Women's Health Flashcards
1
Q
What are the risk factors for Ovarian Cancer?
A
Family History - mutations of BRCA1 or BRCA2 gene
Many ovulations - early menarche, late menopause, nulliparity
2
Q
What are the features of Ovarian Cancer?
A
- Abdominal distension and bloating
- Abdominal and pelvic pain
- Urinary symptoms e.g. Urgency
- Early satiety
- Diarrhoea
3
Q
What are the investigations for ovarian cancer?
A
CA125
(Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level)
- If CA125 is raised, urgent ultrasound scan must be ordered
4
Q
What is the management of ovarian cancer?
A
Combination of surgery and platinum-based chemotherapy
5
Q
Which cancers does BRCA2 increase risk for?
A
- Ovarian cancer
- Breast cancer
6
Q
Which female cancers does obesity increase risk for?
A
- Breast cancer
- Endometrial cancer
7
Q
Which risk factor is the strongest for endometrial cancer?
A
Polycystic ovarian syndrome
8
Q
What are the risk factors for endometrial cancer?
A
- Obesity
- Nulliparity
- Early menarche
- Late menopause
- Unopposed oestrogen
- Diabetes Mellitus
- Tamoxifen
- PCOS
- Hereditary non-polyposis colorectal cancer
9
Q
What are the features of endometrial cancer?
A
Postmenopausal bleeding - classic symptom
Change intermenstrual bleeding in premenopausal women
Pain and discharge are unusual features
10
Q
What is the management of endometrial cancer?
A
Localised disease -> Total abdominal hysterectomy and bilateral salpingo-oophorectomy
High risk disease will have post-operative radiotherapy
11
Q
What are protective factors for endometrial cancer?
A
Oral contraceptive pill
Smoking
12
Q
What is the stereotypical history for endometriosis?
A
Nulliparous woman presenting with severe dysmennorhoea, heavy and irregular bleeding, dyspareunia and pain on defecation
13
Q
What is endometriosis?
A
Condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity
14
Q
What are the features of endometriosis?
A
Chronic pelvic pain
Secondary dysmenorrhoea - pain begins before bleeding
Deep dyspareunia
Subfertility
Urinary symptoms
15
Q
What would be noted in a pelvic examination in endometriosis?
A
Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometriotic lesions
16
Q
What is the gold standard investigation for endometriosis?
A
Laparoscopy
17
Q
What is the primary management of endometriosis?
A
NSAIDs and/or paracetamol
OCP or progestogens
18
Q
What is the secondary management of endometriosis?
A
GnRH analogues
Surgery may improve fertility
19
Q
From which ages is incidence of cervical cancer highest?
A
Ages 25-29
50% of cases occur in women under 45
20
Q
Which types of cervical cancer are there?
A
Squamous cell cancer (80%)
Adenocarcinoma (20%)
21
Q
What is the biggest risk factor for cervical cancer?
A
HPV virus
Serotypes 16, 18, 33
22
Q
What are the risk factors for cervical cancer
A
- Smoking
- HPV
- HIV
- Early first intercourse, many sexual partners
- High parity
- Lower socioeconomic status
- Combined OCP
23
Q
What are the features of cervical cancer?
A
- Abnormal vaginal bleeding - postcoital, intermenstrual or postmenopausal bleeding
- Vaginal discharge
- Can be detected during routine cervical cancer screening
24
Q
What are the benefits and harms of the Combined OCP?
A
Benefits:
1. >99% effective if taken correctly
Harms:
1. Small risk of blood clots
2. Very small risk of heart attacks and strokes
3. Increased risk of breast cancer and cervical cancer
25
How can the Combined OCP be taken?
1. Conventionally - 21 days on then stopped for 7 days (withdrawal bleeding)
2. No pill-free interval
3. "Tricycling" - three 21 day packs back to back before having a 4-7 day break
26
What is the mechanism of the intrauterine contraceptive device?
Decreases sperm motility and survival
27
What is the mechanism of the combined OCP?
Inhibits ovulation
28
What is the mechanism of the progesterone-only-pill
Thickens cervical mucus
29
What is the mechanism of action of the Desogestrel-only pill?
Primary: Inhibits ovulation
Also thickens cervical mucus
30
What is the mode of action of levonorgestrel (Morning-after pill/Levonelle/ellaOne)
Inhibits ovulation
31
Which contraceptives are effective immediately?
