesium sulfate toxicity
<ul><li>Hypo-reflexia</li><li>Respiratory distress</li></ul>
What are the risks of BP treatment for a patient with eclampsia
<ul><li>If drop in BP is too rapid-> fetal HR abnormalities-> continuous CTG monitoring</li></ul>
Name some differentials for eclampsia
<ul><li>Hypoglycaemia</li><li>Stroke</li><li>Head trauma</li><li>Pre-existing epilepsy</li><li>Meningitis</li><li>Medication induced</li></ul>
Name some differentials for t<span>richomoniasis</span>
<ul><li>Bacterial vaginosis</li><li>Candidiasis</li><li>Gonorrhoea</li><li>Chlamydia</li></ul>
Name some complications in females of t<span>richomoniasis</span>
<ul><li>Perinatal complications</li><li>HIV transmission</li><li>PID</li><li>Bacterial vaginosis</li><li>Cervical cancer risk</li><li>Infertility</li></ul>
Name some complications in males of t<span>richomoniasis</span>
<ul><li>Prostatitis</li><li>HIV transmission</li><li>Prostate cancer risk</li><li>Infertility</li></ul>
What is chancroid?
<ul><li>STI of the genital skin</li></ul>
What causes chancroid?
<ul><li>Gram negative bacillus haemophilius ducreyi</li></ul>
Name some risk factors for chancroid
<ul><li>Tropical areas</li><li>Poor living conditions</li><li>Lack of public health infrastructure</li></ul>
Name some differentials for chancroid
<ul><li>HSV</li><li>Syphilis</li><li>Lymphogranuloma venereum</li></ul>
Name some risk factors for l<span>ymphogranuloma venereum</span>
<ul><li>MSM</li><li>Tropics</li><li>Developed countries: concurrent HIV infection more common</li></ul>
Name some differentials for lymphogranuloma venereum?
<ul><li>Primary syphilis</li><li>HSV</li><li>Chancroid</li></ul>
What is balanitis?
<ul><li>Inflammation of the glans penis</li><li>Balanoposthitis: extends to underside of foreskin</li></ul>
Name some causes of balanitis
<ul><li>Candidiasis</li><li>Dermatits</li><li>Bacterial-mc Staph spp</li><li>Anaerobic</li><li>Lichen planus</li><li>Lichen sclerosus</li></ul>
What are the different stages of syphilis?
<ul><li>Primary</li><li>Secondary</li><li>Tertiary</li></ul>
Name some differentials for syphilis
Primary:<br></br><ul><li>Herpes</li><li>Lymphgranuloma venereum</li><li>Malignancy</li></ul><div>Secondary:</div><div><ul><li>HIV</li><li>Mono</li><li>Malignancy</li></ul><div>Tertiary:</div></div><div><ul><li>Dementia</li><li>Psych conditions</li><li>Chronic granulomatous lesions</li></ul></div>
Name some causes of a false positive non-treponemal test for syphilis
<ul><li>Pregnancy</li><li>SLE</li><li>APS</li><li>TB</li><li>Leprosy</li><li>Malaria</li><li>HIV</li></ul>
What conclusion could be drawn from a positive non-treponemal test and positive treponemal test for syphilis?
<ul><li>Consistent with active syphilis infection</li></ul>
What conclusion could be drawn from a positive non-treponemal test and negative treponemal test for syphilis?
<ul><li>False positive syphilis result</li></ul>
What conclusion could be drawn from a negative non-treponemal test and positive treponemal test for syphilis?
<ul><li>Successfully treated syphilis</li></ul>
What is a Jarisch-Herxheimer reaction?
<ul><li>May occur on treatment initiation for syphilis</li><li>Rash, fever, tachycardia after 1st dose NO wheeze/hypotension</li><li>Due to release of endotoxins following bacterial death</li><li>Tx: reassuring and antipyretics</li></ul>
Name some complications of syphilis
<ul><li>Neurosyphilis: general paresis, tabes dorsalis, meningitis, ocular/auditory abnormalities</li><li>CVR: aortic aneurysm, regurg, angina, heart failure</li><li>Gummatous syphilis: granulomatous lesions affecting skin and bone</li><li>HIV transmission facilitation</li></ul>
Name some complications of syphilis in pregnancy
<ul><li>Hydrops</li><li>Preterm labour</li><li>Low birth weight</li><li>Fetal loss</li><li>Congeital syphilis of the newborn</li></ul>
What is intraductal papilloma?
