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Year 3 - Reproduction and Sexual Health > Week 2 > Flashcards

Week 2 Flashcards

1
Q

How long can sperm survive in the female genital tract?

How long do ovum survive in the female genital tract?

A

5 days

17-24 hours

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2
Q

How does cervical position vary during fertility?

A

More fertile - cervix is high in the vagina, soft and open

Less fertile - cervix is low in vagina, firm and closed

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3
Q

In a ‘regular’ 28 day menstrual cycle, which days are considered to be the most fertile?

A

8-18

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4
Q

What are the 3 criteria for lactational amenorrhoea?

How effective is this as a contraceptive?

A

1) exclusively breast feeding
2) less than 6 months post natal
3) amenorrhoeic

98% effective (woman will still ovulate after delivery, hence why not 100%)

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5
Q

What is the mode of action of the combined oral contraceptive pill (COCP)?

A

Primarily inhibits ovulation through negative feedback on pituitary via oestrogen and progestogen

Also has an effect on cervical mucus and the endometrium

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6
Q

What kind of contraception is desogestrel?

How does it work?

A

Newer progesterone-only pill (POP)

Inhibits ovulation (NB - older POPs don’t inhibit ovulation!)

Also has effects on cervical mucus, fallopian tube transport and endometrial thickness

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7
Q

How long does the contraceptive implant last for?

What is its mechanism of action and how effective is it?

A

Up to 3 years

Main mode of action is inhibition of ovulation (and again, has effects on endometrium and cervical mucus)

Failure rate is 0.05% - very effective as it doesn’t rely on patient compliance

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8
Q

How long does the depo injection last for?

What is its mechanism of action and how effective is it?

A

Depo injection is repeated every 13 weeks, but lasts 14 weeks

Primarily inhibits ovulation

Failure rate is 0.2%

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9
Q

What are the 3 doses of IntraUterine System (IUS) currently available?

What is their mechanism of action and how effective are they?

A

Mirena - 52mg

Kyleena - 19.5mg

Jaydess - 13.5mg

Releases a small amount of hormone daily and mainly causes contraception through affecting implantation (renders the endometrium unfavourable)

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10
Q

High frequency pulses of GnRH result in release of ____

Low frequency pulses of GnRH result in the release of ____

A

High frequency pulses = LH release

Low frequency pulses = FSH release

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11
Q

What is the mode of action for the intrauterine device (IUD)

How long is it licensed for and what is the failure rate?

A

Primary mode of action is prevention of fertilisation - causes an inflammatory response in the endometrium and is toxic to both the sperm and the egg

Licensed for 5/10 years

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12
Q

What is the most effective form of contraception, based on % of women experiencing pregnancy in their first year of use?

A

Progesterone only implant (0.05%)

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13
Q

Before providing contraception, what examinations are done by the clinician?

A

Depends on the contraceptive being given

BP and BMI are recorded (a lot of options increase weight due to affecting appetite)

Check smear status if relevant

PV to check uterine size/position if required for IUD fit

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14
Q

What forms of contraception may be quick-started (started immediately and not waiting until next period) and which should not be?

A

Possible to Quick start

  • Some CHCs
  • POP
  • Implant
  • (Depo)

Avoid

  • IUD (may cause miscarriage)
  • Pills containing cyproterone acetate
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15
Q

When is emergency contraceptive required?

A

When contraception hasn’t been used/used correctly

Before new contraceptive method has had a chance to become effective

If more than one COC has been missed

If patch/ring has been off/out for more than 48 hours

If an implant has been fitted out with the first 5 days of cycle, and unprotected sexual intercourse has happened within the first 7 days of use

Up to 5 days after UPSI or within 5 days of predicted ovulation

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16
Q

What methods of emergency contraception are currently available?

Which is most effective?