Intrauterine device (Copper coil)
32
Which contraceptives are effective after 7 days?
Nexplanon (implantable contraceptive)
Combined oral contraceptive pill
Intrauterine system (e.g. Mirena)
Depo Provera (injectable contraceptive)
33
What are the causes of Post partum haemorrhage (PPH)?
Four T's:
1. Tone (uterine atony)
2. Trauma (e.g. perineal tear)
3. Tissue (e.g. retained placenta)
4. Thrombin (e.g. clotting/bleeding disorder)
34
What are the risk factors for PPH?
1. Previous PPH
2. Prolonged labour
3. Pre-eclampsia
4. Increased maternal age
5. Polyhydramnios
6. Emergency Caesarean section
7. Placenta praevia, placenta accreta
8. Macrosomia
35
What is the management of PPH?
Life-threatening emergency - senior members of staff involved immediately
1. ABC Approach
- Two peripheral cannulae, 14 gauge
- Lie the woman flat
- Bloods including group and save
- Commence warmed crystalloid infusion
2. Mechanical
- Palpate the uterine fundus and rub to stimulate contractions
- Catheterisation to prevent bladder distension, monitor urine output
3. Medical
- IV oxytocin - slow IV injection, followed by IV infusion
- Ergometrine slow IV or IM
- Carboprost IM
- Misoprostol sublingual
4. Surgical - if medical options fail
- Intrauterine balloon tamponade
- B-Lynch suture, ligation of uterine arteries or internal iliac arteries
36
When would a secondary postpartum haemorrhage occur?
24 hours-6 weeks after birth
Usually due to retained placental tissue or endometriosis
37
What are the drug contraindications of breastfeeding?
1. Antibiotics - ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
2. Psychiatric drugs - lithium, benzodiazepines, clozapine
3. Aspirin
4. Carbimazole
5. Methotrexate
6. Sulfonylureas
7. Cytotoxic drugs
8. Amiodarone
38
What other contraindications of note are there to breastfeeding?
Galactosaemia
Viral infections +/- HIV
39
What treatment would be offered at 36 weeks gestation?
Check presentation - offer external cephalic version if needed
Information on breast feeding, VitK and "baby blues"
40
What is offered at 18-20+6 weeks gestation?
Anomaly Scan
41
What is PCOS (Polycystic ovary syndrome)?
- Complex condition thought to affect 5-20% of women of reproductive age
- Both hyperinsulinaemia and high levels of LH are seen
42
What are the features of PCOS?
1. Subfertility and infertility
2. Menstrual disturbances: oligomenorrhoea and amenorrhoea
3. Hirsutism, acne (due to hyperandrogenism)
4. Obesity
5. Acanthosis nigricans (due to insulin resistance)
43
What are the investigations for PCOS?
- Pelvic ultrasound - multiple cysts on ovaries
- FSH, LH (LH:FSH ratio raised), prolactin (normal or mildly elevated), TSH, testosterone (normal or mildly raised), sex-hormone-binding globulin (normal to low)
- Check for impaired glucose tolerance
44
What is used to diagnose PCOS?
Rotterdam Criteria - 2/3 of:
1. Infrequent or no ovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
45
What are the risk factors for urinary incontinence?
1. Advancing age
2. Previous pregnancy and childbirth
3. High BMI
4. Hysterectomy
5. Family history
46
What are the types of urinary incontinence?
1. Overactive bladder/urge
2. Stress
3. Mixed
4. Overflow
5. Functional
47
What is the treatment for stress incontinence?
1. Pelvic floor muscle training
2. Surgical procedures - retropubic mid-urethral tape procedures
3. Duloxetine - increases stimulation of urethral striated muscles within sphincter
48
When would you refer a woman for a colposcopy after a smear test?
1. Sample is hrHPV +ve + cytologically abnormal
2. Two consecutive inadequate samples then
3. 2nd repeat smear at 24 months is still hrHPV +ve (all recent smears cytologically normal)
49
When would you repeat a smear in 12 months?
1. Sample is hrHPV +ve + cytologically normal
2. 1st repeat smear at 12 months is still hrHPV +ve (all recent smears cytologically normal)
50
At what gestation would a rhesus negative woman receive Anti-D prophylaxis?
28 weeks - 1st dose
34 weeks - 2nd dose
51
What is androgen insensitivity syndrome?
