Women and Men's Health Flashcards
Treatment for PID?
PO Floxacin + PO metronidazole
Or
IM ceftriaxone + PO doxycycline + PO metronidazole
What is the likely diagnosis?
A 25 year old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding. O/E BP= 90/60
Placental Abruption
What is the likely diagnosis?
A 31 year old woman presents with painless vaginal bleeding at 15 weeks gestation. She has not had any antenatal care despite suffering from severe vomiting. O/E she is large for dates.
Hydratidiform mole
What is the most likely diagnosis?
A 19 year old woman presents with a 2/7 Hx of central lower abdo pain and 1/7 Hx of vaginal bleeding. Her last period was 8/52 ag. O/E her cervix is tender to touch
Ectopic pregnancy
What are the three major causes of bleeding in the 1st trimester?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
What are the three major causes of bleeding in the second trimester?
Spontaneous abortion
Hydratidiform mole
Placental Abruption
What are the four major causes of bleeding in the third trimester?
Bloody show
Placenta Abruption
Placenta Praevia
Vasa Praevia
Diagnosis?
Hx of 6-8 wks Amenorrhoea with lower abdo pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Ectopic pregnancy
Diagnosis?
Typically bleeding in 1st or early 2nd trimester ass. with exaggerated symptoms of pregnancy eg. Hyperemesis. The uterus may be large for dates and serum hCG is very high
Hydratidiform Mole
Diagnosis?
Constant lower abdo pain, and women may be more shocked than is expected by visible blood loss. Tender, tense uterus with normal lie and presentation. Foetal heart may be distressed
Placental Abruption
Diagnosis?
Vaginal bleeding, no pain. Non-tender uterus but lie and presentation may be abnormal.
Placental Praevia
NB - VE should not be done in primary care setting as women with Placental Praevia may haemorrhage
Diagnosis?
Rupture of membranes followed immediately by vaginal bleeding. Foetal bradycardia is classically seen.
Vasa Praevia
Medical Treatment for Bacterial Vaginosis?
PO 400 mg metronidazole BD for 5-7 days
Or PO metronidazole 2 grams STAT (unless pregnant)
Or intravaginal metronidazole gel or intravaginal clindamycin cream
Medical Treatment for Trichomoniasis?
PO 400 mg metronidazole BD for 5-7 days
Or PO metronidazole 2 grams STAT (unless pregnant)
Or PO Tinidazole 2 g STAT (unless pregnant)
Treatment for Chlamydia
PO 1g Azithromycin STAT
Or
PO doxycycline 100mg BD 7/7
Mechanism of the Implantable contraceptive (Etonogestrel)
Prevents endometrial proliferation
Mechanism of the copper IUD
Decreases sperm motility and survival
Mechanism of Progesterone-only pill (excluding desogestrel)?
Thickens cervical mucus
Mechanism for Desogestrel-only pill?
Primary: inhibits ovulation
Also: thickens cervical mucus
Mechanism for injectable contraceptive (medroxyprogesterone)?
Primary: inhibits ovulation
Also: thickens cervical mucus
Mechanism for IUS (Levonorgestrel)?
Primary: prevents endometrial proliferation
Also: thickens cervical mucus
Causes for Primary Postpartum Haemorrhage?
Tone - uterine atony
Tissue - retained placenta
Trauma
Thrombin - coagulation abnormalities
What is the definition of premature ovarian failure?
The onset of menopausal symptoms and elevated gonadotropin levels before the age of 40 years
Features of PID?
Lower Abdo pain Fever Deep dyspareunia Possible dysuria and menstrual irregularities Vaginal/cervical discharge Cervical excitation
What day does the morula normally implant?
Day 6
What day does the zygote normally enter the uterus?
Day 4
When is placental morphology normally complete by?
12 weeks
When is a foetal heart beat normally established?
4-5 weeks
When can a foetal heart beat normally be detected by transvaginal ultrasound?
5-6 weeks
What type of miscarriage is this?
There is bleeding but the foetus is still alive, the uterus is the size expected from the dates and the os is closed.
Threatened miscarriage
NB. Only 25% go on to miscarry
What is this type of miscarriage?
Bleeding is usually heavy. Although the the foetus may be alive, the os is open.
Inevitable miscarriage (miscarriage is about to occur)
What type of miscarriage is this?
Some foetal parts have been passed but the os is usually open.
Incomplete miscarriage
What type of miscarriage is this?
All foetal tissue has been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.
Complete miscarriage
What type of miscarriage is this?
The foetus has not developed or died in utero, but this is not recognised until the bleeding occurs or USS is performed. The uterus is smaller than expected for dates and the os is closed.
Missed miscarriage
What three main tests are carried out for investigating recurrent miscarriage?