<ul><li>Benign tumour: local areas of epithelial proliferation in large mammary ducts</li><li>Hyperplastic lesions rather than malignant</li></ul>
What is a breast cyst?
<ul><li>Benign fluid-filled sacs inside the breast</li></ul>
What groups of people are more likely to get breast cysts?
<ul><li>Women before menopause: <50yrs</li><li>Post menopausal women on HRT</li></ul>
What is HELLP syndrome?
<ul><li>Complication of pregnancy characterised by hemolysis(H), elevated liver enzymes(EL) and low platelets(LP)</li></ul>
What can HELLP syndrome follow on from?
<ul><li>Severe pre-eclampsia: 10-20% of patients go on to get HELLP</li><li>Considered separate disorder</li></ul>
Name some differentials for HELLP syndrome
<ul><li>Acute fatty liver of pregnancy</li><li>ITP</li><li>TTP</li></ul>
Name somme investigations for HELLP syndrome
<ul><li>FBC: low platelets, hemolysis</li><li>LFTs: elevated liver enzymes</li><li>Coags: assess for DIC</li><li>US: liver abnormlities and placental abruption</li></ul>
Name some maternal complications of HELLP syndrome
<ul><li>Organ failure</li><li>Placental abruption</li><li>DIC</li></ul>
Name some fetal complications of HELLP syndrome
<ul><li>Intrauterine growth restriction</li><li>Preterm delivery</li><li>Neonatal hypoxia</li></ul>
What is cord prolapse?
<ul><li>Umbilical cord descends through the cervix into the vagina before the presenting part of the feotus</li></ul>
Name some risk factors associated with cord prolapse
<ul><li>Abnormal lie: breech, transverse</li><li>Multiple pregnancy</li><li>Polyhydramnios</li><li>High fetal head at deliveery</li><li>Multiparity</li><li>Low birth weight</li><li>Prematurity</li><li>Premature rupture of membranes</li></ul>
Name some differentials for cord prolapse
<ul><li>Cord presentation</li><li>Funic presentation</li><li>Vaginal bleeding or unkown origin</li></ul>
Name some risk factors for vasa praevia
<ul><li>Multiparity</li><li>Previous C sectionn</li><li>IVF</li><li>Velamentous cord insertion-BIG one</li></ul>
Name some differentials for vasa praevia
<ul><li>Placenta praevia-no change in fetal hr unless maternal haemorrhage</li><li>Placental abruption</li><li>Premature rupture of membranes</li></ul>
Name some complications of vasa praevia
<ul><li>Fetal exsanguination: rupture or unprotected vessels</li><li>Hypoxic ischaemic encephalopathy</li><li>Preterm labour</li><li>Intrauterine growth restriction-> compromised placental perfusion</li></ul>
Name some risk factors for peruperal psychosis
<ul><li>Hx of schizophrenia</li><li>Hx of bipolar affective disorder</li><li>FHx/hx of postpartum psychosis</li></ul>
Name a differential for peurperal psychosis
<ul><li>Postpartum depression</li><li>Baby blues</li></ul>
Name 2 antipsychotics that are safe for use in breastfeeding
<ul><li>olanzapine</li><li>quetiapine</li></ul>
Name some risk factors for postpartum depression
<ul><li>Low socioeconomic status</li><li>History of mental health disorders</li><li>Lack of social support</li></ul>
Name some differentials for postpartum depression
<ul><li>Baby blues</li><li>Postpartum psychosis</li><li>Adjustment disorders</li><li>GAD</li></ul>
Name some fetal complications of PPROM
<ul><li>Prematurity</li><li>Infection</li><li>Pulmonary hyoplasia</li></ul>
Name a maternal complication of PPROM
<ul><li>Chorioamnionitis</li></ul>
Name some risk factors for primary postpartum haemorrhage
<ul><li>Previous PPH</li><li>Prolonged labour</li><li>Pre-eclampsia</li><li>Increase maternal age</li><li>Polyhydramnios</li><li>Emergency C-section</li><li>Plaacenta praevia/accreta</li><li>BMI>35</li><li>Instrumental delivery and episiotomy</li></ul>
What investigations might be done in a patient with postpartum haemorrhage
<ul><li>Bloods for group/save and crossmatch</li><li>Consider FFP if clotting abnormalities</li><li>Secondary: US looking for retained products of conception</li><li>Endocervical/high vaginal swabs-infection</li></ul>
What health professionals are needed for a termination of pregnancy?