A

Intrauterine

  • copper IUD - TEN TIMES MORE EFFECTIVE than oral alternatives

Oral

  • LNG-EC - up to 72 hours post UPSI (96 hours off license)
  • UPA-EC - up to 120 hours post UPSI
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17
Q

Why can the copper IUD be used at emergency contraceptive up to 5 days post UPSI, or after 5 days after likely ovulation?

A

Because pregnancy doesn’t implant during the first 5 days post-fertilisation. Most happen at days 8-10, but earliest is 6

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18
Q

How does oral emergency contraceptive work?

A

LNG-EC - high dose progestogen (works before LH surge)

UPA-EC - anti-progestogen (works until after start of LH surge)

Both DELAY ovulation but neither are ​abortifactant and NEITHER work after ovulation

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19
Q

Under what circumstances should someone avoid UPA-EC?

A

If they are wishing to quick-start a hormonal contraceptive

They must delay their ongoing contraception for 5 days

If hormonal contraception has been used in the past 7 days

If the patient has acute severe asthma that is uncontrolled by oral steroids

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20
Q

Other than contraception, what are some of the other benefits of using hormonal contraception

A

Manage heavy menstrual bleeding

Managing painful periods

Managing irregular periods

Managing premenstrual symptoms

Endometriosis (oral contraptive helps to manage symptoms and prevent progression)

PCOS

Managing menstrual migraine

Acne, mood, hirsutism

Protection from certain cancers - endometrial, ovarian

Prevention of osteoporosis

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21
Q

What forms of combined hormonal contraceptive are there?

A

Combined oral contraceptive pill

Combined transdermal patch

Combined vaginal ring

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22
Q

What is the efficacy like for combined hormonal contraceptive?

How does weight affect this?

A

If perfect compliance - 0.3% failure rate

Typical compliance rate - 9% failure rate (people forget to take pill!)

The transdermal patch may have a possible decrease in efficacy in patients over 90kg

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23
Q

How should the combined oral contraceptive pill be taken?

A

Start in first 5 days of regular menstruation OR at any time in cycle when reasonably sure not pregnant, plus condoms for 7 days (“belt and braces”)

Take daily for 21 days followed by a 7 day break (during which there will be a period-like bleed) then start a new pack

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24
Q

By what mechanism might the combined hormonal contraceptive be thrombogenic?

A

Alteration in antithrombin III and Protein S, affecting the body’s natural coagulation defences

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25
Q

What are the main risks of taking the combined hormonal contraceptive?

A

Venous thrombosis - increased risk

Arterial thrombosis - increased risk

Adverse effect on some cancers due to hormonal action e.g. breast cancer, cervical cancer (both reduce back to baseline risk after 10 years of stopping CHC)

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26
Q

What risk factors propagate the risk for VTE in women taking the combined hormonal contraceptive?

A

Obesity

Smoking

Increased age

Known thrombophilia

Family history

Up to 6 weeks postnatal

Long haul flights/reduced mobility

APLS

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27
Q

When would the combined hormonal contraceptive be contraindicated?

A

In patients with a personal history or genetic family history (i.e. BRCA) of breast cancer

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28
Q

Which cancers is the combined hormonal contraceptive protective against? Which is it a risk factor for developing?

A

Protective - endometrial, ovarian

Risk - breast, cervical

…RCGP study showed a 12% reduction in all-cause mortality and no overall increase in cancer risk

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29
Q

What common skin condition is the combined hormonal contraceptive effective in treating?

A

Acne

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30
Q

How should Progestogen only methods of contraception be started/taken?

A

Day 1-5 of period

OR

Anytime if reasonably certain not pregnant plus condoms for 7 days (2 for POP). Again, belt and braces…

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31
Q

When can an IUS/copper IUD be inserted?

A

IUS - anytime in cycle if no unprotected sex (UPSI) in the past 3 weeks or since last menstrual period

Cu-IUD - as above, plus as emergency contraception

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32
Q

What 3 documents need to be completed in Scotland when performing an abortion?