An X-linked recessive condition due to end-organ resistance to testosterone, causing genotypically male children to have female phenotype
52
What are the features of androgen insensitivity syndrome?
1. 'Primary amennorhoea'
2. Undescended testes causing groin swellings
3. Breast development may occur as a result of conversion of testosterone to oestradiol
53
What can be used to diagnosed androgen insensitivity syndrome?
Buccal smear or chromosomal analysis to reveal 46XY genotype
54
What is the management of androgen insensitivity syndrome?
Counselling
Bilateral orchidectomy
Oestrogen therapy
55
When should a booking visit occur with a midwife?
8-12 weeks
Ideally <10 weeks
56
What is placental abruption?
Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into intervening space
57
How common is placental abruption?
Occurs in 1/200 pregnancies
58
What are the factors associated with placental abruption?
1. Proteinuric hypertension
2. Cocaine use
3. Multiparity
4. Maternal trauma
5. Increasing maternal age
59
What are the clinical features of placental abruption?
1. Shock out of keeping with visible loss
2. Constant pain
3. Tender, tense uterus
4. Normal lie and presentation
5. Fetal heart: absent/distressed
6. Coagulation problems
Beware pre-eclampsia, DIC, anuria
60
What is the typical presentation of pelvic inflammatory disease?
20-year-old woman presenting with 1 week history of constant cramping lower abdominal pain, intermenstrual bleeding, dyspareunia and dysuria
61
What are the causative organisms of Pelvic inflammatory disease?
Chlamydia trachomatis
Neisseria gonorrhoea
Mycoplasma genitalium
Mycoplasma hominis
62
What is Pelvic inflammatory disease (PID)?
Infection and inflammation of female pelvic organs including uterus, fallopian tubes, ovaries and peritoneum
63
What are the clinical features of PID?
1. Lower abdominal pain
2. Fever
3. Deep dyspareunia
4. Dysuria and menstrual irregularities may occur
5. Vaginal or cervical discharge
6. Cervical excitation
64
What are the investigations of PID?
- Pregnancy test should be done to exclude an ectopic pregnancy
- High vaginal swab - these are often negative
- Screen for Chlamydia and Gonorrhoea
65
How is PID managed?
Low threshold for treatment:
- Oral ofloxacin + oral metronidazole or;
- Intramuscular ceftriaxone + oral doxycycline + oral metronidazole
66
What complications are associated with PID?
- Perihepatitis (Fitz-Hugh Curtis Syndrome) - occurs in around 10% of cases (RUQ pain)
- Infertility - the risk may be as high as 10-20% after a single episode
- Chronic pelvic pain
- Ectopic pregnancy
67
What are the symptoms of menopause
1. Change in periods - length, dysfunctional uterine bleeding
2. Vasomotor symptoms - hot flushes, night sweats
3. Urogenital changes -Vaginal dryness and atrophy, urinary frequency
4. Psychological - anxiety, depression, short-term memory impairment
5. Longer term complications - osteoporosis, increased risk of IHD
68
What causes symptoms in menopause
Reduced levels of female hormones - mainly oestrogen
69
What are the risk factors for vulval cancer?
HPV infection
Vulval intraepithelial neoplasia
Immunosuppression
Lichen sclerosus
70
What are the features of vulval cancer?
1. Lump or ulcer on labia majora
2. Inguinal lymphadenopathy
3. Itching, irritation
71
What is shoulder dystocia?
A complication of vaginal cephalic delivery in which the body of the fetus cannot be delivered despite the head being delivered.
It usually occurs due to impaction on the anterior fetal shoulder on the maternal pubic symphysis
72
What are the risk factors for shoulder dystocia?
1. Fetal macrosomia (hence association with maternal diabetes mellitus)
2. High maternal body mass index
3. Diabetes mellitus
4. Prolonged labour
73
How can shoulder dystocia be managed?
- Senior help should be called as soon as it is identified
- McRoberts' manoeuvre
74
What is McRobert's Manoeuvre
- Used in Shoulder dystocia
Flexion and abduction of the maternal hips, bringing mothers' thighs toward abdomen, increasing relative anterior-posterior angle of the pelvis and often facilitates successful delivery
75
What are the potential complications of shoulder dystocia?
Maternal:
- Postpartum haemorrhage
- Perineal tears
Fetal
- Brachial plexus injury
- Neonatal death
76
How is an ectopic pregnancy investigated?
