Sexual Health Flashcards
1
Q
What organs of the female reproductive system lie in the pelvic cavity?
A
Ovaries
Uterine tubes
Uterus
Superior part of the vagina
2
Q
What organs of the female reproductive system lie in the perineum?
A
Inferior part of the vagina Perineal muscles Bartholin's glands Clitoris Labia
3
Q
What is the most inferior part of the peritoneal cavity? What implications does this have?
A
Pouch of Douglas:
- Excess fluid tends to collect here
- Can be drained via a needle through the posterior fornix of the vagina
4
Q
What is the broad ligament?
A
Double layer of peritoneum
5
Q
Where does the broad ligament extend between?
A
Uterus and pelvis (lateral walls and floor)
6
Q
What is the function of the broad ligament?
A
Keeps uterus in midline
7
Q
What is contained within the broad ligament?
A
Uterine tubes
Proximal part of the round ligament
8
Q
What is the round ligament?
A
An embryological remnant
9
Q
Where does the round ligament attach?
A
Lateral aspects of the uterus
10
Q
Through what does the round ligament pass and attach to?
A
Deep inguinal ring to attach to superficial perineal tissue
11
Q
What are the 3 layers of support for the uterus?
A
Strong ligaments (eg. Uterosacral) Endopelvic fascia Muscles of pelvis floow
12
Q
What can weakness in the 3 layers of uterine support result in?
A
Prolapse
13
Q
What is the most common position of the uterus?
A
Anterverted:
- Cervix tipped anteriorly relative to vaginal axis
AND
Anteflexed:
- Uterus tipped anteriorly relative to cervical axis
- Mass of uterus lies over bladder
14
Q
What is a normal variation in the uterine position?
A
Retroverted:
- Uterus tipped posteriorly relative to vaginal axis
AND
Retroflexed:
- Uterus tipped posteriorly relative to cervical axis
15
Q
Why is a speculum needed for cervical examination?
A
Walls of vagina usually collapsed
16
Q
What does radiopaque dye spilling out into the peritoneal cavity on a hysterosalpinogram indicate?
A
Patency of uterine tubes
17
Q
Where do ovaries develop?
A
On posterior abdominal wall
18
Q
The cervix holds apart the walls of the vagina at the superior part, what does this form?
A
A space around the cervix, known as a fornix
19
Q
What are the four parts of the fornix?
A
Anterior
Posterior
2 lateral
20
Q
How can the position of the uterus be palpated?
A
Bimanually
21
Q
How can adnexae be palpated?
A
Place examining fingers into lateral fornix
Press deeply with other hand into ipsilateral iliac fossa
Repeat on oppsite
22
Q
What are the adnexae?
A
Uterine tubes
Ovaries
23
Q
What can adnexae examination detect?
A
Large masses
Tenderness
24
Q
What forms the urogenital triangle?
A
Pubic symphysis (anteriorly) Ischial spines (laterally): - A line between them completes the triangle
25
What forms the anal triangle
Coccyx (posteriorly)
Ischial spines (laterally):
- A line between them completes the triangle
26
What is the perineum?
Shallow space between pelvic diaphragm and skin
27
What type of muscle is the levator ani?
Skeletal
28
What forms most of the pelvic diaphragm?
Levator ani
29
What is the function of the levator ani?
Supports pelvic organs:
- Tonic contraction
- Contracts more when intra-abdo. pressure rises
30
What nerve supplies the levator ani?
Nerve to levator ani:
| - S3, S4 and S5 sacral plexus
31
What nerve are the superficial and deep perineal muscles supplied by?
Pudendal nerve (S2, S3 and S4)
32
What is the perineal body?
Bundle of collagenous and elastic tissue into which the perineal muscles attach
33
What is the perineal body important to?
Pelvic floor strength
34
What can damage the perineal body?
Labour
35
Where is the perineal body located?
Just deep to skin
36
What are the Bartholin's glands?
Glands which secrete mucous to lubricate the vagina
37
Where are Bartholin's glands located?
Slightly posterolateral to the left and right of the vaginal opening
38
What is the other name for Bartholin's glands?
Greater vestibular glands
39
Where does the bed of the breast extend from?
Ribs 2-6
| Lateral border of sternum to mid-axillary line
40
What does the female breast line on?
Deep fascia covering:
- Pec. major
- Serratus anterior
41
What is the pace between the fascia and the breast?
Retromammory space
42
How is the breast attached to the skin?
Suspensory ligaments
43
How can we assess if a breast lump is fixed to any underlying tissue?
Ask patient to put hands on hips (contracts pectoralis major)
Assess all four quadrants as well as:
- Axilla
- Supraclavicular area
44
Where does most of the lymph from the female breast drain to?
Ipsilateral axillary nodes (>75%)
| Then to supraclavicular nodes
45
Where can lymph from the inner quadrants drain to?
Ipsilateral or contralteral nodes
46
Where else can lymph from the lower quadrants drain to?
Abdominal nodes
47
Lymph from the upper limbs also drains to axillary nodes; what clinical implications does this have?