A
  1. HSA1: two doctors are required to sign
  2. HSA2: to be completed by the doctor within 24 hours of an emergency abortion
  3. HSA4: must be completed by the doctor and sent to the Chief Medical Officer within 7 days of the abortion taking place
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33
Q

When performing an abortion in a woman under the age of 16, what framework is used to assess competence?

A

Gillick competence

(NB - Fraser guidelines are only concerned with contraception and focus on the desirability of parental involvement and the risks of unprotected sex in that area)

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34
Q

What are some of the important points to remember regarding a doctor’s right to conscientiously object?

A

Respect a patient’s point of views and avoid discrimination

Must not impose views on others but may explain their own views if invited

Ensure patient’s treatment is not delayed or denied

Treatment in the event of an emergency may not be denied

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35
Q

What are the gestational limits for termination of pregnancy, both in Tayside and the UK?

A

Tayside

  • 18 weeks and 6 days
  • Surgical termination up to 12 weeks
  • Medical termination up to 18 weeks and 6 days

Legal limit for UK

  • For social termination of pregnancy - 23 weeks and 6 days
  • For foetal anomaly - any gestation
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36
Q

How is a medical Termination of Pregnancy performed?

How does this vary depending on length of gestation?

A

1) Oral Mifepristone 200mg (anti-progesterone)
2) 24-48 hours later - vaginal (or oral) prostaglandin e.g. misoprostol, gemeprost

If Early in pregnancy (e.g. <9 weeks) - option to complete part 2) at home

If Late/Mid-trimester - repeated doses of prostaglandin every 3 hours (maximum of 5 in 24 hours)

If this fails, move on to surgical evacuation

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37
Q

What are the 3 categories of time period in which an abortion may be performed?

A

Early (<9 weeks)

Late (9-12 weeks)

Mid-trimester (12-24 weeks)

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38
Q

How is a surgical termination of pregnancy performed?

What time period can each method be done?

A

Vacuum aspiration - 6-12 weeks (risk of failure if done sooner)

Dilatation and evacuation - 13-24 weeks (not available in Scotland)

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39
Q

When performing a surgical Termination of Pregnancy, what is given to ‘prime’ the cervix and minimise damage?

A

Vaginal prostaglandin is given

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40
Q

How is vacuum aspiration performed?

A

After vaginal prostaglandin is given, patient is taken in as a day case and put under GA. Routine USS is not required.

After the procedure is done, patient is fitted with a Long Acting Reversible Contraceptive (LARC) e.g. implant or IUD

Pregnancy test is done 2-3 weeks later to confirm if successful

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41
Q

What are some of the effects that HIV has on the immune system?

A

Sequestration of cells in lymphoid tissues >reduced circulating CD4+ cells

Reduced proliferation of CD4+ cells

Reduction in activation of CD8+ cells

Reduction in antibody class switching > reduced affinity of antibodies that are produced

Chronic immune activation

This all increases susceptibility to viral infections, fungal infections, mycobacterial infections and infection-induced cancers

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42
Q

What are the functions of CD4+ T helper cells?

A

Essential for the induction of the adaptive immune response. Done by…

  • recognition of MHC2 APCs
  • activation of B cells
  • activation of cytotoxic T cells
  • release of cytokines
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43
Q

What are the normal parameters for CD4+ T cells and at what point does the risk of opportunistic infections become noticeable?

A

Normal range - 500-1600 cells/mm3

Risk of opportunistic infections at <200 cells/mm3

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44
Q

At what points in HIV infection is rapid replication of virus seen?

After exposure, by when is infection established?

A

Very early (primary infection) and very late in infection (symptoms of AIDS)

Infection is established by day 3

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45
Q

What are the 3 phases of HIV infection, and what is the typical presentation at each phase?

A

Primary Infection (80% symptomatic, 2-4 weeks) - very high risk of transmission

  • fever
  • rash (maculopapular)
  • myalgia
  • pharyngitis
  • headaches/asceptic meningitis

Asymptomatic Infection (can take years)

  • ongoing viral replication and depletion of CD4+ count
  • also ongoing immune activation

Symptoms of AIDS

  • increase of opportunistic infections rises considerably
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46
Q

What are some of the opportunistic infections someone with HIV is at risk of?