<ul><li>2 registered medical practitioners mmust sign legal document(only one needed in emergency)</li><li>Must be performed by a registered medical practitioner and done in an NHS hospital or licensed premise</li></ul>
What advice is there regarding anti D and termination of pregnancy?
<ul><li>Anti-D prophylaxis should be given to women who are rhesus D negative and having an abortion after 10 weeks gestation</li></ul>
Name some side effects/complications of medical termination of pregnancy
<ul><li>Severe nausea</li><li>Cramps</li><li>Diarrhoea</li><li>Vaginal bleeeding</li><li>Incomplete termination of pregnancy-> must be maanaged surgically</li></ul>
Name some side effects/complications of surgical termination of pregnancy
<ul><li>Retained products of conception</li><li>Haemorrhage</li><li>Infection</li><li>Perforation</li></ul>
Name some risks of trichomoniasis vaginalis in pregnancy
<ul><li>Premature births</li><li>Low birth weight</li><li>Maternal postpartum sepsis</li></ul>
What is a uterine rupture?
<ul><li>Full-thickness disruption of the uterine muscle and overlying serosa</li><li>Can extend to affect bladder and broad ligament</li></ul>
<div><br></br></div>
<div><img></img><br></br></div>
What are the 2 main types of uterine rupture?
<ul><li>Incomplete: peritoneum overlying uterus is intact-uterine contents remain inside</li><li>Compleete: peritoneum is torn and uterine contents can escape into peritoneal cavity</li></ul>
Name some risk factors for uterine rupture
<ul><li>Previous C-section(especially classical/vertical incision)</li><li>Previous uterine surgery</li><li>Induction(esp prostaglandins or augmentation of labour)</li><li>Obstruction of labour</li><li>Multiple pregnancy</li><li>Multiparity</li></ul>
Name some differentials for a uterine rupture
<ul><li>Placental abruption</li><li>Placenta praevia</li><li>Vasa praevia</li></ul>
What investigations might be done for a patient with a suspected uterine rupture
<ul><li>USS: abnormal fetal lie/presentation, haemoperitoneum and absent uterine wall</li><li>CTG: ;changes in fetal heart rate patern and prolonged fetal bradycardia: early indicators for uterine rupture</li></ul>
Name some causes of folic acid deficiency
<ul><li>Phenytoin</li><li>Methotrexate</li><li>Pregnancy</li><li>Alcohol excess</li></ul>
Name some connsequences of folic acid deficiency
<ul><li>Macrocytic, megaloblastic anaemia</li><li>Neural tube defects</li></ul>
What advice should be given around pregnancy and folic acid?
<ul><li>All women should take 400mcg folic acid until 12th week of pregnancy</li><li>Women at higher risk of children with neural tube defects should take 5mg folic acid from before conception to 12th week</li></ul>
Name some risk factors for developing gestational diabetea
<ul><li>BMI>30kg/m2</li><li>Previous macrosomic baby weighing >=4.5kg</li><li>Previous gestational diabetes</li><li>1st degree relatives with diabetes</li><li>Ethnic backgrounds with high prevalence of diabetes(middle easterm south asian, afro-caribbean)</li><li>Hx of stilllbirth/perinatal death</li></ul>
Name some fetal complications of gestational diabetes
<ul><li>Macrosomia(birtthweight >4kg)-> shoulder dystocia, birth injuries and C section</li><li>Sacral agenesis </li><li>Pre-term delivery and neonatal respiratory distress syndrome</li><li>Neonatal hypoglycaemia</li><li>Increased risk of T2DM later in life</li></ul>
Name some maternal complications of gestational diabetes
<ul><li>Increased risk of hypertension and pre-eclampsia</li><li>Increased risk of T2DM and gestational diabetes in subsequent pregnancies</li></ul>
What is hypertension defined as in pregnancy?