If nodes removed (eg. in breast cancer treatmet) it can result in lymphedema
48
Where is level 1 of axillary clearance?
Inferior and lateral to pectoralis minor
49
Where is level 2 of axillary clearance?
Deep to pectoralis minor
50
Where is level 3 of axillary clearance?
Superior and medial to pectoralis minor
51
What is the blood supply to the breast?
```
Internal thoracic (internal mammary) artery:
- Branch of the subclavian artery
```
52
What is the venous drainage of the breast?
Internal thoracic
53
How long is the male urethra?
~20cm
54
Which urethral sphincter is under voluntary control?
External
55
What is the most anterior organ in the pelvis?
Bladder
56
Where does the prostate lie in relation to the bladder?
Inferiorly
57
Where does the rectum lie in relation to the bladder?
Posteriorly
58
What forms the trigone of the bladder?
2 ureteric orifices
| Internal urethral orifice
59
What forms the majority of the bladder wall?
Detrusor muscle
60
How does the detrusor muscle prevent reflux of urine into the ureters?
Fibres encircle ureteric orifices:
| - Tighten when bladder contracts
61
The detrusor muscle also forms the internal urethral sphincter in men. What is its purpose?
Prevents retrograde ejaculation
62
As the testes travel through the spermatic cord, what 3 layers of coverings do they pick up from the inguinal canal?
1. Internal spermatic fascia:
- Continuous with transversalis fascia
2. Cremasteric muscle (and fascia)
- Formed from internal oblique (and fascia)
3. External spermatic fascia:
- Extension of aponeurosis over external oblique
63
What are the contents of the spermatic cord?
```
Testicular artery and vein
Vas deferens
Lymphatic vessels
Nerves:
- Autonomic (vas deferens)
- Somatic (cremaster muscle)
```
64
Where do the testes sit within in the scrotum?
Tunica vaginalis
65
What is a hydrocoele?
Excess fluid in the tunica vaginalis
66
How many sperm are produced per second?
1500
67
How long does a sperm take to mature?
64 days
68
Where do the sperm pass to after production in the seminiferous tubules?
1. Rete testis
2. Head of the epididymis
3. Vas deferens
69
What is the approximate length of a testis?
~5cm
70
Where are the testis and epididymis attached to the spermatic cord? What are the clinical implications of this?
Superiorly:
- Risk of torsion
- Disruption of blood supply
- Severe pain and risk of necrosis
71
Where is the proximal end of the epididymis located?
Posterior aspect of the superior pole of the testis
72
Where do the arteries supplying the testes arise from?
The lateral aspects of the abdominal aorta
73
Where does the left testicular vein drain to?
Left renal vein
74
Where does the right testicular vein drain to?
IVC
75
Where do the arteries supplying and the veins draining the testes pass through?
Deep inguinal ring
76
What is the inferior aspect of the prostate gland in contact with?
Levator ani
77
What zone of the prostate is felt on PR exam?
Peripheral
78
What zone of the prostate is where most prostate cancers arise?
Peripheral
79
Where does the root of the penis attach to laterally?
Ischium
80
What cylinders of erectile tissue are located posteriorly and what do they transmit?
```
Corpa cavernosa (right and left)
Transmit the deep arteries of the penis
```
81
What cylinder of erectile tissue is located anteriorly and what do they transmit? What do they expand distally to form?
Corpus spongiosum
Transmits spongy urethra
Expands distally to form the glans
82
What contains the root of the penis, the proximal spngy urethra, the superficial transverse perineal muscle and branches of the internal pudendal vessels and the pudendal nerves?
Superficial perineal pouch
83
What does the bulb of the penis form?
Corpus spongiosum
84
What do the crura of the penis form?
Corpa cavernosa
85
What muscles are associated with the bulb of the penis?
Bulbospongiosus
| Ischiocavernosus
86
Where do the deep arteries of the penis branch from?
Internal pudendal artery (which is a branch of the internal iliac artery)
87
What blood vessels supply the scrotum?
Internal pudendal artery
| External iliac artery branches
88
Where does lymph from the scrotum and the penis (except the glans) drain to?
Inguinal lymph nodes in superficial groin fascia
89
Where does lymph from the testes drain to?
Lumbar lymph nodes (around abdominal aorta)
90
When is basal body temperature measured?
Before rising in the morning
91
How much does the basal body temperature rise by when fertile?
>0.2 degrees celcius
92
What changes in basal body temperature are indicative of ovulation?
Sustained increase for 3 days after at least 6 days of lower temperature
93
How can cervical mucous be used in natural family planning?
Ovulation indicated by thick and sticky mucous for >=3 days after thinner, watery mucous
94
When fertile, where does the cervix sit? What is it like?
High in vagina
| Soft and open
95
When less fertile, where does the cervix sit? What is it like?
Low in vagina
| Firm and closed
96
What days is a woman most fertile?
Days 8-18
97
When does breastfeeding work as contraception?
If the woman is:
- Exclusively breast feeding
- Less than 6 months post-natal
- Amenorrhoeic
98
What does the UK MEC apply to?