BONUS: What are the treatments for these infections?

A

Pneumocystis pneumonia - high dose co-trimoxazole +/- steroid

Tuberculosis - 2 RIPE 4 RI

Cerebral toxoplasmosis - pyrimethamine and sulfadiazine and calcium folinate

CMV - ganciclovir

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47
Q

How does being underweight affect a woman’s fertility?

A

Reduced fertility

Underweight women are more than twice as likely to take more than a year to get pregnant

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48
Q

How does being overweight affect a woman’s fertility?

A

Reduced fertility

Have less chance of getting pregnant overall

More likely to take more than a year to get pregnant

Up to 3 times more likely to suffer oligo/anovulation

Impairs endometrial development and implantation

Associated with PCOS

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49
Q

What supplementation is recommended for all women trying to conceive?

How long should they be taking this for and at what dose?

A

400 micrograms Folic Acid pre-conception and throughout the first trimester

OR

5mg Folic Acid if the woman is obese, diabetic, on antiepileptics or there is a history of babies with neural tube defects

10 micrograms Vitamin D through pregnancy and continue afterwards if breastfeeding

(possibly Iron supplementation as well - shouldn’t be offered routinely as it doesn’t benefit the mother’s or baby’s health and may have unpleasant side effects)

50
Q

What are the maternal and fetal risks of not taking Vitamin D supplementation during pregnancy?

A

Maternal risks - osteomalacia, pre-eclampsia, gestational diabetes, C section, bacterial vaginosis

Fetal risks - small for gestational age, neonatal hypocalcaemia, asthma/respiratory infection, rickets

51
Q

Which groups of pregnant women are at the highest risk of iron deficiency?

How does iron deficiency affect pregnancy?

A

At risk - young first pregnancy, repeated pregnancies, multiple pregnancies

Iron deficiency increases the risk of stillbirth

52
Q

Should Vitamin A supplementation be given in pregnancy?

What caution should be taken if so?

A

Should only be given in cystic fibrosis patients as they are lacking in Vitamin A

High doses of Vitamin A are teratogenic

53
Q

Who is the Healthy Start Scheme (UK) available to and what does it contain?

A

Available to expecting mothers under 18 and those receiving benefits

Includes 70mg Vitamin C, 10 micrograms Vitamin D and 400 micrograms Folic Acid

54
Q

What foods should be avoided in pregnancy and why?

A

Soft cheese, undercooked meat, cure meats, game, tuna, raw/partially cooked eggs, pate, liver and vitamin and fish oil supplements should all be avoided

They should be avoided because pregnant women are at greater risk of food-derived infections, mainly Listeria and Salmonella

55
Q

How do the demands of lactation compare with pre-pregnancy demands (last two trimesters) in terms of calorie requirement?

A

Lactation calorie demands exceed prepregnancy demands by approx. 640 kcal/day

This is compared with 300 kcal/day during the last two trimesters of pregnancy

This deficit is usually covered by fat stores acquired during pregnancy, however if the woman was underweight she will then require more calories

56
Q

What are the risks of obesity to the mother and the fetus?

A

Mother - diabetes, hypertension, thrombosis, infection

Fetus - macrosomia, NICU admission, still birth, neonatal death

57
Q

What is the most common bacterial STD in the UK?

How is it transmitted and which age range shows the highest incidence?

A

Chlamydia

Transmission is vaginal, oral or anal

Highest incidence is in the 20-24 age range

58
Q

What bacterial STD is associated with pelvic inflammatory disease in women?

What % of women develop this? What is the risk of PID?

A

Chlamydia is associated with PID in women

% of women w/ Chlamydia that develop PID is estimated at 9%

An episode of PID increases the risk of ectopic pregnancy ten-fold, and carries a tubal factor infertility of 15-20%

59
Q

If symptoms of Chlamydia infection appear in a woman, how might she present clinically?