1) antiphospholipid antibody screen
2) karyotyping of both parents
3) pelvic USS (or hysterosalpingogram HSG)
Which four groups of patients are at high risk of developing pre-eclampsia?
1) HTN in previous pregnancies
2) CKD
3) autoimmune disorders such as SLE/antiphospholipid syndrome
4) type 1 or 2 DM
What is the main indication for Clomiphene?
To induce ovulation in patients with anovulatory infertility
What is the main indications for Danazol?
Derivative of ethisterone
Used to treat endometriosis and fibrocystic breast disease
Contraindicated in pregnancy as it causes virilisation of female foetuses
When are women screened for anaemia in pregnancy?
Booking visit and again at 28 weeks
What are the NICE limits for treating anaemia in pregnancy with oral iron therapy?
Booking visit less than 110g/l
28 weeks less than 105g/l
Which antibiotics are safe during breastfeeding? (3)
And which are not? (4)
Safe - penicillins, cephalosporins, trimethoprim
Avoid - ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
What is IUGR and what is it associated with?
IUGR - intrauterine growth restriction where a foetus fails to meet its ‘growth potential’
Associated with pre-eclampsia and still birth
What is abnormal umbilical artery Doppler used for?
To look for an indication of placental insufficiency in a foetus that is SFD (small for dates). Increased pulsatility or resistance suggests resistance in the placental circulation.
How should placental insufficiency be managed?
Increased resistance - USS assessment and dopplers weekly
Absent or reversed end-diastolic flow - monitoring daily. The resistance is so high the blood is being forced backwards in diastole
Name four differences in presentation of placental Abruption vs placenta Praevia
Abruption - painful, dark bleeding (may not bleed), tender hard uterus, normal USS
Praevia - painless, profuse red blood, rarely tender, low placenta on USS
Risk factors for shoulder dystocia?
Foetal macrosomia
High maternal BMI
DM
Prolonged labour
What is a McRoberts manoeuvre?
Used for shoulder dystocia. Flexion and abduction of the maternal hips, bringing the thighs towards her abdomen. Thought to allow the maternal pelvic symphysis to rotate, as well as flatten the maternal sacrum
What are the three stages of labour?
1) from the onset of true labour to when the cervix is fully dilated
2) from full dilation to delivery
3) from delivery of the foetus to when the placenta and membranes have been completely delivered
What is the definition of Puerperal Pyrexia?
A temperature >38 degrees in the first 14 days following delivery
Name three causes of Puerperal Pyrexia?
Endometritis UTI Wound infections (perianal tears and Caesarean section) Mastitis VTE
What is the management for Peurperal Pyrexia from ?endometritis?
Admit to hospital for IV clindamycin and gentamycin until afebrile for >24hrs
When should Anti-D be given for Rhesus negative mothers?
At 28 weeks
After any bleeding or potentially sensitising event
After delivery if neonate is Rhesus positive
What are potentially sensitising events regarding Rhesus D isoimmunisation?
TOP or ERPC after miscarriage Ectopic pregnancy Vaginal bleeding Invasive uterine procedure (amniocentesis or CVS) Intrauterine death Delivery
What is the Kleihauer test?
Assess the number of foetal cells in maternal circulation by adding acid to maternal blood smear. Foetal haemoglobin is resistant and so cells appear in red-pink colour.
Name some causes of Primary Amenorrhoea? (Max 4)
Turner’s syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of the genital tract
Name some causes of secondary Amenorrhoea (excluding pregnancy)?
Hypothalamic (stress, excessive exercise) PCOS Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis Sheehans syndrome Ashermans syndrome
What is Sheehan Syndrome?
Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic Shock during and after childbirth.
What is Asherman’s syndrome?
Adhesions and/or fibrosis of the endometrium most often associated with dilatation and curettage of the intrauterine cavity
What initial investigations would be carried out for secondary Amenorrhoea?
Urinary/serum beta HCG Gonadotrophins Prolactin Androgen levels Oestradiol TFTs
Name some risk factors for endometrial cancer? (Max 8)
Obesity, nulliparity, early menarche, late menopause, unopposed oestrogen, DM, tamoxifen, PCOS
What are some of the possible main features of a Listeria infection?
Diarrhoea, flu-like illness
Pneumonia, meningoencephalitis
Ataxia and seizures
Why is Listeria infection worrying in pregnancy? And how is it spread?
Dangerous to the unborn child and can lead to miscarriage.
Other complications - premature labour, stillbirth, chorioamnionitis
Pregnant women 20x more likely to get this infection
Spread via contaminated food, typically unpasteurised dairy products
What is the medical management for Listeria?
Sensitive to amoxicillin/ampicillin
IV amoxicillin/ampicillin + gentamycin to treat Listeria meningitis
Which contraceptives are effective A) instantly? B) from 2 days? C) from 7 days?