Hormonal contraception
IUDs
Emergency contraception
Barrier methods
99
What does UK MEC Category 1 indicate?
No restriction
100
What does UK MEC Category 2 indicate?
Advantages generally outweigh risks
101
What does UK MEC Category 3 indicate?
Risks generally outweigh advantages
102
What does UK MEC Category 4 indicate?
A condition represents an unacceptable risk if contraceptive method is used
103
How is the Pearl Index calculated?
Number of Pregnancies x 1200
--------------DIVIDED BY----------------
Number of women x Number of months
104
What does the Pearl Index represent?
Number of contraceptive failures per 100 women users/year
105
How is Depo Provera administered?
IM
106
What does Depo Provera contain?
Medroxyprogesteron acetate
107
How is Sayana press administered?
S/C
108
How does Depo Provera primarily work?
Inhibits ovulation
109
How often are Depo Provera IM injections given and how long does it last?
Given every 12 weeks
| Last 13 weeks
110
What are the secondary mechanisms of action of Depo Provera?
Thickens cervical mucous
| Converts endometrium to secretory phase
111
What is the Pearl Index for Depo Provera?
0.2%
112
What examinations must be done before the prescription of Depo Provera?
BP and BMI before first prescription
Check smear status
Risk factors for osteoporosis
113
When can Depo Provera be started up to without the need for additional contraception?
Up to and including day 5 of the cycle
114
When can Depo Provera be started beyond day 5?
If she is 'reasonably certain' she is not pregnant
AND
She must use condoms/abstain for 7 days
115
What is 'reasonably certain'?
No sex since last period
Consistently using reliable contraception
<7 days since last normal period
<4 weeks post-partum (not breastfeeding)
Fully breastfeeding, amenorrhoeic and <6 months post-partum
Negative pregnancy text AND >3 weeks since UPSI
116
When can Depo be started post-TOP?
Up to day 5
117
When can Depo be started post-partum?
Up to day 21 with immediate cover
118
In the context of a Depo injection, what should be done if pregnancy cannot be excluded?
Do pregnancy test in 3 weeks
Give Depo. thereafter
eg. After emergency contraception
119
What are the side effects of the Depo injection?
Weight gain
Delay in return of fertility
Irregular bleeding
Possible risk of osteoporosis
120
How does the IUD work?
```
Prevents fertilisation (Cu is toxic to sperm)
Inflammatory response in endometrium
```
121
How long is an IUD licensed for?
5-10 years
122
What is the Pearl Index for IUDs?
0.6-0.8%
123
What does Mirena contain?
52mg of levonorgestrel:
- 20mcg released daily
- Decreased to 10mcg per day after 5 years
124
What does Jaydress contain?
13. 5mg of levonorgestrel:
- 14mcg released daily for first 24 days
- 5mcg released daily after 5 years
125
How do IUSs work?
Primarily affect implantation:
| - Endometrium render unfavourable for implantation
126
What are some secondary effects of IUSs?
Cervical mucous thickened
| Pre-fertilisation effects
127
What is the Pearl Index of an IUS?
0.2%
128
What are some contraindications to IUD/IUS?
```
Current pelvic infection
Abnormal uterine anatomy
Pregnancy
Sensitivity to constituents
Gestational trophoblastic disease:
- When beta-hCG levels abnormal/persistently raised
Endometrial cancer
Cervical cancer awaiting treatment
```
129
Within how many days of beginning a period can an IUD be fitted?
Within first 7 days when they are reasonably certain they aren't pregnant
130
When can an IDU be used for emergency contraception?
Up to 5 days after UPSI
OR
Up to 5 days after predicted date of ovulation
131
When can an IUD be given post-partum?
Within 48 hours
OR
>4 weeks post-partum
132
When can an IUD be given post-TOP?
Immediately
133
Can an IUS be used for emergency contraception?
No
134
If an IUS is fitted outwith the first seven days of a a cycle, how long must condoms be used?
For first 7 days
135
When can an IUS be used post-TOP?
Up to day 7
136
What are some side effects of IUDs?
Heavy, prolonged menses
Pain/Infection/PID risk increased in first 20 days
Perforation (1-2/1000)
Expulsion (1/20 - Most in first 3 months)
Higher post-2nd trimester abortion
137
What is the ectopic risk associated with the use of an IUD?
0.08 per 100 women years
If pregnant:
- 9-50%
138
What are the side effects of using an IUS?
Lighter, less frequent bleeding
Pain/Infection/PID risk increased in first 20 days
Perforation (1-2/1000)
Expulsion (1/20 - Most in first 3 months)
Failure
139
What is the ectopic risk associated with the use of an IUS?
0.02 per 100 women years
140
How long is the subdermal rod licensed for?
3 years
141
What does the subdermal implant contain?
68mg Etonogestrel (Nexplanon):
- Released 60-70mcg per day in weeks 5-6
- 25-30mcg per day at end of 3rd year
142
How does the subdermal implant work?
Primarily inhibits ovulation
Others:
- Effect on endometrium
- Thickens cervical mucous
143
What is the Pearl Index of the subdermal implant?