<ul><li>Systolic >140mmHg or diastolic >90mmHg OR</li><li>Increase above booking readings of >30 systolic or >15 diastolic</li></ul>
What are women with pregnancy induced hypertension more at risk of later in life?
<ul><li>Future pre-eclampsia</li><li>Future hypertension</li></ul>
Name some risk factors for Group B strep infection
<ul><li>Prematurity</li><li>Prolonged rupture of membranes</li><li>Previous sibling GBS infection</li><li>Maternal pyrexia (e.g. secondary to chorioamnionitis)</li></ul>
Name some clinical features of Group B strep infection in the newborn
<ul><li>Sepsis</li><li>Pneumonia</li><li>Meningitis</li></ul>
Name some maternal risks of obesity in pregnancy
<ul><li>Miscarriage</li><li>VTE</li><li>Gestational diabetes</li><li>Pre-eclampsia</li><li>Postpartum haemorrhage</li><li>Wound infections</li><li>Higher C section rate</li></ul>
Name some fetal risks of maternal obesity in pregnancy
<ul><li>Congenital abnormality</li><li>Prematurity</li><li>Macrosomia</li><li>Stillbirth</li><li>Increased risk of developing obesity and metabolic disorders in childhood</li><li>Neonatal death</li></ul>
What is cephalopelvic disproportion?
<ul><li>Mismatch between size of fetal head and maternal pelvis causing difficulty in the safe passage of the fetus through the birth canal</li></ul>
Name some causes of absolute cephalopelvic disproportion
Maternal:<br></br><ul><li>Contracted pelvis</li><li>Spondylolisthesis</li></ul><div>Fetal:</div><div><ul><li>Hydrocephalus</li><li>Macrosomia</li></ul></div>
Name some causative factors for prolonged labour
<ul><li>Cephalopelvic disproportion</li><li>Insufficient uterine contractions</li><li>Fetal malpresentation</li><li>Macrosomia</li><li>Anomalies in birth canal</li></ul>
Name some complications of prolonged labour
<ul><li>Maternal exhaustion</li><li>Post partum haemorrhage</li><li>Post partum infection</li><li>Fetal distress: hypoxia or acidosis</li></ul>
Name some differentials for obstetric cholestasis
<ul><li>Prurigo of pregnancy</li><li>Pruritus gravidarum</li><li>Other hepatobiliary dirsorders</li></ul>
What investigations might be done for obstetric cholestasis
<ul><li>LFT's-. raissed bilirubin</li><li>Bile acid measurements</li><li>Fetal monitoring may be required due ot risk of spontaneous intrauterine death</li></ul>
What is chorioamnionitis?
<ul><li>Bacterial infection that affects the amniotic sac and amniotic fluid within the uterus</li><li>Life threatening emergency to both mother and fetus</li></ul>
What is a major risk factor for chorioamnionitis?
<ul><li>Preterm premature rupture of membranes: expose normally sterile environment of uterus to pathogens</li></ul>
Name some signs and symptoms of chorioamnionitis
<ul><li>Fever</li><li>Abdo pain</li><li>Offensive vaginal discharge</li><li>Evidence of preterm rupture of memebranes</li><li>Maternal and fetal tachycardia</li><li>Pyrexia</li><li>Uterine tenderness</li></ul>
Name some differentials for chorioamnionitis
<ul><li>UTI</li><li>Appendicitis</li><li>Placental abruption</li></ul>
What is female genital multilation?
<ul><li>Harful practice of injuring or cutting the female genitalia for non-medical reasons</li></ul>
Name some risk factors for shoulder dystocia
<ul><li>Maternal gestational diabetes</li><li>Macrosomia</li><li>Birthweight >4kg</li><li>Advanced maternal age</li><li>Maternal short stature/small pelvis</li><li>Maternal obesity</li><li>Post-dates pregnancy/prolonged labour</li></ul>
Name some internal rotational manoeuvres used in shoulder dystocia management
<ul><li>Woods' screw: anterior shoulder pushed towards fetal chest and posterior shoulder pushed towards fetal back</li><li>Rubin 2: rotate anerior shoulder towards fetal chest</li></ul>
What is celidotomy?