Instant - IUD
2 days - POP
7 days - COC, injection, implant, IUS
Which is often the contraceptive method of choice for young people?
The progesterone only implant (Nexplanon)
- may be less reliable remembering to take pills
- concerns over possible effect of Depoprovera on bone density
What daily supplements should pregnant women be taking?
Which vitamin should she not be getting in high doses?
Folic acid 400mcg for the first 12 weeks and Vit D through out pregnancy
Vitamin A is teratogenic in high doses
Which antibiotic should be avoided in the first trimester?
Trimethoprim
What is the NiCE guidance related to alcohol in pregnancy?
Avoid in the first three months
After this time, if women wish to drink alcohol, no more than 1-2 units or twice a week
What is the Bishops score used for and what are its five components?
Pre-labour scoring system to help assess whether induction of labour is need
Components - cervical position, cervical consistency, cervical effacement, cervical dilation, foetal station
What is the difference between a complete hydatidiform mole and a partial mole?
Complete - empty egg plus a single sperm. Only paternal DNA
Partial - egg plus two sperm/one sperm with duplication of paternal chromosomes. Both maternal and paternal DNA
Which organism commonly causes Bacterial Vaginosis?
Gardnerella vaginalis
What is Amsel’s criteria?
Diagnosis of BV - need 3/4
- thin, white homogenous discharge
- clue cells on microscopy
- vaginal pH of >4.5
- positive whiff test
What is the treatment for Gentital Warts?
1st - topical podophyllum or cryotherapy
2nd - topical imiquimod
What are the three cardinal signs of Meigs syndrome?
Benign ovarian tumour (fibroma, Brenner tumour, occ. granulosa cell tumour)
Ascites
Pleural effusion
What symptoms are suggestive of ovarian cancer? (Especially if over 50 years)
Persistent abdominal distension
Early satiety or loss of appetite
Pelvic/abdominal pain
Increased urinary frequency and/or urgency
What are the steps in investigating a suspected ovarian cancer?
Palpable mass/ascites - 2 week wait for gynae referral
No mass/ascites - measure Ca125. If >35 IU/ml - USS abdo and pelvis. If this is suggestive then 2 week gynae referral
What is the treatment for mastitis?
Flucloxacillin for 10-14 days. Continue breast feeding/expressing
What are the different gradings for placenta Praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but does not cover it
III - placenta covers the internal os before dilatation but not when dilated
IV - placenta completely covers the internal os
What features during labour would warrant continuous CTG monitoring?
Suspected chorioamnionitis/sepsis or temp of 38 or above
Severe HTN 160/110 or above
Oxytocin use
The presence of significant Muconium
Fresh vaginal bleeding that develops in labour
What increase the risk of ovarian cancer?
HRT Age greater than 50 Endometriosis Sub-fertility Familial cancers (brca, lynch syndrome)
What are the components to assessing a CTG?
DR – Define Risk C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression
What is the definition of Neonatal Mortality Rate?
The number of deaths during the first 28 days of life per 1,000 births in a given year or period
What would you expect the blood results to be in PCOS?
Increased LH:FSH ratio, raised testosterone, raised prolactin
What blood tests should be done at an antenatal booking visit?
FBC, Rhesus D, screening for anaemia, haemoglobinopathies, red-cell alloantibodies, hep B, HIV, Rubella susceptibility, syphilis
When is USS screening carried out to look for structural anomalies?
18 + 0 weeks
And
20 + 6 weeks
When can the combined test for Down’s be carried out?
Between 11+0 and 13+6 weeks
Which screening test for Down’s can be carried out between 11+0 and 13+6 weeks?
The combined test
When during pregnancy can the serum screening test (triple or quadruple test) be carried out?
Between 15+0 weeks and 20+0 weeks
Which screening test for Down’s could be used between 15+0 weeks and 20+0 weeks of pregnancy?
Serum screening test (triple or quadruple)
What is the biggest risk of taking HRT?
Doubles your risk of venous thromboembolism
What are the features/criteria of severe Pre-eclampsia?
BP 160/110 or higher + proteinuria
Or BP 140/90-159/109 + any of the following: headache, problems with vision, severe pain below ribs or vomiting, papilloedema, signs of 3 clonus beats or more, liver tenderness, HELLP syndrome, platelets below 100, abnormal AST or ALT
What is HELLP syndrome?
Haemolysis, elevated liver enzymes, and low platelet count
What is the treatment for eclamptic seizures?
Magnesium sulphate and plan delivery
Plus anti-HTN
What drugs can be used in the treatment of severe HTN in pregnancy?
Labetalol
Hydralazine
Nifedipine
What blood pressure target are you aiming for when managing severe HTN in pregnancy?
Below 150/80-100 mmHg
When can levonorgestrel be given?