0-0.1%
144
When can a subdermal implant be fitted without any need for additional precautions?
If:
- Within first 5 days of cycle
- Up to day 5 post-1st/2nd trimester abortion
- On or bfeore day 21 postpartum
145
When can a subdermal implant be fitted with the need for additional precautions for first 7 days?
She is reasonably certain she is not pregnant
'Quick start' after emergency contraception
'Off-licence'
146
When is the subdermal implant immediately effective if fitted (in the context of switching from another method)?
```
After last active COC pill in pack
Within 14 weeks of Depo
If week 2-3 of:
- COC
- CHC patch
- CHC vaginal ring
```
147
When are additional precautions required when switching to the subdermal implant?
For first 7 days if:
- Changing from POP or IUS
- Switching from non-hormonal method
148
What are the side effects of the subdermal implant?
```
Irregular bleeding
Weight gain
Acne
Neurovascular injury
Deep insertion
```
149
What does the subdermal implant have no know effect on?
Bone mineral density
CV risk
VTE risk
MI risk
150
What does the COC contain?
35mcg ethinyl estradiol
AND
A progestogen
151
What does the combined transdermal patch contain?
33mcg ethinyl estradiol
AND
A progestogen
152
What does the combined vaginal ring contain?
15mcg ethinyl estradiol
AND
A progestogen
153
How do combined hormonal contraceptives work?
Primary:
- Inhibit ovulation via action on HPO axis
- By reducing FSH and LH release
Secondary:
- Thickens cervical mucous
- Renders endometrium unfavourable for implant
154
What is the Pearl Index for combined hormonal contraceptive?
Perfect use - 0.3%
| Typical use - 9%
155
Over what weight is there possibly a decreased efficacy on the combined transdermal patch?
>=90 kg
156
What is a typical regime for the COC?
Daily for 21 days then stopped for 7 days to allow a withdrawal bleed
157
What do the first 7 pills in a COC regime do?
Inhibit ovulation
158
What do the last 14 pills in a COC regime do?
Maintain anovulation
159
What is a standard CTP regime?
One patch applied for 1 week to suppress ovulation
Patch reapplied weekly for 2 weeks
4th week is patch free - Withdrawal bleed
160
What is a standard CVR regime?
Placed in vagina and left for 21 days
| Removed for 7 days for a withdrawal bleed
161
What is an extended use COC regime?
Use pills continuously until a breakthrough bleed:
| - Then stop for 4 or 7 days
162
How does cytochrome P-450 induction affect the efficacy of the COC?
Increased EE metabolism
Reduces circulating [EE]
Reduces clinical effect
163
What enzyme inducers can affect the efficacy of CHCs?
Rifampicin
Some anticonvulsants
St John's Wort
Some antiretrovirals
164
How can one missed COC pill be managed?
If over 24hrs but less than 48hrs:
- Take missed pill ASAP
- Remaining pills taken at normal time
- Emergency contraception not required
165
How are two or more missed COC pills be managed?
More than 48 hours without a pill:
- Take the most recent missed pill
- Take remaining pills at normal time
- Use condoms/abstain until 7 consecutive pills take
166
If 2 (or more) pills are missed in Days 1-7, what must be considered?
Emergency contraception
167
If 2 (or more) pills are missed in Days 8-14, what must be considered?
No extra instructions
168
If 2 (or more) pills are missed in Days 15-21, what must be considered?
Omit pill-free interval
169
How long can the CTP be removed for before efficacy is reduced?
48 hours
170
How long can a patch be worn continuously for before efficacy is reduced?
9 days
171
How long can the patch-free interval be extended to before efficacy is reduced?
9 days
172
How long can the CVR be removed for before efficacy is reduced?
48 hours
173
How long can a CVR be worn inserted for before efficacy is reduced?
4 weeks
174
How long can the CVR-free interval be extended to before efficacy is reduced?
9 days
175
How can CHCs result in thrombosis?
Alteration in clotting factors induced by EE:
Reduced levels of:
- Antithrombin III
- Protein S
176
In who might EE promote superimposed arterial thrombosis?
Those with significant arterial wall disease
177
In who is the fibrinolytic activity of CHC reversed?
Heavy smokers
178
COC combined with what FHx of VTE results in an increased risk of your own VTE?
1st degree relative aged <45 years
179
How long post-natal is the risk of VTE increased?
6 weeks
180
What is the relative risk of the following progestogens in CHC vs. Levonorgestrel:
- Norgestimate
- Gestofene (Desogestrel, Drospirenone)
- Etonogestrel
```
Norgestimate = 1.0
Gestofene = 1.5-2.0
Etonogestrel = 1.0-2.0
```
181
What effects does cyproterone acetate have?
Anti-androgen
Progestogen
Antigonadotropin
182
What is cyproterone acetate called when combined with EE?
Co-cyprindiol (Dianette):
- 35mcg EE
- 2mg cyproterone acetate
183
When else is cyproterone acetate with EE used?
