Women's Flashcards
describe the hormonal changes in pregnancy
↑ acth = ↑ cortisol + aldosterone
↑ prolactin
↑ T3/4
↑ progesterone - to maintain pregnancy
↑oestrogen - produced by placenta
describe the resproductive system changes in pregnancy
uterus increase in size = hypertrophy/hyperplasia
cervical discharge
hypertrophy of vaginal muscles + vaginal discharge
describe the CVS changes in pregnancy
↑ blood volume
↑ plasma volume
↑ cardiac output/stroke volume/heart rate
↓ peripheral vasc resistance
↓ blood pressure in early/mid pregnancy
varicose veins
peripheral vasodilation = flushing/hot sweats
describe the respiratory changes in pregnancy
increase tidal volume
increase resp rate
describe the renal changes in pregnancy
↑ renal blood flow
↑ GFR
↑ aldosterone = ↑ Na/water retention
↑ protein excretion
LESS urea + creatinine
dilatation of ureters and collecting system = hydonephrosis
describe the haematological changes in pregnancy
↑ RBC
↑ iron/folate/B12/calcium requirements
↑ WBC
↑ ESR/d dimer
↑ ALP (secreted by placenta)
↓haemoglobin concentration
↓ clotting factors/fibrinogen
↓ haemocrit
↓ platelets
↓ albumin (loss thru kidneys)
describe the skin and hair changes in pregnancy
increase pigmentation due to ↑ melanocyte stimulating hormone = linea nigra and melasma
striae gravidarum
pruitus
spider naevi
palmar erythema
postpartum hair loss
describe the GI changes in pregnancy
delayed gastric emptying
cardiac sphincter relaxation (= heart burn)
reduced secretion of CCK from GB
increased risk of gallstones
dyspepsia
slower gut transit time
small bowel = increase nutrient uptake
large bowel = increased water absorption = constipation risk
what is an ovarian cyst and what is the main type
fluid filled sac
functional = common in premenopausal + fluctuate with hormones
= follicular cyst most common but not harmful
= corpus luteum cyst can cause pain/discomfort/delayed menstruation
describe 5 other types of ovarian cysts
- serous cystadenoma = benign
- mucinous cystadenoma = benign but can become huge
- endometrioma = endometriosis lumps of tissue = pain/disrupt ovulation
- dermoid cyst/germ cell tumour = benign, associated with torsion
- sex cord-stromal tumours = rare, can be malignant
what features suggest ovarian cyst malignancy
abdo bloating
reduced appetite
weight loss
urinary symptoms
pain
ascites/lymphadenopathy
describe the investigations and management for a simple/small ovarian cyst
blood test
USS
CT or MRI if unable to see on USS
laparoscopy and fine needle aspirate
premenopausal + simple cyst <5cm on USS = no further
rule out pregnancy + CA125 tumour marker
what is the tumour marker for ovarian cancer and what does a raised marker indicate
CA125
raised = not specific:
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy
what is the risk of malignancy index
RMI = risk of malignant ovarian mass:
1. menopausal status
2. USS findings
3. CA125 level
describe the management for a larger ovarian cyst
5-7cm - refer to gynae and yearly USS
>7cm - MRI or surgical evaluation = laparoscopy/ovarian cystectoomy/oopherctomy
what are the complications of an ovarian cyst
= ACUTE ONSET PAIN
torsion
haemorrhage into the cyst
rupture = bleeding into peritoneum
what is Meig’s syndrome
triad:
1. ovarian fibroma (mass)
2. pleural effusion
3. ascites
= older women
= remove tumour to resolve effusion/ascites
what is early miscarriage vs late miscarriage
spontaneous termination of pregnancy
early = before 12 weeks
late = 12-24 weeks gestation
what is a missed miscarriage
fetus no longer alive but no symptoms
what is a threatened miscarriage
vaginal bleeding with closed cervix and alive foetus
what is an inevitable miscarriage
vaginal bleeding and open cervix (finger into internal os)
what is an incomplete miscarriage vs complete miscarriage
incomplete = retained products of conception remain in uterus = may need medical/surgical management for miscarriage
complete = full miscarriage, no products left in uterus
what is an anembryonic pregnancy
gestational sac present but no embryo
how is a miscarriage diagnosed
transvaginal USS
1. mean gestational sac diameter (should be >25mm before pole)
2. fetal pole and crown-rump length (should be >7mm before heartbeat)
3. fetal heartbeat = pregnancy considered viable
how is a miscarriage <6 weeks gestation managed
expectantly = allow natural course
repeat urine test 7-10 days
how is a miscarriage >6 weeks gestation managed
early pregnancy assessment unit = USS
1. expectant
2. medical = misoprostol = prostaglandin analogue
3. surgical = manual/electric vacuum aspiration
describe the medical management of miscarriage
misoprostol = prostaglandin analogue
softens cervix and stimualtes contracions
vaginal suppository/oral dose
SE of bleeding/nausea/vomiting/diarrhoea
what is the most common site of ectopic pregnancy
fallopian tubes
what are the risk factors for ectopic pregnancy
previous ectopic
previous PID
previous surgery to fallopian tube
coils
older age
smoking
how does ectopic pregnancy present
6-8 weeks
missed period
constant LIF/RIF pain
vaginal bleeding
lower abdo/pelvic pain
cervical motion tenderness
describe the findings on transvaginal USS of ectopic pregnancy
gestational sac in fallopian tube
mass moving separately to ovary
empty uterus
fluid in uterus
describe a pregnancy of unknown location
positive test but no evidence on USS
= monitor hCG:
should rise by >63% in 48hrs = normal pregnancy
rise <63% = ectopic
fall >50% = miscarriage
describe the management for ectopic pregnancy
- expectant - monitor
- medical = methotrexate
- surgical =laproscopic salpingectomy 1st line
laparoscopic salpingotomy may be used if increased risk of infertility = remove ectopic but fallopian tube remains
what is hyperemesis gravidarum
excessive vomiting with dehydration and ketosis