A

Post-coital or intermenstrual bleeding

Lower abdominal pain

Dyspareunia

Mucopurulent cervicitis

60
Q

If symptoms of Chlamydia infection appear in a man, how might he present clinically?

A

Urethral discharge

Dysuria

Urethritis

Epididymo-orchitis

Proctitis

61
Q

What are some of the complications of a Chlamydial infection?

A

PID (CT accounts for 50% of all cases)

Tubal damage in women - infertility and ectopic pregnancy

Chronic pelvic pain

Transmission to neonate if pregnant - 17% develop conjunctivitis, 20% develop pneumonia

Adult conjunctivitis

Reiter’s Syndrome (reactive arthritis, can’t see can’t pee can’t bend the knee), more common in men

Fitz-Hugh-Curtis Syndrome (perihepatitis), occurs almost exclusively in women as a complication of PID

62
Q

What is lymphogranuloma venereum (LGV)? How does it present?

A

Serovars L1-L3 of Chlamydia trachomatis

Diagnosed mostly in MSM

Presents with rectal pain, discharge and bleeding, and there is a high risk of there being concurrent STIs (67% have HIV)

63
Q

How is Chlamydia diagnosed and treated?

A

Females - NAAT (using a vulvovaginal swab)

Males - first void urine and add rectal swab if history of receptive anal sex

Treatment - Doxycycline 100mg BD for 1 week, PLUS Azithromycin 1G stat followed by 500mg daily for 2 days (NB - azithromycin no longer given, just doxy now due to the downstream effects of azithromycin)

64
Q

Why was the treatment for Chlamydia trachomatis updated?

A

Updated to include Azithromycin due to the emerging STD Mycoplasma genitalium - exhibits high levels of macrolide resistance (JUST GIVE DOXYCYLINE! DON’T ANGER DR MOOKA!)

Associated with non-gonococcal urethritis and PID

Prevalence estimated at 1-2% of the ppn, asymptomatic carriage

Diagnosed with NAAT

65
Q

What is the morphology of Gonorrhoea?

A

Gram negative, intracellular, diplococcus (looks like 2 kidney beans)

66
Q

Describe the incubation period of Gonorrhoea

Are men or women more likely to transmit the infection?

A

Incubation of urethral infection in men is usually short (2-5 days)

Men are more likely to transmit the infection (50-90% risk of male to female vs 20% risk of female to male)

67
Q

How might Gonorrhoea present clinically in males?

A

Asymptomatic in up to 10%

>80% present with urethral discharge

Dysuria

Pharyngeal/rectal infections, mostly asymptomatic

68
Q

How might Gonorrhoea present clinically in females?

A

Asymptomatic (up to 50%)

Increased/altered vaginal discharge (40%)

Dysuria

Pelvic pain

Pharyngeal and rectal infections are also usually asymptomatic

69
Q

Complications of Gonorrhoea infection is more likely in women than in men (3% vs 1%). What are some of the complications that could develop?

A

Bartholinitis

Tysonitis

Periurethral and rectal abscesses

Epididymitis

Urethral stricture

Endometritis

PID

Infertility

Ectopic pregnancy

Prostatitis

70
Q

How is potential Gonorrhoea infection investigated?

A

NAATs (screening test) used in both symptomatic and asymptomatic cases with >96% sensitivity

Microscopy if symptomatic (urethral sensitivity 90-95%, endocervical 37-50%)

Culture if microscopy is +ve (more sensitive in male)

71
Q

How is Gonorrhoea treated?

What has to be done following treatment?

A

First line is IM Ceftriaxone 500mg

Second line is Cefixime orally, 400mg (only done if IM Ceftriaxone is contraindicated or refused by patient)

Also have to do a test of cure following treatment

72
Q

What is the incubation period and duration of a primary infection of genital herpes?

A

Incubation period - 3-6 days

Duration - 14-21 days

73
Q

How might the primary infection of genital herpes present clinically?