Pregnancy test
Investigation of choice - transvaginal ultrasound
77
What are the stages of Ovarian cancer?
Stage 1 - Tumour confined to ovary
Stage 2 - Tumour outside ovary but within pelvis
Stage 3 - Tumour outside pelvic but within abdomen
Stage 4 - Distant metastasis
78
What is endometrial hyperplasia?
Abnormal proliferation of endometrium in excess of normal proliferation occurring during menstrual cycle
79
What does endometrial hyperplasia increase the risk of?
Endometrial cancer
80
What are the two main types of caesarean section?
1. Lower segment caesarean section - 99% of cases
2. Classic caesarean section - longitudinal incision in the upper segment of the uterus
81
What are the indications for C-Section?
1. Absolute cephalopelvic disproportion
2. Placenta praevia grades 3/4
3. Pre-eclampsia
4. Post-maturity
5. IUGR
6. Fetal distress in labour/cord prolapse
7. Failure to progress
8. Malpresentations - brow
9. Placental abruption
10. Vaginal infection
11. Cervical cancer
82
What would categorise a Category 1 C-Section?
Immediate threat to life of mother or baby
e.g. Suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia, persistent fetal bradycardia
- Delivery should occur within 30 minutes of decision
83
What would categorise a Category 2 C-Section?
Maternal or fetal compromise not immediately life threatening
- Should occur within 75 minutes of decision
84
What would categorise a Category 3 C-Section?
Delivery required but both mother and baby are stable
85
What would categorise a Category 4 C-Section?
Elective caesarean
86
When is Vaginal Birth after caesarean (VBAC) appropriate?
Appropriate for delivery for pregnant women >= 37 weeks gestation with single previous caesarean
- Successful in 70-75%
87
What are the contraindications for VBAC?
Previous uterine rupture
Classical caesarean scar
88
What is menorrhagia?
Heavy menstrual bleeding (defined as total blood loss >80ml per menses)
- Tailored to what a woman believes is excessive
89
What are the investigations for menorrhagia?
FBC
Transvaginal ultrasound scan if relevant symptoms
90
How can menorrhagia be managed?
Requiring contraception:
1. Intrauterine system (mirena) - first-line
2. Combined oral contraceptive pill
3. Long-acting progestogens
Not requiring contraception:
1. Menenamic acid or tranexamic acid
2. Referral
91
What is used as first-line treatment in infertility in PCOS?
Clomifene
92
What are the long term complications of vaginal hysterectomy?
Enterocele
Vaginal vault prolapse
93
What are the typical symptoms of vaginal candidiasis?
Vulval discomfort
Thick, white, 'curdy', non-odorous vaginal discharge with pH <4.5
Vulval erythema, fissuring, satellite lesions
94
What are the typical symptoms of bacterial vaginosis?
1. Vulval itching
2. Discomfort
3. Thin, homogenous, white-grey, 'fishy' discharge
4. pH >4.5
95
What are the risk factors for candidiasis?
Diabetes mellitus
Drugs: antibiotics, steroids
Pregnancy
Immunosuppression: HIV
96
What are the management options for vaginal candidiasis?
1. Oral fluconazole
2. Clotrimazole intravaginal pessary
3. Topical imidazole
97
What are the side effects of hormone replacement therapy?
Nausea
Breast tenderness
Fluid retention and weight gain
98
What are the potential complications with HRT?
1. Increased risk of breast cancer - increased by progesterone
2. Increased risk of endometrial cancer
3. Increased risk of VTE
4. Increased risk of stroke
5. Increased risk of IHD if taken more than 10years post-menopause
99
What are the signs of fetal hypoxia on a CTG?
One or more of:
1. Baseline bradycardia
2. Baseline tachycardia
3. Loss of variability
4. Early decelerations
5. Late decelerations
6. Variable decelerations
100
What is the normal fetal heart rate?
100-160 bpm
101
What should be given to pregnant obese women?
5mg Folic acid
102
What is premature ovarian insufficiency defined as?
Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
Occurs in 1 in 100 women
103
What are the causes of premature ovarian insufficiency?
Idiopathic
Bilateral oophorectomy
Radiotherapy and chemotherapy
Infection
Autoimmune disorders
Resistant ovary syndrome
104
What are the symptoms of premature ovarian failure?
Climacteric symptoms - hot flushes, night sweats
Infertility
Secondary amenorrhoea
Raised FSH and LH
Low oestradiol
105
How is premature ovarian insufficiency managed?