thought that higher hCG = more vomiting/nausea
start 4-7 weeks
worst 10-12 weeks
resolve 16-20
what is the diagnostic criteria for hyperemesis gravidarum
more than 5% weight loss
dehydration
electrolyte imbalance
describe the antiemetics used in pregnancy
- prochlorperazine (stemetil)
- cyclizine
- ondansetron
- metoclopramide
(ranitidine or omeprazole if bad reflux)
how is moderate/severe hyperemesis gravidarum managed
= unable to tolerate oral
= ketones present on dipstick
1. admit to hospital
2. IV/IM antiemetics
3. IV fluids
4. monitor U&E
5. thiamine supplements
6. thromboprophylaxis
what is menopause
retrospective diagnosis after no periods for 12 months = end of menstruation
average age 51 years
what is perimenopause
period leading up to menopause
irregular periods
mood swings
hot flushes
urogenital atrophy
women >45 years
describe the physiology of menopause
lack of ovarian follicular function
= oestrogen and progesterone LOW
= LH/FSH are HIGH due to absence of negative feedback
describe the symptoms of perimenopause
hot flushes
emotional instability
PMS symptoms
irregular periods
heavier/lighter perods
vaginal dryness/atrophy
reduced libido
what risks are associated with perimenopause
CVS/stroke
osteoporosis
pelvic organ prolapse
urinary incontinence
why is the progesterone depot injection unsuitable for women over 45 years old and when else is it CONTRAINDICATED
SE = weight gain and reduced mineral bone density
contraindicated in current breast cancer
describe the benefits of HRT
relief of menopause symptoms
bone mineral density protection
possible prevent long term morbidity
describe the risks of HRT
breast cancer
VTE - oral HRT increases risk
CVS disease - fine if started under 60y/o or monitored well
stroke - oral HRT increases risk
how should HRT be given in women with intact uterus
need progestogen to be given with oestrogen to protect endometrium from over-proliferating = neoplasm risk (oestrogen effect)
what is the difference between sequential and continuous combined form of HRT
oestrogen everyday
sequential = progesterone 12-14 days every 4 weeks = bleeding
continuous combined = progesterone every day = no bleeding
what is Tibolone
synthetic form of continuous combined HRT taken daily
how is HRT given in those without a uterus/ with a MIRENA in situ
mirena = already supplies progesterone
= no progesterone needed in combination with oestrogen
when is transdermal HRT given
malabsoprtion syndromes
need for steady absorption (epilepsy)
medical conditions
older women
increased risk of VTE
what is premature ovarian insufficiency POI
menopause <40 y/o
= hypergonadotrophic hypogonadism
= under-activity in gonads = lack of negative feedback on pituitary gland = excess of gonadotrophins
= ↑ FSH/LH
= low oestradiol
what are the causes of POI
idiopathic (50%)
iatrogenic - chemo/radio/surgery
autoimmune - associated coeliac, T1DM, adrenal insufficiency
genetic
infections - mumps/TB/CMV
how does POI present and how is it diagnosed
irregular/lack of menstrual periods
hot flushes
night sweats
vaginal dryness
diagnosis = symptoms + <40 y/o + persistently raised FSH
what conditions are women with POI at risk of
CVS disease
stroke
osteoporosis
cognitive impairment
dementia
parkinsons
how is POI managed
HRT until 51 y/o
traditional hrt OR combined OCP
* can still be fertile so contraception is needed*
describe some non hormonal treatments for menopause
CBT
SSRI antidepressants
antiepileptics
what are some contraindications for HRT
breast cancer current or past
known or suspected oestrogen-dependent cancer
undiagnosed vaginal bleeding
VTE previous or current
acute liver disease
pregnancy
thrombophilic disorder
what is the puerperium and what are the features
delivery of placenta to 6 weeks following birth
= return to prepregnant state
= intitiation/suppression lactation
= trasnition to parenthood
describe the prolactin response with breast feeding
baby suckles
prolatin secreted by ant. pit. goes to breasts
lactocytes produce milk
suppresses ovulation
more at night
describe the oxytocin reflex in breastfeeding
baby suckles
oxytocin secreted by post. pit. goes to breasts
myoepithelial cells contract to expel milk
helped by senses of baby
happens before and after feed
what is lactoferrin and what does it do
functional protein in breast milk
high colostrum earlier
regulates Fe absorpt
protects against bacteria/viruses/funghi
helps regulate bone marrow function
boost immune system
what are the signs of sepsis in a new mother
3 Ts with sugar
Temp <36 or >38
Tachycardia >90bpm
Tachypnoea >20
Hyperglycaemia >7.7mmol
WBC >12 or <4(x10^9)
what is adenomyosis and who is it more common in
endometrial tissue inside myometrium = muscle layer of uterus
10% of women
premenopausal women but older than endometriosis
previous uterine surgery
how does adenomyosis present
dysmenorrhoea
menorrhoea
dyspareunia (pain in intercourse)
fertility/pregnancy complications
examination = enlarged and tender uterus
how is adenomyosis diagnosed
transvaginal USS = 1st line
MRI/transabdo USS = alternate
GOLD STD = histological exam after hysterectomy but not always possible
how is adenomyosis managed
depends on sympt/age/pregnancy plans
same Tx as for menorrhagia
specialist options = GnRH to induce menopause or endometrial ablation or hysterectomy
what are some complications of adenomyosis
infertility
miscarriage
preterm birth/rupture of membranes
small for gestational age
postpartum haemorrhage
describe the different types of fibroids
intramural = within myometrium
subserosal = just below outer layer uterus = can fill abdo cavity
submucosal = below lining of uterus
pedunculated = on a stallk
a pregnant woman with history of fibroids presents with severe abdo pain and low grade fever - likely diagnosis?