<ul><li>Division of fetal clavicle</li></ul>
Name some maternal complications of shoulder dystocia
<ul><li>PPH</li><li>Perineal tears</li><li>Genital tract trauma</li></ul>
Name some fetal complications of shoulder dystocia
<ul><li>brachial plexus injury</li><li>Neonatal death</li><li>Hypoxic brain damage</li><li>Humeral/clavicle fractures</li></ul>
Name some risk factors for anaemia in pregnancy
<ul><li>Haemoglopinathies: thalassaemia/sickle cell disease</li><li>Increasing maternal age</li><li>Low socioeconomic staus</li><li>Poor diet</li><li>Anaemia during previous pregnancy</li></ul>
Name some differentials for congenital rubella syndrome
<ul><li>Toxoplasmosis</li><li>CMV</li><li>HSV</li><li>Syphillis</li><li>VZV</li></ul>
Name some risk factors for perineal tears
<ul><li>Primigravida</li><li>Large babies</li><li>Precipitant labour</li><li>Shoulder dystocia</li><li>Forceps delivery</li></ul>
What is an amniotic fluid embolism?
<ul><li>Life threatening condition that occurs when amniotic fluid or other debris enters the maternal circulation</li></ul>
Name some differentials for an amniotic fluid embolism
<ul><li>Septic shock</li><li>Anaphylactic shock</li><li>PE</li><li>Hypovolaemia shock</li></ul>
What is hyperemesis gravidarum?
<ul><li>Severe nausea and vomiting commencing before the 20th week gestation</li><li>Different to 'morning sickness' -more severe</li></ul>
What is hyperemesis gravidarum thought to be related to?
<ul><li>Raised B hCG levels</li></ul>
Name some risk factors for hyperemesis gravidarum
<ul><li>Increased levels of B-hCG-multiple pregnancies, trophoblastic disease</li><li>Nulliparity</li><li>Obesity</li><li>Personal/family hx of hyperemesis gravidarum</li></ul>
Name a protective factor for hyperemesis gravidarum
<ul><li>Smoking</li></ul>
What criteria should be met for a diagnosis of hyperemesis gravidarum?
<ol><li>5% pre-pregnancy weight loss</li><li>Dehydration</li><li>Electrolyte imbalance</li></ol>
Name some differentials for<b> </b>hyperemesis gravidarum
<ul><li>Infections: gastroenteritis, UTI, hepatitis, meningitis</li><li>GI: appendicitis, cholecystitis, bowel obstruction</li><li>Metabolic: DKA, thyrotoxicosis</li><li>Drug toxicity</li><li>Molar rpegnancy</li></ul>
What is a risk of odansetron use in pregnancy?
<ul><li>In first trimester: increased risk of cleft lip/palate</li></ul>
Name some complications of hyperemesis gravidarum
<ul><li>AKI</li><li>Wernicke's encephalopathy</li><li>Oesophagitis</li><li>Mallory-Weiss tear</li><li>VTE</li></ul>
What is acute fatty liver of pregnancy?
<ul><li>Severe, rare, liver disease related to pregnancy which can result in hepatic failure and results in immediate medical and obstetric intervention</li></ul>
Name some risk factors for acute fatty liver of pregnancy
<ul><li>Fetal homozygous mutation for long chain 3 hydroxyl CoA dehydrogenase</li><li>Multiple pregnancies</li><li>Male fetuses</li></ul>
Name some signs and symptoms of acute fatty liver of pregnancy
<ul><li>N+V</li><li>Headache</li><li>Anorexia</li><li>Abdo pain</li><li>Can rapidly progress to liver failure: HE, jaundice, hypoglycaemia and coagulopathy</li></ul>
What criteria can be used to diagnose acute fatty liver of pregnancy
<ul><li>Swansea criteria</li></ul>
What are the best predictors for the need for liver transplantation or risk of maternal death in acute fatty liver of pregnancy
<ul><li>Elevated lactate levels+hepatic encephalopathy</li></ul>
What are the 3 stages of postpartum thyroiditis?
<ol><li>Thyrotoxicosis</li><li>Hypothyroidism</li><li>Normal thryoid function(high recurrence rate in future pregnancies)</li></ol>
What antibodies are found in postpartum thyroidits?