A

Blistering and ulceration of the external genitalia

Pain

Dysuria

Vaginal or urethral discharge

Local lymphadenopathy

Fever and myalgia

74
Q

What subtype of the herpes simplex virus is most likely to present with recurrent episodes?

What is it often mistaken for?

A

HSV-2 is more likely to present with recurrent episodes

Often overlooked/misdiagnosed as thrush

Recurrent episodes are usually unilateral, small blisters and ulcers, and minimal systemic symptoms. Episode typically resolves within 5-7 days

75
Q

How is genital herpes diagnosed and managed?

A

Swab the base of the ulcer and send for HSV PCR

Give oral antivirals (Aciclovir 400mg TDS for 5-7 days)

Consider topical lidocaine 5% ointment if particularly painful

Can also recommend saline bathing and analgesia

76
Q

Which subtype of HSV displays a greater degree of viral shedding?

When is this most common?

A

HSV-2 viral shedding is consistently higher

More frequent in the first year of infection and seen more in individuals with frequent recurrences

77
Q

Which HPV subtypes are associated with the following presentations?

  • anogenital warts
  • palmar and plantar warts
  • cellular dysplasia/intraepithelial neoplasia
A

Anogenital warts - HPV 6 and 11

Palmar and Plantar warts - HPV 1 and 2

Cellular dysplasia/intraepithelial neoplasia - HPV 16 and 18

78
Q

What is the most common viral STI in the UK?

A

HPV - lifetime risk of acquiring infection is 80%

79
Q

What is the incubation period of HPV?

How detectable is the infection?

A

3 weeks - 9 months (advise people that they may have had it for years before they go blaming their partners!)

Subclinical disease is common on all anogenital sites

If 80% of the ppn are exposed, approx. 10% of these will harbour detectable infection with only 1% developing anogenital warts

80
Q

What are the potential outcomes of anogenital warts?

A

20-34% will resolve spontaneously

60% will clear following treatment

20% will persist despite treatment

81
Q

Which subtypes of HPV are the cause of >90% of anogenital warts?

How are they treated?

A

HPV 6 and 11

Can use…

  • Podophyllotoxin (topical and cytotoxic. Quick effect but not licensed for extra genital warts)
  • Imiquimod (immune modifier and can be used on all anogenital warts. Better in IC/IS patients)
  • Cryotherapy (cytolytic, can require repeated treatments)
  • Electrocautery
  • Vaccination
82
Q

What bacterial species causes syphilis?

How might it be acquired?

A

Treponema pallidum

Transmitted through…

  • sexual contact
  • trans-placental/during birth
  • blood transfusions
  • non-sexual contact e.g. healthcare workers
83
Q

What stages of syphilis infection are infectious and non-infectious?

What is the incubation period?

A

Infectious - primary, secondary, early latent

Non-infectious - late latent, tertiary

Incubation period is 9-90 days (mean of 21)

84
Q

How does primary syphilis present?

A

Painless ulcer at the site of innoculation (chancre)

Site is usually genital (90%) but can also be extra-genital (10%)

Also presents with non-tender local lymphadenopathy

85
Q

How does secondary syphilis present?

A

Skin - macular, follicular or pustular rash on the palms and soles)

Lesions of the mucous membranes

Generalised lymphadenopathy

Patchy alopecia

Condulomata lata - MOST HIGHLY INFECTIOUS LESION IN SYPHILIS, oozes a serum containing +++ treponemes

86
Q

How is syphilis diagnosed?

A

Demonstration of treponema

  • PCR

Serological testing - detecting antibody to pathogenic treponemes

  • Non-treponemal
    • VDRL (venereal disease research laboratory)
    • RPR
  • Treponemal
    • TPPA (treponema pallidum particle agglutination)
    • ELISA/EIA (screening test)
    • INNO-LIA
    • FTA abs
87
Q

How is a) early syphilis and b) late syphilis treated?