red degeneration of fibroids
what is pelvic congestion syndrome
incompetence of pelvic vein valves
typical after pregnancy
occurs in 1 in 5 with varicose veins
what are the features of pelvic congestion syndrome
constant dull ache lower abdomen
worse after standing/prolonged standing or after intercourse
can cause interstitial cystitis
what is salpingitis, oophoritis and parametritis
salpingitis = inflammation of fallopian tubes
oophoritis = inflammation of ovaries
parametritis = inflammation of the parametrium (connective tissue around uterus)
what is a vault prolapse
hysterectomy = no uterus
top of vagina descends into vagina
what is a rectocele
defect of post. wall of vagina = rectum prolapse into vagina
= causes constipation and urinary retention
= can use fingers to temporarily fix
what is a cystocele
ant. vagina wall defect = bladder prolapse backwards into vagina
urethra prolapse also possible = urethrocele
what are some risk factors for pelvic organ prolapse
multiple vaginal deliveries
prolonged/traumatic delivery
advanced age an post menopause
obesity
chronic resp disease causing coughing
chronic constipation causing straining
describe the pregnancy trimesters
1st = conception to 12 weeks
2nd = 13-26 weeks
3rd = 27 weeks until birth
what is an USS used to assess in pregnancy
assess growth
liquor volume
umbilical artery doppler
= if abnormal then placenta is insufficient
what mneumonic is used for CTG interpretation
CTG = cardiotocography
Dr = define risk
C = contractions
Bra = baseline rate
V = variability
A = accelerations
D = decelerations (early/variable/late)
O = overall assessment
when is CTG used, when is it suspicious and when is it pathological
high risk pregnancies in hospital
suspicious = 1 non-reassuring feature
pathological = 2+ non reassuring feature or 1+ abnormal feature
what is the gold standard for fetal heart monitoring
fetal scalp ECG
when is the dating scan and what happens at it
10-13+6 weeks
gestational age calculated from crown rump length
multiple pregnancies identified
when is the anomaly scan
18-20+6 weeks
USS to identify anomalies e.g. heart conditions
what occurs at the routine antenatal appointments
symphysis-findal height measured from 24 weeks +
fetal presentation from 36+ wks
urine dip for protein for pre-eclampsia
BP for pre-eclampsia
urine for microscopy = asymptomatic bacteruria
what vaccines are offered to pregnant women
pertussis form 16 wks
influenza when available
live vaccines avoided
how does low lying placenta present and how is it diagnosed
antepartum bleeding
painless bleed
USS
what is intrauterine growth restriction
baby’s growth slows or ceases when in the uterus
part of wider group of small for gestational age fetusus (SGA)
applies to neonates born with features of malnutrition and IN UTERO growth restriction IRRESPECTIVE of birth weight percentile
what signs indicate IUGR
reduced amniotic fluid
abnormal doppler studies
reduced foetal movements
abnormal CTGs
how are low risk women monitored for IUGR
symphysis fundal height at every antenatal appt after 24 wks
plotted on a graph
SFH <10th centile = need serial growth scans with umbilical artery doppler
how are high risk women for SGA monitored
USS measuring:
estimated fetal weight +
abdominal circumference
= growth velocity
umbilical arterial pulsatility index
amniotic fluid volume
what is chorioamnionitis
infection of chorioamniotic membranes and amniotic fluid
= leading cause of maternal sepsis and can cause DEATH
occurs later in pregnancy/during labour
what constitutes a primary/secondary/minor/major PPH
primary = >500mls blood loss after birth of baby
secondary = >24hrs to 2 weeks after birth
minor = <1500mls lost and no shock
major = 1500ml + continuing to bleed OR shock
describe the management of post partum haemorrhage (8 steps)
- resus ABCDE
- lie flat, warm and calm
- 2 large bore cannulas
- bloods for FBC/U&E/clotting
- cross match 4 units
- warmed IV fluid and blood resus as needed
- oxygen regardless of sats
- fresh frozen plasma if clotting abnormalities/after 4 units
what is a secondary postpartum haemorrhage
bleeding occurs 24hrs to 12 week postpartum
likely due to retained products of conception or infection
USS/endocervical swab for infection
treat by surgery or antibiotics for infection
what is a postdural puncture headache and how does it present
accidental dural puncture during epidural
leakage of CFS and reduced pressure in fluid around brain
headache worse on sitting/standing
1-7 days after epidural
neck stiffness/photosensitivity
how is postdural puncture headache treated
lying flat
analgesia
epidural blood patch
what is the leading cause of maternal death up to 6 weeks after pregnancy in the UK
VTE
what is the leading cause of direct deaths 6wk- 1 year after end of pregnancy
maternal suicide
when is the risk of VTE highest
postpartum
name some of the VTE risk factors
smoking
parity over 3/multiple pregnancy
age over 35
bmi under 30
reduced mobility
preeclampsia
varicose veins
family history
thrombophilia
IVF pregnancy
when should VTE prophylaxis be started
28 weeks if 3 RFs
first trimester if 4+ RFs
continues until 6 wk postnatal
temporarily STOPPED in labour
what prophylaxis is given for VTE
LWMH
= enoxaparin
= dalteparin
= tinzaparin
name 2 forms of mechanical VTE prophylaxis
intermittent pneumatic compression
anti-embolic compression socks
how does VTE present
UNILATERAL
calf leg swelling
dilated veins
tender calf
oedema
colour changes
>3cm between calf diameter = significant
how does a PE present
SoB
cough +/- blood
pleuritic chest pain
hypoxia
tachypnoe/tachycardia
how is VTE diagnosed
doppler USS
suspected PE = CXR and ECG
CTPA = definitive diagnosis (higher risk mother)
VQ scan also can be used (higher risk foetus)
what is NOT used for investigation of VTE in pregnancy
D dimer
what are the Tx options for PE in pregnancy
unfractionated heparin
thrombolysis
surgical embolectomy
what is baby blues and when does it present
> 50% women affected
within 1st week post natal
mood swings
low mood
anxiety
irritable
tearful
= usually resolve within 2 weeks
what is postnatal depression and when does it present
1 in 10 women
peak 3 months postnatal
1. low mood
2. anhedonia (lack of pleasure in activities)
3. low energy
sympt for 2 weeks before diagnosis can be made
how is postnatal depression treated
mild = behavioural/therapy
moderate - antidepressants and CBT
severe = specialist psychiatry
what screening tool is used for postnatal depression
edinburgh postnatal depression scale
10 questions 30 points