Acne
| Hirsutism
184
What UK MEC score does using a CHC in someone age >35 years have?
2
185
When should BP be checked when taking a CHC?
Initially
At 3 months
Then annually
186
When is the risk of arterial disease while taking a CHC raised?
If a smoker (increased MI risk)
| If hypertension >=160/95
187
What is a user of a CHC at increased risk of if they have migraines WITH auras?
CVA
188
What is the relative risk increase in breast cancer when using a CHC?
1.24x
189
How long does the risk of breast cancer take to return to normal after stopping a CHC?
10 years
190
In the context of breast cancer, when is CHC directly contraindicated?
If personal history of CHC
191
If there is a family history of breast cancer, what UK MEC score is assigned to CHCs?
1
192
If a woman has the BRCA gene, what is the UK MEC score for taking a CHC?
3
193
How do CHCs affect the risk for cervical cancer?
Slightly increased
194
How long does the risk of cervical cancer take to return to normal after stopping a CHC?
10 years
195
What effect do CHCs have on ovarian cancer?
20% reduction for every 5 years use
| Max 50% reduction after 15 years use
196
What effect do CHCs have in endometrial cancer?
2-0-50% reduction
197
What effect does stopping CHCs have in its protective functions over certain cancers?
Protection can last for years
198
How long can CHCs be used?
Up to 50 years of age (provided there are no risk factors)
199
What conditions do CHCs have a benefit in?
```
Acne:
- Dianette is licensed for acne (not contraception)
Withdrawal bleeds
Functional ovarian cysts
Premenstrual syndrome
PCOS
```
200
What are some general side effects of CHCs?
```
Unscheduled bleeding (in 20%):
- Don't change CHC before 3 months
Mood changes
?Weight gain
```
201
What are some side effects of the CTP?
Breast pain
Nausea
Painful periods
202
What are some side effects of CVP?
Less bleeding problems
Less acne problems
Less mood changes
203
When can COCs be started without the need for additional contraception?
Up to and including day 5
204
When can COCs be started after day 5?
At any time:
- If reasonably certain they aren't pregnant
- Use condoms/abstain for 7 days
205
When resuming a CHC after Levonelle 1500 (progestogen) for emergency contraception, what precautions must be used?
Condoms/Abstain for 7 days
206
When resuming a CHC after EllaOne (ulipristal acetate) for emergency contraception, what precautions must be used?
Do not start CHCs for 5 days:
- EllaOne is an anti-progesterone
- CHCs interfere with EllaOne
207
If wanting to start a CHC but pregnancy can't be excluded, how should this be done?
'Quick start' (condoms/abstain for 7 days)
| Do a pregnancy test in 4-5 weeks
208
What progestogens are in 'traditional' POPs?
Levonorgestrel
| Norethisterone
209
What progestogen is in the 'newer' POPs?
Etonorgestrel (longer-acting)
210
What are the primary mechanisms of POPs?
All:
- Thicken cervical mucous
Etonorgestrel:
- Suppresses ovulation in up to 97% of cycles
211
What are the secondary mechanisms of POPs?
All:
- Reduced endometrial receptivity to blastocyst
- Reduced cilia activity in fallopian tubes
Levonorgestrel:
- Ovulation suppressed in 60% of cycles
212
What is the UK MEC score for POPs when their use is deemed 'safer than pregnancy'?
UK MEC 3
213
What is the UK MEC score for POPs when the patient has current breast cancer?
UK MEC 4
214
What drugs does the POP interact with?
Liver enzyme inducers (Cytochrome P-450)
215
What are suitable POP alternatives if taking enzyme inducing drugs?
Depo
IUS
Cu IUD
216
How long does the effect of POPs continue after stopping?
28 days
217
What is the dosing regime for the 'traditional' POPs?
Daily at same time
No break
Within 24-27 hours of last dose
218
What is the dosing regime for Etonorgestrel?
Daily at same time
Within 24-36 hours of last dose
No break
219
When is emergency contraception and condom use/abstaining for 2 days required in the context of missed POPs?
One missed pill AND UPSI
220
What are the Pearl Indices for POPs?
Perfect use = 0.3%
| Typical use = 9%
221
What is the Pearl Index for vasectomy?
0. 1%
| 0. 05% after clearance
222
How many practitioners must agree than an abortion is justified under The Abortion Act 1967?
2
223
Where must an abortion take place under the The Abortion Act 1967?
NHS hosptial
OR
Approved premises
224
For a planned abortion, what form must be signed in Scotland and how many doctors must sign it? (What is the English/Welsh equivalent)
Cert. A (HSA1)
| 2 doctors
225
After an emergency abortion, what form must be signed in Scotland and how many doctors must sign it? How soon after must it be signed?(What is the English/Welsh equivalent)
Cert. B (HSA2)
1 doctor
Within 24 hours of the abortion
226
When is the HSA4 form completed? Who is it sent to?
Within 7 days of the abortion
| Sent to Chief Medical Officer
227
What are grounds for termination of pregnancy?