Preferably within 12 hours, can be given up to 72 hours after UPI
When can Ulipristal Acetate be considered for emergency contraception?
Up to 120 hours after UPI (before 72 hours, levonorgestrel is normally used)
When can an IUD be used as emergency contraception?
Within 5 days of UPI
More effective than levonorgestrel
What us the treatment for Candida or ‘thrush’?
Clotrimazole
Why are inductions booked at 42 weeks?
There is an increased risk of unexplained foetal death beyond 42 weeks gestation
What are the main causes of postpartum haemorrhage?
Uterine atony
Lacerations
Retained products of conception
Defects in coagulation
What is the first line management of post-partum haemorrhage?
Uterine massage and IM Syntocinon
If unsuccessful consider Syntocinon infusion with carboprost
What would be used to treat Chlamydia in a pregnancy?
Erythromycin
NB doxycycline is contraindicated
What is the mechanism of action of oxybutynin?
Direct antimuscarinic
What is the main indication of oxybutynin?
To treat symptoms of an overactive bladder by reducing muscle spasms of the bladder and urinary tract
What is the commonest organism causing a UTI?
E.coli
What is the commonest STI in the UK?
Chlamydia
What are the main symptoms of chlamydia in men?
Often asymptomatic
Dysuria, epididymo-orchitis, clear penile discharge, low-grade fever
Antibiotic prophylaxis is offered to HIV patients against which organism?
Pneumocystis jirovecii
What is the most common cause of multiple painful ulcers on the genitals?
Genital herpes
Which anti epileptics can be continued through pregnancy?
Carbamazepine and lamotrigine are the safest.
Sodium valproate should be avoided
What is the preferred anti-thyroid drug in pregnancy?
Propylthiouracil
Less likely to cross the placenta than carbimazole
What is the first line treatment for HTN during pregnancy?
Labetalol
Methyldopa and nifedipine are suitable alternatives
ACE inhibitors are teratogenic and affect foetal urine production
What is the definition for pre-existing HTN in pregnancy?
BP is >140/90 before pregnancy or up to 20 weeks gestation or the woman is already on anti-HTN
What is the definition for pregnancy induced HTN?
BP is >140/90 after 20 weeks gestation
May be due to transient HTN or pre-eclampsia
What is the medical management for UTI in pregnancy?
Follow local abx guidelines where possible.
Generally nitrofurantoin is preferred, then trimethoprim and then cefalexin
Avoid nitro at term due to risk of neonatal haemolysis
Avoid trimethoprim in first trimester due to its actions as a folic acid antagonist
When should trimethoprim be avoided in treating UTI in pregnancy? Why?
Avoid trimethoprim in first trimester due to its actions as a folic acid antagonist
When should nitrofurantoin be avoided in treating UTI in pregnancy? Why?
Avoid nitrofurantoin at term due to the increased risk of neonatal haemolysis
What is the time frame between men presenting with erectile dysfunction and signs of IHD?
18 months
What are the absolute contraindications to the oral contraceptive pill?
Cancer of the breast and genitalia, end stage liver disease, prev or present VTE, cardiac abnormalities, congenital hyperlipidaemia, undiagnosed abnormal uterine bleeding
What is the risk of a 40 year old woman having a child with Down’s syndrome?
~1/100
What is post-partum thyroiditis?
Hyperthyroidism often within 3 months after birth followed by hypothyroidism at 3-6 months which spontaneously resolves in a third of cases
What is the main indication for the drug Mifepristone?
Medical termination of pregnancy
Can be taken up to 49 days after the last menstrual period
Usually filled by an oral prostaglandin analogue
What is the most common cause of increased testosterone in women?
PCOS
Which medications/classes can cause increase prolactin levels
Anti-psychotics
Metoclopramide
Anti-depressants
Anti-epileptics
What are the main risks to the foetus of obstetric cholestasis
Perinatal mortality Increased incidence of passage of meconium Premature delivery/delivery by caesarean Foetal distress Postpartum haemorrhage
What is the test recommended for screening gestational diabetes?
Oral glucose tolerance test
Why is the HbA1c unreliable in pregnancy?
Because of altered cell turnover and often there is iron deficiency
What is Peyronie’s disease?
Chronic inflammation of the tunica albuginea due to a connective tissue disorder causing the growth of fibrous plaques
Indications for induction of labour?
Prolonged pregnancy - >12 days after EDD
Pre labour PROM where labour does not start
DM mother >38 weeks
Rhesus incompatibility
What is the Bishop’s score?
Pre-labour scoring system to predict whether induction of labour will be required
Score based on the station, dilation, effacement, position and consistency of the cervix
5 or less - unlikely to start without induction
What is the triad of features for Vasa Praevia?
Membrane rupture
Painless vaginal bleeding
Foetal bradycardia/death