>10 = suggests diagnosis
what is puerperal psychosis and when/how does it present
rare but severe
2-3 weeks postnatal
- delusions
- hallucinations
- depression
- mania
- confusion
how is puerperal psychosis treated
urgent assessment and input from specialist services
1. admit to mother and baby unit
2. CBT
3. antidepressants/antipsychotics/mood stabilisers
4. electroconvulsive therapy
how are pregnant women with existing mental health concerns managed
referred to perinatal mental health services for specialist input
continue on medications
plan for delivery
neonates monitored for neonatal abstinence syndrome
what is the difference between stress incontinence and urge incontinence
stress incontinence = weak pelvic floor and sphincter muscles
urge incontinence = overactivity of detrusor muscle
what is overflow incontinence
chronic urinary retention due to obstruction to the outflow of urine = overflow of urine = incontinence without urge to pass urine
can occur with neurological conditions (MS, diabetic neuropathy, spinal cord injury)
more common in men
what are the risk factors for urinary incontinence
increased age
post menopause
increase BMI
previous pregnancies/vaginal deliveries
pelvic organ prolapse
pelvic floor surgery
neuro conditions (MS)
cognitive impairment/dementia
describe the physiology of detrusor contraction
parasympathetic S2,3,4 nerves from brain => ACh to muscarinic M3, M3 receptors => detrusor contraction
what is an obstetric fistula
hole develops in birth canal due to childbirth
can be between vagina and rectum/ureter/bladder
result in incontinence of urine or faeces
rare in developed world
urinary catheter/stent can be useful treatment
surgery may be needed to close fistula/repair tissue
what advice should you give when prescribing metronidazole
NO ALCOHOL
can cause disulfiram-like reaction:
nausea/vomiting/flushing
rare = shock + angioedema
what is trichomonas vaginalis and what does it increase the risk of
protozoan with flagella
increase risk:
- contracting HIV
- BV
- cervical cancer
- PID
- pregnancy complications
what is the typical discharge associated with trichomonas vaginalis
frothy
yellow-green
(maybe fishy)
what is the typical examination findings of trichomonas vaginalis
strawberry cervix (colpitis)
= inflammation
= tiny haemorrhages
vaginal pH above 4.5
where should swabs be taken for trichomonas vaginalis
from the posterior fornix of vagina
describe the different strains of herpes virus and what they are associated with
HSV-1 :
= cold sores
= contracted in childhood
= cause genital herpes by oral sex
HSV-2:
= genital herpes
= STI spread
describe the presentation of herpes
initial episode more severe, recurrent = milder
ulcers/blisters
neuropathic pain = tingling/burning
flu-like sympts
dysuria
inguinal lymphadenopathy
how is herpes diagnosed and managed
clinically based on history and exam
viral PCR swab
refer to GUM
Tx = acyclovir
topical lidocaine
paracetamol
vaseline
what is the concern with herpes in pregnancy
risk of neonatal herpes simplex infection = high morbidity and mortality
pregnant woman antibodies should cross placenta and give baby passive immunity
acyclovir still given in pregnancy
asympt women can have vaginal delivery
sympt women should have C section
what is lymphogranuloma venerum (LGV)
condition affects lymphoid tissue around site of chlamydia infection
most common MSM
primary stage = painless ulcer
secondary stage = lyphadenitis swelling/pain
tertiary stage = inflammation of the retum and anus (proctitis)
what is proctocolitis and how does it present
inflammation of rectum and colon
anal pain
change in bowel habit
tenesmus
discharge
how is LGV treated
doxycycline 100mg twice daily for 21 days = 1st line
describe the natural course of HIV
- acute primary infection = transient immunosuppression = low then high CD4
- asymptomatic phase = progressive loss of CD4 = poor immunity
- early symptomatic phase = manifestation of clinical features
how is AIDS defined (late stage HIV)
CD4 <200
immune deficiency symptoms and opportunistic infections
normally 5-10 years to reach AIDS
how is HIV transmitted
- unprotected vaginal/anal/oral sex
- mother to child = vertical
- mucous membranes = blood/bodily fluids
name 6 examples of AIDS defining illnesses
kaposi’s sarcoma
pneumocystisis jirovecci pneumonia (PCP)
CMV
candidiasis
lymphoma
TB
who should be tested for HIV and when
all persons admitted to hospital with infectious disease
all high risks persons
test initially then repeat 3 months later as antibodies take 3 months to build up
what are the HIV infection markers
CD4 count
RNA = viral load
how is HIV treated and what are the treatment aims
antiretroviral therapy (ART) for all people - different regimes depending on person
aims:
achieve normal CD4 count and undetectable viral load
treat individual infections
what is the prophylactic for PCP
co-trimoxazole (septrin)
what monitoring do female patients with HIV need
yearly cervical smears
increased risk HPV and cervical cancer
how should women with HIV give birth
normal vaginal if viral load <50
CS if viral load >50
IV zidovudine if high or unknown viral load
what prophylaxis is given to babies of HIV+ mothers
low risk = zidovudine for 4 weeks
high risk = zidovudine + lamivudine + nevirapine for 4 weeks
what should new mothers with HIV NOT do
breastfeed
what is post menopausal bleeding until proven otherise
endometrial cancer
what is endometrial hyperplasia
precancerous condition = thickening of endometrium
<5% progress to cancer
hyperplasia +/- atypia
treat with IUS or continuous oral progestogens
what HPV strains are responsible for the majority of cervical cancers
type 16
type 18
how does HPV promote the development of cancer
inhibits tumour suppressor genes p53 and pRb
describe the management of smear results (PHE guidelines)
inadequate sample = repeat after at least 3 months
HPV negative = continue routine screening
HPV positive with normal cytology = repeat HPV test 12 months
HPV positive with abnormal cytology = refer for colposcopy
what is a colposcopy
insert speculum and magnify the cervix
can apply stains to differentiate abnormal areas e.g. acetic acid pr schillers iodine test
what is a large loop excision of the transformation zone LLETZ
loop biopsy
can be performed during a colposcopy = removes abnormal epithelium and cauterises the wound
what is a cone biopsy and what is it used for
treatment for cervical intraepithelial neoplasia (CIN)
under GA = cone shaped piece of cervix removed = sample sent to histology