A) Continuance risk > Termination risks
B) Termination prevents grave mental/physical injury
C) <24 weeks and risk to mum's physical/mental health
D) <24 weeks and risk to existing child's health
E) Risk of baby having severe physical/mental deficits
228
What are grounds for emergency termination?
F) Necessary to save the woman'e life
| G) Necessary to prevent grave physical/mental injury
229
If a doctor has a conscientious object to carrying out a planned abortion, what must they do?
Respect patient's dignity and views
Do not impose views
Do not delay/deny treatment
Timely referral to a willing colleague
230
If a doctor has a conscientious object to carrying out an emergency abortion, what must they do?
They cannot object on conscientious grounds - They cannot deny the treatment and must do it if they are the only doctor immediately available
231
How long after a TOP consultation will the patient be referred for termination?
2 weeks
232
What is the legal limit for a social abortion?
23 weeks and 6 days
233
What is the legal limit for an abortion of a foetus with an abnormality?
Any gestation
234
What is the Tayside limit for a surgical abortion?
12 weeks
235
What is the Tayside limit for a medical abortion?
18 weeks and 6 days
236
Up to what gestation is a medical abortion deemed early?
Up to 9 weeks
237
Up to what gestation is a medical abortion deemed late?
9-12 weeks
238
Up to what gestation is a medical abortion deemed mid-trimester?
12-24 weeks
239
What is the process of a medical termination of pregnancy?
1. Oral Mifepristone 200mg:
- An anti-progesterone
- Endometrial degeneration
- Cervical softening and dilatation
2. Vaginal/Oral prostaglandin:
- Eg. Misoprostol and Gemeprost
- Given 24-48 hours later
- Stimulate contractions
- Can be done at home in early TOP
- Repeated doses if late/mid-trimester (3 hourly with a max of 5 does in 24 hours)
240
When can vacuum aspiration be used for termination of pregnancy?
Weeks 6-12
241
When can dilatation and evacuation be used for termination of pregnancy?
13-24 weeks
| Not available in Scotland
242
How is the cervix 'primed' prior to surgical TOP?
Vaginal prostaglandin
243
What is the procedure for electric vacuum aspiration?
Day case
Under GA
Routine USS not required
LARC fitting
244
What is the procedure for manual vacuum aspiration?
```
For early gestation TOP/RPOC
Under LA
Useful in:
- Resource poor settings
- Developing countries
```
245
What is the overall risk of a serious complication following TOP?
1-2/100
246
What are some features of the aftercare following a TOP?
Urine pregnancy test at 2-3 weeks
Anti-D
Counselling
Contraception
247
What are some indications for emergency contraception following TOP?
```
UPSI
Barrier fails
'Missed' pills
Late injection
Expelled IUD
```
248
What does Levonelle 1500 contain?
1.5mg Levonorgestrel
249
How does Levonelle 1500 work?
Inhibits ovulations
250
How long after UPSI can Levonelle 1500 be used?
Up to 72 hours
251
What is the failure rate of Levonelle 1500?
1-2%
252
What is the cost per unit of Levonelle 1500?
£5.11
253
What cautions are required when using Levonelle 1500?
Enzyme-inducers
254
What does ellaOne contain?
30mg Ulipristal acetate
255
How does ellaOne work?
Inhibits/Delays ovulation
256
How long after UPSI can ellaOne be used?
Up to 120 hours
257
What is the failure rate of ellaOne?
<1%
258
What is the cost per unit of ellaOne?
£16.95
259
What cautions are required when using ellaOne?
Antacids
260
When should a urine pregnancy test be carried out after emergency contraception?
3 weeks after
261
When can an IUD be used as emergency contraception?
Up to 120 hours post-UPSI
| Up to 5 days after earliest expected date of ovulation
262
What must be screened (+/- treated) for prior to IUD insertion?
STIs
263
Where did HIV-2 originate?
West African Sootey Mangabey (SIV)
264
Where did HIV-1 originate?
Central/West African chimpanzees
265
What group of HIV is responsible for the global pandemic starting in 1981?
HIV-1 group M
266
On what cells is CD4 found?
Th cells
Dendritic cells
Macrophages
Microglial cells
267
What is the function of CD4+ Th lymphocytes?
Recognise MHC II APCs
Activate B and Tc cells (CD8+)
Cytokine release
268
What are normal levels of CD4+ Th lymphocytes?
500-1600 cells/mm^3
269
At what CD4+ Th lymphocyte level is there an opportunistic infection risk?
<200 cells/mm^3
270
What effects does HIV have on the immune response?
```
Sequestration of cells in lymphoid tissues:
- Reduces circulating CD4+ cells
Reduces proliferation of CD4+ cells
Reduced CD8+ cell activation:
- Dysregulated expression of cytokines
- Increased viral susceptibility
```
271
How quickly is a new generation of HIV produced?
Every 6-12 hours in the very early and very late stages
272
What is the average time from infection to death without treatment of HIV?
9-11 years
273
How does HIV infection someone?
```
Infects mucosal CD4+ cells:
- Langerhands
- Dendritic cells
Transport to regional lymph nodes
Infection established within 3 days of entry
Dissemination of virus
```
274
In the primary HIV infection, how many present with symptoms?