A

a) Early - 2.4 MU Benzathine penicillin x1
b) Late - 2.4 MU Benzathine penicillin x3

88
Q

What is Gillick competence?

What are the Fraser guidelines?

A

Gillick competence - concerned with determining a child’s capacity to consent

Fraser guidelines - refers specifically to consent for contraceptive treatment and sexual health matters

89
Q

Which of the following are NOT STIs?

  • Genital warts
  • Vaginal thrush
  • Bacterial vaginosis
  • Herpes
A

Vaginal Thrush and Bacterial vaginosis are NOT STIs

90
Q

What is the name of the space that lies inferior to the levator ani?

What is contained in this space in the woman?

A

The perineum

Contains the inferior part of the vagina, the perineal muscles, Bartholin’s glands, clitoris and labia

91
Q

How can fluid collection in the pouch of Douglas be sampled?

A

Drained via a needle being passed through the posterior fornix of the vagina

92
Q

What are the two main ligaments of the uterus?

Describe both briefly

A

Broad Ligament (wings)

  • double layer of peritoneum
  • extends between uterus and the lateral walls&floor of the pelvis
  • helps to maintain the uterus in the correct midline position
  • contains the uterine tubes and the proximal part of the round ligament

Round Ligament (tubes)

  • embryological remnant
  • attaches to the lateral aspect of the uterus
  • passes through the deep inguinal ring to attach to the superficial tissue of the female perineum
  • contained (proximally) within the broad ligament
93
Q

The round ligament is/is not a formation of the peritoneum.

What is this structure in the male?

A

Round ligament is NOT a formation of the peritoneum

The round ligament is a remnant of the gubernaculum and in the male is the spermatic cord)

94
Q

What are the 3 surfaces/components of the broad ligament?

A

Mesometrium

Mesovarium (surrounding the ovary)

Mesosalpinx (surrounding the uterine tube)

95
Q

Externally to internally, what are the 3 layers of the body of the uterus?

What part of the conception process occurs in the body of the uterus?

A

Perimetrium

Myometrium

Endometrium

Implantation occurs in the body of the uterus (anywhere else is an ectopic!)

96
Q

What 3 layers of support are provided to the uterus to hold it in position?

What condition could result if any of these layers is damaged?

A

Numerous strong ligaments (e.g. the uterosacral ligaments)

Endopelvic fascia

Muscles of the pelvic floor (e.g. levator ani)

Weakness in any of these structures could result in uterine prolapse

97
Q

Regarding the axes of the vagina, cervix and uterus, what is the most common position seen clinically?

A

Anteverted - cervix is tipped anteriorly relative to the axis of the vagina

Anteflexed - uterus is tipped anteriorly relative to the axis of the cervix

This results in the mass of the uterus lying over the bladder

98
Q

What area must be sampled by the clinician during a cervical smear test?

A

The squamo-columnar junction (transition zone)

Brush is inserted into the external cervical os with firm pressure and then rotated

99
Q

Where does fertilisation occur?

Where does implantation occur?

A

Fertilisation - ampulla of the fallopian tube

Implantation - body of the uterus

100
Q

What is a bilateral salpingo-oophrectomy?

A

Removal of both uterine tubes and ovaries

101
Q

How can you tell if there is an ectopic pregnancy within the fallopian tubes using a hysterosalpingogram (HSG)?

A

Normally, the radiopaque dye used in an HSG would spill out of the end of the uterine tube and into the peritoneal cavity, suggesting that the tube is patent

In an ectopic pregnancy contained within the fallopian tube, this dye would be blocked

102
Q

What hormones are secreted by the ovaries in response to LH and FSH?

A

Oestrogen and progesterone

103
Q

When performing a vaginal digital examination, what structures are felt for?

A

Ischial spines at 4 and 8 oclock laterally

Position of the uterus e.g. anteverted or retroverted

Adnexae (appendages) - uterine tubes and ovaries. Place examining fingers into lateral fornix, press deeply with the other hand into the iliac fossa of the same side. Can detect large masses or tenderness in these structures

104
Q

What are the two triangles that make up the perineum? What make the points of these triangles?