risk of bleeding/infection/pain/scars
what is vulval intraepithelial neoplasia
premalignant proliferation of squamous epithelium of vulva
high grade = associated with HPV + young women 35-50
differentiated = associated lichen sclerosis age 50-60
Tx:
W&W
wide local excision
imiquimod cream
laser ablation
describe the initial investigations for infertility
BMI
chlamydia screening
semen analysis
female hormonal testing
rubella immunity in mum
describe the female hormone testing for infertility
serum LH/FSH on day 2-5 of cycle
serum progesterone on day 21
anti-mullarian hormone
TFT
prolactin when sypts = galactorrhea or amenorrhoea
what is the most accurate indicator of ovarian reserve
antimullarian hormone
what is a hysterosalpingogram (HSG)
scan used to assess shape of uterus and fallopian tube patency
also has therapeutic effect = increase rate of conception
contrast and XR
risk of infection with procedure = prophylactic Abx
screening for STI needed before scan
what is a laparoscopy and dye test
dye injected into uterus = can see entering fallopian tubes
can assess for endometriosis/adhesions and treat
describe the management of anovulation
- weight loss
- clomifene/letrozole = stimulate ovulation
- gonadotrophins
- ovarian drilling = for PCOS
- metformin for insulin insenstitivity and obesity in PCOS
what is clomifene and how does it work
ani-oestrogen given on day 2-6
stops neg feedback of oestrogen = greater GnRH and FSH/LH
how is infertility treated when it is a tubal problem
tubal cannulation during HSG
laparoscopy to remove adhesions/endometriosis
IVF
how are sperm fertility problems managed
surgical sperm retrieval = directly from epididymis
surgical correction of obstuctrion
intra-uterine insemination
intracytoplasmic sperm injection ICSI
donor insemination
what are dermoid cysts/germ cell tumours
benign ovarian tumours can contain hair/skin/teeth/bone
can cause raised alpha FP and hCG
what is a krukenberg tumour
metastasis in the ovary usually from GI tract
‘signet-ring’ appearance on histology
when are women screened for anaemia in pregnancy
booking clinic
28 weeks
screening for haemoglobinopathies, sickle cell and thalassaemia also occur
what are the normal ranges of Hb in pregnancy
booking = >110
28 weeks = >105
post partum = >100
how does the MCV indicate the cause of anaemia
low MCV = iron deficiency
normal MCV = physiological anaemia (pregnancy)
raised MCV = B12/folate deficiency
how is anaemia in pregnancy treated
- iron replacement 200mg 3x daily ferrous sulfate
- low ferritin = iron supplement
test for pernicious anaemia = IM hydroxocobalamin or oral cyanocobalamin - ALL women to take 400mcg folic acid every day + 5mg folic acid if deficient
- thalassaemia = specialist Mx
why is iron deficient anaemia bad in pregnancy
associated with preterm birth and low birthweight
which asthma meds can be used in pregnancy
all of them
what is the leading cause of maternal death in the UK
cardiac disease
ischaemic or congenital
what are some high risk cardiac issues in pregnancy
aortic stenosis
coarctation of aorta
prostetic valves
cyanosed mum
what are the lower risk cardiac issues in pregnancy
mitral/aortic incompetence
ASD
VSD
describe hyperthyroidism in pregnancy
uncommon
often resolves after 1st trimester
risk of thyroid crisis with caridac failure
risk of foetal thyrotoxicosis
can treat with antithyroid drugs (carbimazole)
describe hypothyroidism in pregnancy
common
if untreated = early foetal loss and impaired neuro development
aim for adequate replacement with thyroxine in 1st trimester especially
what screening is needed in pregnant women with pre-existing diabetes
retinopathy screening after booking + at 28 weeks
what is recommended for pregnant women with pre-existing diabetes
planned delivery at 37-38+6 weeks
sliding scale insulin during labour in T1DM
what are the foetal complications for babies with diabetic mothers
neonatal hypoglycaemia
jaundice
polycytheamia
congenital heart disease
cardiomyopathy
what medications should be stopped in pregnancy
(AST)
ACEi/ARBs
Statins
Thiazide and thiazide-like diuretics
what are the complications of gestational diabetes for the mother
DKA
hypoglycaemia (common)
progression of retiopathy
pre-eclampsia
premature labour
what are the complications of gestational diabetes for the baby
miscarriage
stillbirth
macrosomia = shoulder dystocia
fetal abnormality
neonatal hypoglycaemia
what is the effect of chronic renal disease on pregnancy
severe HTN
deterioration renal function
growth restriction
abnormalities due to drug therapy
pre-eclampsia
C section
premature delivery
stillbirth
which medications for HTN are suitable for use in pregnancies
labetalol (other BB not suitable)
CCBs (nifedipine)
alpha blockers (doxazosin)
how are pregnant women with epilepsy managed
5mg folic acid reduce neural tube defects
AVOID sodium valproate = neural tube defects
AVOID phenytoin = cleft lip/palate
CAN USE levetiracem/lamotrigine/carbamazepine
how is a pregnant woman with rheumatoid arthritis managed
AVOID methotrexate = teratogenic
1st choice = hydroxychloroquine
sulfasalazine is safe
corticosteroids can be used in flare ups
how are pregnant women monitored for UTIs
urine dip and urine sample for asymptomatic bacteriuria at booking and routinely at appointments
what are the causes of UTI in pregnant women and how are they managed
e.coli most common
klebsiella pneumoniae
7 days of Abx
- nitrofurantoin (NOT in 3rd trim)
- amoxycilin (after sensitivities)
- cefalexin
AVOID trimethoprim in 1st trimester (and most of pregnancy)
what is chronic hypertension vs pregnancy induced HTN/gestational HTN
chronic = exist before 20 weeks gestation and longstanding
pregnancy induced =occuring after 20 weeks WITHOUT proteinuria
what is PlGF testing
test for placental growth factor
in pre-eclampsia = LOW
can be used to rule out pre-eclampsia
what is used to treat eclampsia
IV magnesium sulfate
how is pre-eclampsia treated after delivery
- enalapril
- nifedipine/amlodipine (1st line black/caribbean)
- labetalol or atenolol
what is HELLP syndrome
Haemolysis
Elavated Liver enymes
Low Plateletes
= complication of preeclampsa
= exacerbation of sympts
= definitive Tx is delivery of child
what are the foetal indications to deliver in preeclampsia
severe foetal growth restriction
nonreassuring foetal test results
oligohydramnios
what are the maternal indications to deliver in preeclampsia
over 38 weeks
plt <100,000
deterioration liver and renal function
suspected placenta abruption
persistent symptoms