80%
275
What is the average timing of onset of primary HIV infection symptoms?
2-4 weeks
276
What are the features of a primary HIV infection?
```
Fever
Rash (maculopapular - More on trunk and face)
Myalgia
Pharyngitis
Headache/Aseptic meningitis
```
277
What causes Pneumocystis pneumonia?
Pneumocystis jiroveci
278
At what CD4+ threshold is there a risk of Pneumocystis pneumonia?
<200
279
What are the symptoms/signs of Pneumocystis pneumonia?
Insidious onset
SoB
Dry cough
Exercise desaturation
280
What may a CXR show in Pneumocystis pneumonia?
Interstitial infiltrates
| Reticulonodular markings
281
How is Pneumocystis pneumonia diagnosed?
Bronchio-alveolar lavage and immunofluorescence
| +/- PCR
282
How is Pneumocystis pneumonia treated?
High dose (90-120mg/kg) Co-Trimoxazole in 3 divided doses for 21 days
283
How is Pneumocystis pneumonia prevented?
Low dose co-trimoxazole
284
What features of TB are more common in HIV?
```
Symptomatic primary infection
Reactivation
Lymphadenopathies
Miliary TB
Extrapulmonary TB
MDR-TB
Immun Reconstitution Syndrome
```
285
What causes Cerebral toxoplasmosis?
Toxoplasma gondii
286
What is the CD4+ threshold for the risk of developing Cerebral toxoplasmosis?
<150
287
How does Cerebral toxoplasmosis present?
```
Reactivation
Chorioretinitis
Signs/Symptoms:
- Headache
- Fever
- Focal neurology
- Seizures
- Reduced consciousness
- Increased ICP
```
288
What is the CD4+ threshold for CMV infection?
<50
289
What screening is important for all HIV+ patients with a CD4+ of <50?
Ophthalamic
290
What does CMV reactiviation result in?
Retinitis
Colitis
Oesophagitis
291
What are the signs/symptoms of CMV reactivation?
```
Reduced visual acuity
Floaters
GI symptoms:
- Abdominal pain
- Diarrhoea
- PR bleeding
```
292
What are features of HIV-associated herpes zoster?
Multidermatomal
| Recurrent
293
What are features of HIV-associated herpes simplex?
Extensive
Hypertrophic
Aciclovir-resistant
294
What are features of HIV-associated HPV infection?
Extensive
Recalcitrant
Dysplastic
295
What other skin infections are common in HIV?
Penicilliosis (Penicillium marneffei - a fungus)
Histoplasmosis:
- Lung infection due to Histoplasma capsulatum fungal spores
296
How does HIV-associated neurocognitive impairment present?
Reduced short-term memory
| +/- motor dysfunction
297
What causes Progressive Multifocal Leukoencephalopathy?
JC virus
298
What is the CD4+ threshold for developing Progressive Multifocal Leukoencephalopathy?
<100
299
How does Progressive Multifocal Leukoencephalopathy present?
Rapidly progressing:
- Focal neurology
- Confusion
- Personality change
300
What is "Slim's Disease" and what are its potential aetiologies?
```
HIV-associated wasting
Due to:
- Chronic immune activation
- Anorexia
- Malabsorption/Diarrhoea
- Hypogonadism
```
301
What causes Kaposi's Sarcoma?
Human Herpes Virus 8
302
What kind of tumour is Kaposi's Sarcoma?
Vascular
303
How does Kaposi's Sarcoma present?
```
Cutaneous
Mucosal
Visceral:
- Pulmonary
- GI
```
304
How is Kaposi's Sarcoma treated?
HAART
Local therapies (cryotherapy; surgical excision)
Systemic chemotherapy
305
What causes Non-Hodgkin Lymphoma?
EBV
306
What kinds of EBV NHL is HIV associated with?
Burkitt's lymphoma
| Primary CNS lymphoma (extranodal)
307
How does NHL present in HIV?
```
More advanced
B cell symptoms:
- Fever >38
- Night sweats
- Weight loss >10% over =<6 months
Bone marrow involvement
Extranodal disease
Increased CNS involvement
```
308
What does HPV infection rapidly progress to in HIV?
Persistent infection
Cervical:
- Severe dysplasia
- Invasive disease
309
At what CD4+ range is ITP common?
300-600
310
How can mother-child HIV transmission occur?
In-utero/Trans-placental
At delivery
When breastfeeding
311
How many at risk babies become infected with HIV?
25%
312
How many HIV infants die before their 1st birthday if untreated?
1 in 3
313
What is the prevalence of HIV in the UK?
1.5/1000
314
When is universal testing for HIV on all general medical admissions and all new GP patients recommended?
When local prevalence is >0.2%
315
What is the window period for HIV Ab tests?
~63 days when first established
316
How do 3rd generation HIV Ab tests work?
```
HIV-1 and HIV-2 Abs detected:
- IgM
- IgG
Very sensitive/specific if infection established
Window period ~20-25 days
```
317
How do 4th generation HIV Ab tests work?