A

Urogenital triangle

Anal triangle

Anteriorly, the pubic symphisis

Posteriorly, the coccyx

Laterally, the two ischial spines

105
Q

What structures pass through the pelvic floor?

A

Distal parts of alimentary, renal and reproductive tracts from pelvis to perineum

106
Q

Which nerve supplies the levator ani? What are its spinal roots?

Is this muscle skeletal or smooth?

A

Levator ani is a skeletal muscle (under voluntary control)

Supplied by the nerve to levator ani

Roots are S3, 4, 5

107
Q

What are the 3 parts that make up the levator ani muscle?

A

Iliococcygeus

Pubococcygeus

Puborectalis

108
Q

What nerve supplies the perineal muscles?

Where do all these muscles attach?

A

Supplied by the pudendal nerve

All attach at a bundle of collagenous and elastic tissue called the perineal body - important in pelvic floor strength and can be disrupted during labour

109
Q

What structure can be cut to aid in delivery?

A

The perineal body - done more in the US, in the UK the musculature tends to be cut instead as collagenous material doesn’t heal as well, meaning pelvic floor weakness may develop

110
Q

What structure in the female is the homologue to the bulbourethral gland in the male, and may potentially become enlarged due to infection?

A

Bartholin’s gland

111
Q

What ribs does the female breast span?

A

2-6

112
Q

Breast tissue lies on deep fascia covering which muscles?

A

Pectoralis minor and Serratus anterior

NB - breast tissue and muscle are NOT in direct contact

113
Q

What is the name of the space that lies between the fascia and the breast?

What structures firmly attach the breast to the skin?

A

The retromammary space lies between the fascia and the breast

Firmly attached to skin via Cooper’s suspensory ligaments

114
Q

How do the Level I, Level II and Level III axillary lymph nodes relate to pectoralis minor, respectively?

A

Level I - inferior and lateral to pec minor

Level II - deep to pec minor

Level III - superior and medial to pec minor

115
Q

What is the blood supply to the female breast?

A

Arterial - Axillary and internal thoracic (internal mammary) arteries, both of which are branches of the subclavian artery

Venous - intercostal veins (means that cancers may pass to the thoracic spine)

116
Q

From what point can amniocentesis be performed?

What test needs to be done for fetal screening prior to this?

A

Not before 16 weeks

Chorionic Villus Sampling (CVS) can be performed this

117
Q

When is a booking scan performed?

When is the next, more detailed scan performed?

A

Booking scan is booked at 12 weeks

Next more detailed scan is then at 20 weeks

118
Q

When in a pregnancy can the following be detected via scan?

  • cardiac anomalies
  • microcephaly
  • short limbs
  • brain malformations
A

Cardiac - 12-20 weeks

Microcephaly - typically after 22 weeks

Short limbs - typically after 22 weeks

Brain malformations - between 18 and 21 weeks

119
Q

Typically, all pregnant women are offered at least 2 US scans throughout their pregnancy. When are these performed?

What can also be screened for at the first scan?

A

1st scan (dating scan) - at 8 to 14 weeks

2nd scan (anomalies scan) - at 18 to 21 weeks

At the same time as the dating scan, a nuchal translucency (NT) scan can be included to screen for Down’s Syndrome

120
Q

From what point can CVS testing be done in a pregnancy?

A

At 11.5+ weeks

121
Q

From what point can amniocentesis testing be done in a pregnancy?

A

At 16+ weeks

122
Q

How does free fetal DNA in maternal serum help with diagnosis of certain conditions e.g. Duchenne MD?

A

Patient pregnant 8 weeks w/ FHx of Duchenne MD

8 weeks sexing of fetus using free fetal DNA

If a girl, no need to worry

If a boy, proceed to more invasive testing

Year 3 - Reproduction and Sexual Health (7 decks)

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