HRT or OCP until 51 years (average age of menopause)
106
What SSRIs are appropriate in pregnancy?
Sertraline
Paroxetine
107
What is the epidemiology of preterm prelabour rupture of membranes (PPROM)?
2% of pregnancies
40% of preterm deliveries
108
What are the complications of PPROM?
Fetal - prematurity, infection, pulmonary hypoplasia
Maternal - chorioamnionitis
109
How can PPROM be diagnosed?
- Sterile speculum examination - pooling of amniotic fluid in posterior vaginal vault
- Ultrasound to show oligohydramnios
110
How is PPROM managed?
1. Admission
2. Regular obs to ensure no chorioamnionitis
3. Oral erythromycin for 10 days
4. Antenatal corticosteroids - reduce risk of RDS
5. Delivery considered at 34 weeks gestation
111
When would be classed as an early miscarriage?
Before 13 weeks
112
When would be classed as a late miscarriage?
13-24 weeks
113
What are the signs of a threatened miscarriage?
1. Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
2. The bleeding is often less than menstruation
3. Cervical os is closed
4. Complicates up to 25% of all pregnancies
114
What are the signs of an inevitable miscarriage?
1. Heavy bleeding with clots and pain
2. Cervical os open
115
What are the signs of an incomplete miscarriage?
1. Not all products of conception have been expelled
2. Pain and vaginal bleeding
3. Cervical os open
116
What are the signs of a missed miscarriage?
1. Gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
2. Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
3. Cervical os is closed
4. When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'
117
What can precipitate thrush?
Recent antibiotic exposure
118
What is puerperal pyrexia defined as?
Temperature of >38 degrees in first 14 days following delivery
119
What are the causes of puerperal pyrexia?
1. Endometritis
2. UTI
3. Would infections
4. Mastitis
5. VTE
120
What is the management for endometritis?
Admission, IV Clindamycin and gentamycin until afebrile > 24hours
121
What are the types of ovarian cysts?
1. Physiological cysts
2. Benign germ cell tumours
3. Benign epithelial tumours
122
What are examples of physiological cysts?
1. Follicular cysts
2. Corpus luteum cysts
123
What is a follicular cyst?
- Commonest type of ovarian cyst
- Occurs due to non-rupture of dominant follicle or failure of atresia in a non-dominant follicle
- Commonly regress after several menstrual cycles
124
What is a corpus luteum cyst?
- Occurs when the corpus luteum does not break down - fills with blood or fluid, forming a cyst
- More likely to present with intraperitoneal bleeding than follicular cysts
125
What are the examples of benign germ cell tumours?
Dermoid cysts
126
What are the examples of benign epithelial tumours?
Serous cystadenoma
Mucinous cystadenoma
127
What are the features of a dermoid cyst?
Lined with epithelial tissue, may contain skin appendages, hair and teeth
- Most common benign ovarian tumour in women under age of 30
- Median age of diagnosis is 30
Bilateral in 10-20%
- Usually asymptomatic. Torsion is more likely than with other ovarian tumours
128
What are the features of a serous cystadenoma?
Most common benign epithelial tumour bearing resemblance to most common ovarian cancer (serous carcinoma)
- Bilateral in about 20%
129
What are the features of a mucinous cystadenoma?
Second most common benign epithelial tumour
Typically large
Can cause pseudomyxoma peritonei if ruptured
130
What ovarian cyst is most commonly associated with Meigs' syndrome?
Fibroma
131
What are the classical symptoms of an ectopic pregnancy?
Vaginal bleeding
Referred shoulder tip pain
132
What is placenta praevia?
Placenta lying wholly or partly in the lower uterine segment
133
What are the associated features of placenta praevia?
Multiparity
Multiple pregnancy
Embryos more likely to implant on lower segment scar from previous caesarean section
134
What are the clinical features of placenta praevia?
1. Shock in proportion to visible loss
2. No pain
3. Uterus not tender
4. Lie and presentation abnormalities
5. Fetal heart usually normal
6. Coagulation provlems rare
7. Small bleeds before large
135
How is placenta praevia diagnosed?
Often picked up on 20-week scan
Transvaginal ultrasound
- NOT digital vaginal examination
136
What are the grades of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn't cover it
III - placenta covers the internal os before dilation but not when dilated
IV ('major') - placenta completely covers the internal os
137
What is umbilical cord prolapse?