name 3 causes of antepartum haemorrhage
- placenta praevia
- placental abruption
- vasa praevia
describe the breast imaging pathway for symptomatic women
under 35:
1. clinical exam
2. targeted USS
over 35:
1. clinical exam
2. bilateral mammogram AND targeted USS
what is mammography used for
1st choice imaging >40
screening asymptomatic
characterise symptomatic abnormalities
follow up and surveillance
detect breast cancer 90%
what are the benefits and limitations of breast MRI
high sensitivity for invasive breast carcinoma
does NOT use ionising radiation
limited availability
expensive
limited biopsy facilities
what are the risk factors for breast cancer
radiotherapy <35 y/o
BRCA1 BRCA2
HRT
Li Fraumeni syndrome
moderate/high alcohol consumption
not breast feeding
nuliparous
when was nhs breast screening introduced and how many lives a year does it save
1988
1400 lives a year
how are high risk women screened for breast cancer
= use MRI
further Ix = USS and biopsy
describe the genetics of breast cancer
BRCA1 = chromosome 17 = 60% BC + 40% ovarian cancer
BRCA2 = chromosome 13 = 40% BC + 15% ovarian cancer
where can breast cancer metastasise to
Lungs
Liver
Bones
Brain
what is a ductal carcinoma in situ DCIS
(pre)cancerous epithelial cells of breast duct
localised 1 area
mammogram Dx
potential to spread locally
30% become invasive
good prognosis if fully excised + adjuvant treatment
what is a lobular carcinoma in situ LCIS (lobular neoplasia)
precancerous condition in premenopausal women
asymptomatic and undetectable in mammogram
incidental Dx on biopsy
30% increase risk of invasive cancer
managed with close monitoring (6 monthly)
what is invasive breast cancer NST
no specific type NST
originate in cells from breast ducts
80% of invasive breast cancers Dx on mammogram
what are invasive lobular carcinomas ILC
10% of invasive breast cancer
originate in cells from lobules
not always visible on mammogram
what is inflammatory breast cancer
1-3%
present similar to abcess/mastitis
swollen/warm/red/tender + PEU D’ORANGE
no response to Abx = consider inflamm breast cancer
worse prognosis
what is paget’s disease of the nipple
eczema of nipple/areolar
red scaly rash = breast cancer of nipple
may represent DCIS/invasive BC
requires biopsy/staging/treatment
name the conditions screened for at antenatal clinic
sickle cell and thalassaemia
infectious diseases
Down’s/Edwards/Patau’s
foetal anomaly scan
diabetic eye screening
what is alpha thalassaemia
depletion of alpha chains
no. faulty genes related to severity
african/asian population
alpha thalassaemia major = fatal (hydrops fatalis)
what is beta thalassaemia
depletion of beta chains
no. fautly genes NOT related to severity
mediterranean/middle east/africa/asia
require lifelong transfusion therapy/chelation therapy to Tx iron overload
when are pregnant women screened for sickle cell
8-10 weeks
prenatal diagnosis (of baby?) by 12+6
can be offered termination
what infectious diseases are women screened for
HIV
Hep B
syphillis
reoffered at 20 weeks to anyone who declines
what are the complications of syphilis in pregnancy
miscarriage
pre-term labour
stillbirth
congenital syphilis
describe the testing for fetal anomaly
downs (T21) edwards (T18) Patau’s (T13)
offered to ALL women
combined test = 11+2 - 14+1 weeks
quadruple testing = 14+2 - 20 weeks
low chance = receive letter
higher chance = screening and offer of prenatal diagnosis
DOCUMENT RESULTS/OUTCOMES
what is edward’s syndrome
T18
incidence ^ with maternal age
80% female
survival rates beyond 1 year = 10%
severe learning difficulties + extremely serious physical disabilities
most = stillborn
what is patau’s syndrome
T13
incidence ^ with maternal age
most stillborn/die shortly after birth
associated with multiple severe foetal abnormalities :
congenital heart defects
holoprosencephaly
face/abdo/urogenital malformations
what is the purpose of the early pregnancy scan
confirm viability
singleton or multiple
estimate gestational age
detect major structural abnormalities
component of screening for trisomy
when are ultrasounds performed in pregnancy
early = 10-14 weeks
structural abnormalities = 18+0 - 20+6
what is the triple assessment for breast cancer
- clinical score
- imaging score
- biopsy score
describe the stages of labour
LATENT:
0-4cm
irregular contractions
cervix begins effacement
2-3 days
ACTIVE:
stronger contractions
1st = 4-10cm
2nd = 10cm - head delivery
3rd = head delivery to placenta delivery
describe the mechanism of labour
DESCENT
FLEXION = fetus head flexes
INTERNAL ROTATION = fetus head pushed onto pelvic floor = with each contraction small rotations to 90 degrees
EXTENSION = fetus extends head during birth
RESTITUTION/EXTERNAL ROTATION = fetus head turn to align with shoulders
BODY DELIVERY
what gynae complaints may FGM present as
dysparareunia
sexual dysfunction/anorgasmia
chronic pain
keloid scar
dysmenorrhoea (including haematocolpos)
urinary obstruction/recurrent UTI
PTSD
what obstetric complains may FGM present as
fear of childbirth
increased risk of CS/PPH/episiotomy/vaginal lacerations
difficulty performing VE in labour
difficulty in catheterisation in labour
what is precocious puberty in boys and girls
girls = before 8
boys = before 9
when is an oral glucose tolerance test performed
in women with risk factors (BMI/ethnicity/family history/obstetric history)
24-28 weeks
when does the fetus have rights
in termination - after 24 weeks is person with rights
mum has a right to refuse emergency CS and fetus has no rights there
define abnormal uterine bleeding
any menstrual bleeding from uterus that is abnormal in volume/regularity/timing or is non-menstrual
what are the causes of heavy menstrual bleeding
uterine fibroids
uterine polyps
adenomysosis
endometriosis (rarely presents this way)
40-60% have no clear pathology on investigation
what are uterine polyps
common benign localised growths of endometrium
fibrous covered by columnar epithelium
disordered cycles of apoptosis and regrowth = polyp
malignancy is RARE
describe the investigation of menorrhagia
- FBC
- TVUSS
- endometrial biopsy if >45 + IMB + unresponsive to Tx
- hysteroscopy if abnormal/concerning Ix
what is post menopausal bleeding
bleeding that occurs after 1 year of amenorrhoea in a woman NOT receiving HRT
name the causes of post menopausal bleeding
vaginal atrophy (most common)
use of HRT
endometrial hyperplasia
endometrial cancer
endometrial polyps
cervical/ovarian cancer
what is endometrial hyperplasia, how is it classified and what are the risk factors