Combined Ab and Ag (p24)
Shortens window period by ~5 days:
- Window period ~15-20 days
318
What does the Recent Infection Testing Algorithm identify?
If infection occurred in preceding 4-6 months
319
What does the Recent Infection Testing Algorithm measure?
Different types of Abs
OR
Strength of Ab binding
320
What class of drugs do Nucleoside Analogue RTIs (NRTIs) fall under? Give examples.
Reverse transcriptase inhibits
Examples:
- Zidovudine
- Emtricitabine
321
What class of drugs do Nucleotide Analogue RTIs (NtRTIs) fall under? Give examples.
Reverse transcriptase inhibits
Example:
- Tenofivir
322
What class of drugs do Non-Nucleoside RTIs (NNRTIs) fall under? Give examples.
Reverse transcriptase inhibits
Example:
- Efavirenz
323
What type of drug is Raltegravir (the 'gravirs')?
Integrase inhibitors
324
What types of drugs are the 'avirs' (eg. Atazanavir and Darunavir)?
Protease inhibitors
325
What type of drug is Enfuvirtide?
Fusion inhibitors (entry inhibitor)
326
What type of drug is Maraviroc?
CCR5 receptor inhibitors (entry inhibitor)
327
What is HAART?
Highly-Active Anti-Retroviral Therapy:
- A combo of 3 drugs
- From at least 2 drug classes
- To which the virus is susceptible
328
What is Atripla?
```
Tenofovir (NtRTO)
PLUS
Emtricitabine (NRTI)
PLUS
Efavirenze (NNRTI)
```
329
What is Truvada?
Tenofovir
PLUS
Emtricitabine
330
What are the side effects of protease inhibitors?
GI symptoms
331
What are the skin side effects of HAART?
```
Rash
Hypersensitivity
SJS:
- Abacavir (NRTI)
- Nevirapine (NNRTI)
```
332
What are potential CNS side effects of HAART?
Mood changes
Psychoses:
- Efavirenz (NNRTI)
333
What is a potential renal side effect of HAART?
Proximal renal tubulopathies:
- Tenofovir (NtRTI)
- Atazanavir (Protease inhibitor)
334
What HAART drug can cause osteomalacia?
Tenofovir
335
What HAART drugs increase MI risk?
Abacavir
Lopinavir
Maraviroc
336
What drug can cause anaemia?
Zidovudine
337
What are potential GI side effects of HAART?
Transaminitis
Fulminant hepatitis:
- Nevirapine
338
What classes of ARV drugs are potent liver enzyme inducers?
Protease inhibitors
| NNRTIs
339
When can a vaginal delivery be carried out in a HIV+ mother?
If viral load undetectable
340
When should a C-section be carried out in a HIV+ mother?
If viral load detectable
341
What treatment should be initiated for a neonate with a HIV+ mother?
PEP for 4 weeks
342
How should a neonate be fed?
Exclusive formula feeding
343
What is the commonest STI cause of PID? How many women with this STI develop PID?
Chlamydia
| 9%
344
A woman presents with post-coital and IMB. She has some lower abdominal pain and has experienced dyspareunia. There is evidence of a mucopurulent cervicitis.
Chlamydia
345
How does chlamdia present in men?
Urethral discharge
Dysuria
Urethritis
Epididymo-orchitis
346
What is Fitz-Hugh-Curtis Syndrome?
Perihepatitis due do Chlamydia
347
If IM Ceftriaxone is contraindicated for the treament of Gonorrhoea, what is a suitable alternative?
Cefixime 400mg PO
348
What is the incubation period for gonorrhoea in the male urethra?
2-5 days
349
What is the incubation period for genital herpes?
3-6 days
350
How long does primary genital herpes tend to last?
14-21 days
351
How long do recurrent episodes of genital herpes tend to last?
5-7 days
352
Which HSV virus sheds more?
HSV-2 > HSV-1
353
What is the most common viral STI in the UK?
HPV
354
What type of HPV is associated with palmar warts?
HPV-2
355
What type of HPV is associated with plantar warts?
HPV-1
356
What is the average incubation period for HPV? (And the possible range)
Average is 3 months
| Range from 3 weeks to 9 months
357
How can anogenital warts be treated?
Imiquimod
358
How long is the incubation period for syphilis?
9-90 days (average is 21 days)
359
How does secondary syphilis present?
```
Macular/Follicular/Pustular rash on palms and soles
Mucous membrane lesions
Generalised lymphadenopthy
Patchy apolpecia
Condylomata Lata:
- Most hightly infectious lesions
```
360
How is early syphilis treated?
2.4 MU Benzathine benzylpenicillin once
361
How is late syphilis treated?
2.4 MU Benzathine benzylpenicillin three times
362
How long is serological follow up continued in syphilis?
Until rapid plasma reagin is negative or serofast:
| - Titres should decrease four-fold by 3-6 months in early syphilis
363
How is relapse/reinfection of syphilis detected serologicallu?
If RPR titre increases four-fold