Umbilical cord descending ahead of the presenting part of the fetus
- Can lead to compression of the cord or cord spasm, causing fetal hypoxia
138
What are the risk factors for cord prolapse?
1. Prematurity
2. Multiparity
3. Polyhydramnios
4. Twin pregnancy
5. Cephalopelvic disproportion
6. Abnormal presentations e.g. Breech, transverse lie
139
What percentage of cord prolapses occur at artificial rupture of membranes?
50%
140
How can cord prolapse be managed?
Obstetric emergency:
- Presenting part of fetus may be pushed back into uterus to avoid compression
- If cord is past introitus, minimal handling and should be kept warm to avoid vasospasm
- "All fours" position
- Retrofilling of the bladder
- Tocolytics
- Caesarean section - FIRST LINE
141
What is hyperemesis gravidarum associated with?
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity
142
How is hyperemesis gravidarum managed?
Antihistamines - oral cyclizine/promethazine first-line
Ondansetron/metoclopramide second-line
143
What are the complications of hyperemesis gravidarum?
Wernicke's encephalopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Fetal: small for gestational age, pre-term birth
144
What are the causes of delayed puberty (in people with short stature)?
Turner's syndrome
Prader-Willi syndrome
Noonan's syndrome
145
What are the causes of delayed puberty (in people with normal stature)?
Polycystic ovarian syndrome
Androgen insensitivity
Kallman's syndrome
Klinefelter's syndrome
146
What is pre-eclampsia
Emergence of high blood pressure during pregnancy
- May be a precursor to eclampsia
147
What is the classical triad of pre-eclampsia features?
New-onset hypertension
Proteinuria
Oedema
148
What is the definition of pre-eclampsia?
New-onset BP >= 140/90 after 20 weeks of pregnancy AND 1 or more of:
- Proteinuria
- Other organ involvement
149
What is the most common causative organism in candidiasis (thrush)?
Candida albicans
150
What are the risk factors for ectopic pregnancy?
1. Damage to tubes (pelvic inflammatory disease, surgery)
2. Previous ectopic
3. Endometriosis
4. IUCD
5. Progesterone only pill
6. IVF (3% of pregnancies are ectopic)
151
What is the diagnostic criteria triad of hyperemesis gravidarum?
1. 5% pre-pregnancy weight loss
2. Dehydration
3. Electrolyte imbalance
152
What are uterine fibroids?
Benign smooth muscle tumours of the uterus
153
What are the features of uterine fibroids?
May be asymptomatic
Menorrhagia
Lower abdominal pain
Bloating
Urinary symptoms - frequency
Subfertility
- Uterus can feel bulky on examination
154
What are the features of adenomyosis?
Enlarged uterus
Menorrhagia
Abdominal pain
"Boggy uterus" with subendometrial linear striations
155
How are fibroids diagnosed?
Transvaginal ultrasound
156
What would the management of fibroids be?
Management of menorrhagia:
- Levonorgestrel intrauterine system
- NSAIDs
- Tranexamic acid
- Combined OCP
- Oral progestogen
- Injectable progestogen
Treatment to shrink fibroids
Medical - GnRH agonists
Surgical - myomectomy, hysterectomy, hysteroscopic endometrial ablation
Uterine artery embolisation
157
What is the prognosis for fibroids?
Generally regress after menopause
- Some complications e.g. subfertility and iron-deficiency anaemia
158
What is the medical management of PPH?
IV Oxytocin
Ergometrine slow IV or IM
Carboprost IM
Misoprostol sublingual
159
What is defined as a first degree tear?
Superficial damage with no muscle repair
Does not require repair
160
What is defined as a second degree tear?
Injury to perineal muscle but not involving the anal sphincter
Require suturing on ward
161
What is defined as a third degree tear?
Injury to perineum involving the anal sphincter complex
Requires repair in theatre
162
What is defined as a fourth degree tear?
Injury to perineum involving the anal sphincter complex and rectal mucosa
Require repair in theatre by a suitably trained clinician
163
What are the risk factors for perineal tears?
1. Primigravida
2. Large babies
3. Precipitant labour
4. Shoulder dystocia
5. Forceps delivery
164
What is the definition of labour?
The onset of regular and painful contractions associated with cervical dilation and descent of the presenting part
165
What are signs of labour?
1. Regular and painful uterine contractions
2. A show - shedding of mucous plug
3. Rupture of the membranes
4. Shortening and dilation of the cervix
166
What are the stages of labour?