abnormal proliferation of the endometrium
atypical = premalignant condition
without atypia = low risk of carcinoma
risk factors = anything causing increased oestrogen
how does endometrial hyperplasia present
abnormal vaginal bleeding:
intermenstrual
irregular
menorrhagia
post-menopausal
+/- discharge
how is endometrial hyperplasia investigated
endometrial biopsy = definitive diagnosis
hysteroscopy and biopsy
TVUS = can be used to distinguish between normal proliferation and hyperproliferation + indicate need for biopsy
how is endometrial hyperplasia managed
without atypia:
reassurance (cancer risk)
address RFs
WW
progestogen treatment
follow up and monitoring
atypical: (30-40% progress to carcinoma)
hysterectomy +/- salpingo-oophrectomy
what is dysfunctional uterine bleeding
menorrhagia with no underlying cause
diagnosis when other causes excluded
use contraceptives to treat
hysterectomy/endometrial ablation in severe cases
how does ovarian torsion present
sudden onset severe unilateral pelvic pain
pain constant and progressively worse
nausea + vomiting
localised tenderness
palpable mass (not always)
how is ovarian torsion investigated and managed
pelvic USS - TV ideal = whirlpool sign = free fluid in pelvis and oedema of ovary
laparoscopic surgery = definitive diagnosis + detorsion and removal of ovary
describe the complications of ovarian torsion
lead to loss of ovary
necrotic = infected = abcess = sepsis = rupture = peritonitis = adhesions
name some treatments for PMS
COCP containing dispirenone
continuous use of the pill
GnRH analogues to induce menopausal state + HRT
hysterectomy + bilaterla oophorectomy + HRT
danazole + tamoxifen for breast pain
spirinolactone for oedema in PMS
name the causes of hypogonadotrophic hypogonadism
= low LH low FSH low oestrogen
hypopituitarism
damage to hypothalamus/pituitary (surgery/radiation)
chronic condition (IBD/cystic fibrosis)
excessive diet or exercising or stress
constitutional delay = temporary/no underlying pathology
endocrine disorders (hypothyroid/cushings)
kallman syndrome
name the causes of hypergonadotrophic hypogonadism
high LH/FSH but low oestrogen
previous damage to gonads = torsion/cancer/infections
congenital absence of ovaries
turners syndrome X0
what is ashermans syndrome
adhesions in uterus following damage/surgery
can distort pelvic organs and bind walls together/endocervix shut
secondary amenorrhoea
lighter periods
dysmenorrhoea
how is ashermans syndrome diagnosed and managed
hysteroscopy = gold standard
hysterosalpingography = contrast injected and XR
sonohysterography = uterus filled with fluid and USS
MRI scan
dissection of adhesions = treatment
name some causes of oligomenorrhoea
pcos
contraceptives/HRT
perimenopause
thyroid disease/diabetes
eating disorders/excessive exercise
medications = anti-psychotics or anti-epileptics
when would anti D be given to mothers
to Rh -ve mothers:
- abdo trauma
- miscarriage after 12 wks
- bleeding
- 28 wks pregnant
- after birth if baby is +ve
what is a bishop score and what factors are included
= assessment of how likely a woman will go into labour
- dilation of cervix
- effacement of cervix (how thin)
- consistency of cervix (soft/firm)
- position of cervix
- foetal station (how far up birth canal)
what is tested for in a TORCH screening and when is it routinely performed
Toxoplasmosis
Other (parvovirus)
Rubella
Cytomegalovirus
Hepatitis
routinely at 28 wks in all pregnancies
name some indications for induction of labour
prolonged gestation 40-42+ wks
PROM >37 (unless <37 then depending on baby and mother health, <34 = delay)
maternal health - HTN/preeclampsia/DM etc
foetal growth restriction
intrauterine foetal death
what are the contraindications for induction of labour/vaginal delivery
ABSOLUTE:
cephalic disproportion
major placenta praevia
vasa praevia
cord prolapse
transverse lie
acute primary genital herpes
previous classical C section
RELATIVE:
breech
triplet +
2+ low transverse C section
what is the role of prostaglandins in labour
ripen cervix
contraction of SM of uterus
describe the 2 types of premature rupture of membranes
- PROM = rupture at least 1hr prior to onset of labour >37 weeks
occurs in 10-15% pregnancies
minimal risk to mother and baby - Preterm PROM = rupture of membranes <37 weeks
2% pregnancies
higher risk complications
associated with 40% preterm deliveries
what is the kleihauer test
checks how much foetal blood has passed to mother during sensitising event
used after any sensitising event >20wks
check to see if further doses anti-D needed
how is preterm labour prevented
- vaginal progesterone = decreases activity of myometrium and prevent cervix remodelling for delivery
offered 16-24wks <25mm cervical length - cervical cerclage = stitch in cervix to support and keep closed
removed when in labour
given to 16-24wks <25mm and previous preterm
can be given as rescue stitch
what is preterm labour with intact membranes
painful regular contractions and cervical dilatation without rupture of amniotic sac
requires speculum to assess dilatation
requires management of preterm labour
describe the management of preterm labour
- CTG
- tocolysis with nifedipine (CCB suppresses labour)
- maternal corticosteroids for foetal lungs
- IV magnesium sulfate <34wks to protect fetal brain (CP)
- delayed cord clamping/cord milking = increase baby blood volume/Hb at birth
what is given to babies born <34 weeks
magnesium sulfate bolus then infusion for up to 24hrs following birth
prevent cerebral palsy
what needs to be monitored if mother is given IV MgSo4
magnesium toxicity at least 4 hrly
- reduced RR
- reduced BP
- absent reflexes
what is foetal hydrops
occurs in fetal parvovirus B19 infection
parvovirus causes replication of erythoid progenitor cells in liver and BM = severe anaemia
= high output cardiac failure
= increased hepatic erythropoiesis = portal HTN and hypoproteinaemia = ascites
how is foetal hydrops diagnosed and managed
diagnosis on USS:
ascites
subcutaneous oedema
pleural effusion
pericardial effusion
scalp oedema
polyhydroamnios
treatment limited + high fetal mortality
describe the features of congenital rubella syndrome
congenital deafness
congenital cataracts
congenital heart disease (PDA and pulmonary stenosis)
learning disability
risk is higher earlier in pregnancy
describe the management of rubella in pregnancy
<12 weeks = termination of pregnancy
12-20 weeks = prenatal diagnosis required, if fetal rubella confirmed = termination of pregnancy of USS surveillance of defects
>20 weeks no action required