<ul><li>Thyroid peroxidase antibodies in 90%</li></ul>
Name some risk factors for VTE that might suggest the need for postnatal thromboprophylaxis
>=4:<br></br><ul><li>Previous VTE</li><li>Thrombophilia</li><li>Medical comorbidities(cancer, heart failure, systemic inflammatory conditions)</li><li>Age >35yrs</li><li>Parity >3</li><li>BMI>30</li><li>Smoking</li><li>Multiple pregnancy</li><li>Pre-eclampsia</li><li>C-section</li><li>Prolonged labour</li><li>Obstructed delivery</li><li>Preterm birth</li><li>Stillbirth</li><li>Postpartum haemorrhage >1000mL</li><li>Other surgical prcedure carried out</li><li>Immobility</li><li>Systemic infection</li></ul>
Name some causes of obstructed labour
<ul><li>Head: large fetal head/cephalopelvic disproportion, hydrocephalus</li><li>Presentation: brow, face, shoulder, persistent malposition</li><li>Twin pregnancy: locked/conjoined twins</li><li>Bony pelvis: contracted(malposition), deformed(trauma, polio)</li><li>Soft tissue: tumour in pelvis, viral infection from uterus/abdomen, scars(FGM)</li></ul>
Name some complications from an obstructed labour
<ul><li>Fistula-mc</li><li>PPH</li><li>Sepsis</li><li>Paralytic ileus</li><li>noenatal sepsis</li><li>Asphyxia of the baby</li><li>Facila injury of the baby</li></ul>
What is intrauterine growth restriction?
<ul><li>Fetus is unable to reach its genetically determined potential size</li></ul>
Name some maternal causes of intrauterine growth restriction
<ul><li>Maternal BMI and nutritional status</li><li>Co-morbidities: diabetes, anaemia, htn, infeciton, sickle cell, CVR/renal disease, coelia</li><li>Cigarette smoking, alchol and substance abuse</li><li>Structural uterine malformations</li></ul>
Name dome fetal causes of intrauterine growth restriction
<ul><li>Chromosomal defects</li><li>Multiple pregnancy</li><li>Vertically transmitted infection(CMV, rubella, toxoplasmosis)</li></ul>
Name some placental causes of intrauterine growth restriction
<ul><li>Utero-placental insufficiency</li><li>Pre-eclampsia</li></ul>
Name some differentials for intrauterine growth restriction
<ul><li>Normal physiological variation</li><li>Constitutional smallness-> small for gestational age but healthy</li><li>Chromosomal abnormalities</li></ul>
What investigations might be done for intrauterine growth restriction?
<ul><li>USS: fetal biometry, amniotic fluid volume, placental appearance</li><li>Doppler studies: blood flow in umbilical artery, middle cerebral and ductus venosus</li><li>Biophysical profile to assess fetal wellbeing</li></ul>
What are the risks to the baby if exposed to VZV in pregnancy?
<ul><li>Fetal varicella syndrome</li><li>Shingles in infancy</li><li>Severe neonatal varicella</li></ul>
Name some risk factors for placental insufficiency
<ul><li>Maternal hypertensive disorders</li><li>Smoking, alcohol consumption and drug use</li><li>Primiparity</li><li>Advanced maternal age</li><li>Use of antiepileptics/antineoplastics</li></ul>
What factor would make a pregnant woman immediately high risk for VTE?
<ul><li>Prevous VTE history</li></ul>
What are monozygotic twins?