what is congenital cytomegalovirus
occurs due to CMV infection in mother
spread by infected saliva/urine of asymptomatic children
features:
- fetal growth restriction
- microcephaly
- hearing loss
- vision loss
- learning disability
- seizures
what is congenital toxoplasmosis
toxoplasma gondii parasite spread by cat faeces
risk is higher later in pregnancy
TRIAD:
1. intracranial calcification
2. hydrocephalus
3. chorioentinitis (inflammation choroid and retina of eye)
describe the complications of parvovirus in pregnancy
miscarriage/foetal death
severe foetal anaemia
hydrops fetalis
maternal pre-eclampsia-like sydrome
describe maternal pre-eclampsia-like syndrome
aka mirror syndrome
rare complication of hydrops fetalis
1. hydrops fetalis
2. placental oedema
3. oedema in mother
- HTN
- proteinuria
describe the risk factors of GBS infection of the neonate
GBS in previous baby
prematurity <37 weeks
rupture of membranes >24hrs before delivery
pyrexia during labour
positive GBS in mother
mother diagnosed with GBS UTI in pregnancy
**give benpen
what are the indications for an instrumental delivery
failure to progress
fetal distress
maternal exhaustion
control of the head in various fetal positions
epidural = increased risk instrumental
what are the risks for the mother of an instrumental delivery
PPH
episiotomy
perineal tears
injury to anal sphincter
bladder/bowel incontinence
nerve injury (obturator/femoral)
what are the risk to the baby of an instrumental delivery
cephalohaematoma with ventous
facial nerve palsy with forceps
serious:
- subgaleal haemorrhage
- intracranial haemorrhage
- skull fracture
- spinal cord injury
which type of twin pregnancy is most successful
diamniotic dichorionic
how does each type of twin present on USS
dichorionic diamniotic = membrane between + lamda/twin peak sign
monochorionic diamniotic = membrane between + T sign
monochorionic monoamniotic = no membrane separating
when do foetal movements begin to be felt
16-24 weeks
generally after 20 weeks
what is the average birth weight of a healthy baby
3-4kg
6-8lbs
describe the difference between miscarriage and stillbirth
early miscarriage = <12 weeks
late miscarriage = 12-24wks
stillbirth = birth of a dead foetus after 24 weeks
describe the types malpresentation
most common = breech
complete = hips and knees flexed
frank = flexed at hips, extended at knees (most common)
footling = one or both legs extended at hip, foot is presenting part
oblique lie = head in iliac fossa
transverse lie = lie across abdomen
unstable lie = changes day to day
what is the best foetal position for vaginal delivery
occipito-anterior
which position is most associated with umbilical cord prolapse
footling breech
describe the usual position of the head at engagement
occipitotransverse
describe the important diameters in brow and face presentation
brow presentation = mentovertical
face presentation = submentobregmatic
describe the management of breech birth
- external cephalic version = manipulate foetus into cephalic pres. BUT contraindications
- C section
- vaginal delivery but requires highly skilled practitioners
how might breech presentation present
meconium stained liquor = foetal distress due to breech
what are the risk factors associated with obesity in pregnancy
gestational diabetes
pre-eclampsia
gestational HTN
sleep apnoea
macrosomia
birth defects
miscarriage
preterm birth
stillbirth
what are some risk factors for congenital anomalies
genetic factors
socioeconomic factors (lack of access to healthcare)
environmental factors (chemicals/medications)
infections (rubella/syphillis)
maternal nutrition (folic acid)
what are the most common congenital anomalies
heart defects
neural tube defects
downs syndrome
abortion is legal up until
24 weeks
1990 human fertilisation and embryology act
what are the legal requirements for an abortion
2 registered medical practitioners must agree
carried out by registered practitioner in an NHS hospital/clinic
describe a medical abortion
mifepristone (anti-progestogen) = halt pregnancy/relax cervix
misoprostol (prostaglandin analogue) = softens cervix/stimulate contractions
rhesus negative = require antiD
fetus will be expelled
describe a surgical abortion
under local/local+sedation/general
give misoprostol/mifepristone before
cervical dilation with suction (up to 14weeks) or forceps (14-24 weeks)
what is a hydatiform mole
= molar pregnancy
= growing mass of tissue in uterus that will not develop into a baby
complete hydatidiform mole = empty egg fertilised
partial = 2 sperm 1 egg
higher levels of hCG
vaginal bleeding early in pregnancy
diagnosed through USS and hCG
need to be removed through tube into uterus and suction
small risk of developing gestational trophoblastic neoplasia
continual monitoring of hCG afterwards
what causes gonorrhoea and how does it present
gram negative diplococcus bacteria infecting mucous membranes of columnar epithelium
can affect urethra/rectum/conjunctivwa/pharynx
= STI
females (90% sympt) vs males (50%):
odourless purulent discharge
dysuria
pelvic pain/testicular pain
how is gonorrhoea diagnosed
nucleic acid amplification test NAAT to detect rna/dna of gonorrhoea
charcoal endocervical/vulvovaginal/urethral/1st catch urine/rectal/pharyngeal swabs
standard charcoal endocervical swab for microscopy/culture/sensitivities
how is gonorrhoea managed
high levels of antibiotic resistance
single dose IM ceftriaxone 1g OR oral ciprofloxacin 500mg is sensitivities known
need follow up test
abstain from sex 7 days
treat other STIs
consider safeguarding
name some complications of gonorrhoea
PID
chronic pelvic pain
infertility
epididymo-orchiditis
conjunctivities
neonatal gonococcal conjunctivitis during birth
what is a disseminated gonoccocal infection
= complication of gonorrhoea = bacteria spread to skin and joints
various non-specific skin lesions
polyarthralgia
migratory polyarthritis
tenosynovitis
systemic symptoms
what is the danger of chicken pox in pregnancy
if immune = no problems
not immune = given VZ Igs
chickenpox <28 weeks = developmental problems
chickenpox around delivery = dangerous neonatal infection = VZ Igs + aciclovir
what constitutes proteinuria
urine protein = Cr >30mg/mmol
urine albumin = Cr >8mg/mmol
what is a strong indicator of rupture of membranes and where is it found
insulin-like growth factor protein binding 1 is found in amniotic fluid
if present in vagina = strong indicator of RoM
what are the causes of PPH
Tone = most common
Trauma
Tissue - clots/retained products
Thrombin - bleeding