<ul><li>Identical-fertilisation of one egg and one sperm</li></ul>
What are dizygotic twins? Describe the features
<ul><li>Non-identical</li><li>Fertilisation of 2 different eggs with 2 different sperms</li><li>All will be dichorionic and diamnotic(2 outer separate sacs and inner sacs) and separate placentas</li></ul>
Name some complications associated with monoamniotic monozygotic twins
<ul><li>Increased spontaenous miscarriage</li><li>Increased malformations, IUGR, prematurity</li><li>Twin to twin transfusion syndrome</li></ul>
Name some predisposing factors for dizygotic twins
<ul><li>Previous twins</li><li>Fhx</li><li>Increasing maternal age</li><li>Multigravida</li><li>Induced ovulation and IVF</li><li>Race(Afro-Caribbean)</li></ul>
Name some antenatal complications of monozygotic twins
<ul><li>Polyhydramnnios</li><li>Pregnancy induced hypertension</li><li>Anaemia</li><li>Antepartum haemorrhage</li></ul>
Name some fetal omplications of monozygotic twins
<ul><li>Perinatal mortality (twins x5, triplets x 10)</li><li>Prematurity</li><li>Light for date babies</li><li>Malformation(x3)</li></ul>
Name some labour complications of monozygotic twins
<ul><li>Increased PPH risk(x2)</li><li>Malpresentation</li><li>Cord prolapse, entanglement</li></ul>
Name some differentials for twin-to-twin transfusion syndrome
<ul><li>Anaemia</li><li>Cardiac failure</li><li>Hydrops fetalis</li></ul>
What is asymptomatic bacteriuria
<ul><li>Positive urine culture without UTI sx</li></ul>
What is a puerperal infection?
<ul><li>Occurs when bacteria infect the uterus and surrounding areas after birth</li></ul>
What are the types of puerperal infections?
<ul><li>Endometritis-uterine lining</li><li>Myometritis: uterine muscle</li><li>Parametritis(aka pelvic cellulitis): supportive tissue around uterus</li></ul>
Name some complications of puerperal infection
<ul><li>Sepsis-> organ failure and shock</li><li>Increased risk of infertility/ectopic pregnancy</li></ul>
What is constitutional delay?
<ul><li>Delay in puberty and growth with no medical cause-do reach normal height</li><li>Check fhx for delay in puberty</li></ul>
Name some causes of primary amenorrhoea
<ul><li>Primary hypergonadotropism: Turners</li><li>Primary hypogonadotropism: Kallmann's<br></br></li><li>Androgen insensitivity syndrome</li><li>Imperforated hymen</li></ul>
What investigations might be done to investigate primary amenorrrhoea
<ul><li>Urine BHcg</li><li>HbA1c</li><li>Blood hormones: oestrogen, progesterone, testosterone, FSH ad LH</li><li>Prolactin, thyroid function, IGF1, estradiol</li></ul>
Name some causes of secondary amenorrhoea
<ul><li>Sheehan's</li><li>Asherman's</li><li>Breastfeeding</li><li>Contraceptives</li><li>Stress/exercise induced</li><li>PCOS</li><li>Ovvarian failure</li></ul>
What is Ashermann’s syndrome?
<ul><li>Intrauterine adhesions formed typically as a result of surgery/infeciton and trauma to uterus</li></ul>
What investigations might be done for secondary amenorrhoea?
<ul><li>Pregnancy test</li><li>Bloods including hormones</li><li>USS/MRI</li><li>Endometrial biospy</li></ul>
Name some causes of menorrhagia
<ul><li>Idiopathic</li><li>Fibroids</li><li>Adenomyosis</li><li>Polyps</li><li>Endometriosis</li><li>IUD coontraception</li><li>Bleedig disorders</li></ul>
What is infertility?
<ul><li>Diminished ability of a coupe to conceive a child</li><li>Can be from a definable cause: ovulatory, tubal or sperm problems or</li><li>Unexplained failure to conceive over a two year period despite regule(3-4 times/week) unprotected sexual intercourse</li></ul>
Name some factors affecting natural fertility
<ul><li>Increasing age</li><li>Obesity</li><li>Smoking</li><li>Tight fitting underwear</li><li>Excessive alchohol consumption</li><li>Anabolic steroid use</li><li>Illicit drug use</li></ul>
Name some genetic causes of infertility
<ul><li>Turner's(XO)</li><li>Kleinfelter's(XXY)</li></ul>
Name some cervical abnormalities that can cause infertility
Cervical damage after biopsy/LLETZ procedure
Name some testicular disorders that can result in infertility
<ul><li>Cryptochordism</li><li>Varcicele</li><li>Testicular cancer</li><li>Congenital testicular defects</li></ul>
Name some ejaculatory disorders that can cause infertility
<ul><li>Obstruction of ejaculatory system</li><li>Retrograde ejaculation</li></ul>
What does anti-mullerian hormone show?
<ul><li>Measure of ovarian reserve</li></ul>
In what condition might you find a ‘woody’ uterus?
<ul><li>Placental abruption</li></ul>