Stage 1 - from onset of true labour to when the cervix is fully dilated
Stage 2 - From full dilation to delivery of the fetus
Stage 3 - From delivery of fetus to when the placenta and membranes have been completely delivered
167
What monitoring is performed in labour?
1. FHR monitored every 15min (or continuously via CTG)
2. Contractions assessed every 30min
3. Maternal pulse rate assessed every 60min
4. Maternal BP and temp should be checked every 4 hours
5. VE should be offered every 4 hours to check progression of labour
6. Maternal urine should be checked for ketones and protein every 4 hours
168
Which method of contraception is most associated with weight gain?
Injectable contraceptive - Depo-provera
169
When should a referral to a maternal fetal medicine unit be made when fetal movements have not been felt?
24 weeks
170
What is the most common side effect after inserting an intrauterine device?
Irregular bleeding
171
What are the antenatal tests for Downs' syndrome?
Nuchal translucency measurement
Serum B-HCG
Pregnancy-associated plasma protein A (PAPP-A)
- Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
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How are ovarian cancers stage 2-4 treated?
Surgical excision of tumour
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When should women on antiepileptics take folic acid?
From before conception until 12 weeks
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How can gestational diabetes be diagnosed?
"5678"
Fasting glucose is >= 5.6 mmol/L, or;
2-hour glucose level of >= 7.8 mmol/L
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What are the risk factors for ovarian torsion?
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
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What is ovarian torsion?
Partial or complete torsion of the ovary on its supporting ligament
- May cause bloody supply compromise
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What is ovarian torsion?
Partial or complete torsion of the ovary on its supporting ligament
- May cause bloody supply compromise
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How would ovarian torsion present?
Sudden onset deep colicky abdominal pain
Associated with vomiting and distress
Fever
Adnexial tenderness
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How would ovarian torsion be diagnosed?
Laparoscopy
Ultrasound - free fluid or whirlpool sign
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How is ovarian torsion treated?
Laparoscopy
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What is adenomyosis?
Presence of endometrial tissue within myometrium
- More common in multiparous women
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What are the signs/symptoms of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
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How is adenomyosis managed?
GnRH agonists
Hysterectomy
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What is premenstrual syndrome (PMS)?
Emotional and physical symptoms women experience in luteal phase of normal menstrual cycle
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What symptoms may occur in PMS?
Emotional:
- Anxiety
- Stress
- Fatigue
- Mood swings
Physical:
- Bloating
- Breast pain
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How can PMS be treated?
Mild symptoms - lifestyle advice
Moderate symptoms - COCP
Severe symptoms - SSRI
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What is lichen sclerosus?
Inflammatory condition affecting genitalia
- More common in elderly females
- Leads to atrophy of the epidermis with white plaques forming
- Increased risk of vulval cancer
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What are the features of lichen sclerosus?
White patched which may cause scars
- Itchy
- Pain during intercourse or urination
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How is diagnosis of lichen sclerosus made?
Made on clinical grounds
- May use biopsy with atypical features
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How is lichen sclerosus managed?
Topical steroids and emollients
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What are prolactinomas?
Type of benign pituitary adenoma
Classified according to
Size - microademona (<1cm), macroadenoma (>1cm)
Hormonal status - secretory and non-secretory
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What are the features of prolactinoma?
Excess prolactin in women:
1. Amenorrhoea
2. Infertility
3. Galactorrhoea
4. Osteoporosis
Excess prolactin in men:
1. Impotence
2. Loss of libido
3. Galactorrhoea
Other symptoms:
1. Headache
2. Visual disturbances (bitemporal hemianopia)
3. Symptoms of hypopituitarism
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How are prolactinomas diagnosed?
MRI
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How are prolactinomas treated?
Symptomatic patients - dopamine agonists (Cabergoline, bromocriptine)
Surgery - trans-sphenoidal approach
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What law affects termination of pregnancies?
1967 Abortion Act
(With 1990 amendment)
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What is the upper limit of termination of pregnancy?
24 weeks
Unless woman's life is in danger
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How many medical practitioners must sign a document to complete termination of a pregnancy?
Two
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For less than 9 weeks of pregnancy, how would a termination be performed?
Mifepristone (Anti-progestogen)
48 hours later - prostaglandins to stimulate uterine contractions
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For less than 13 weeks of pregnancy, how would a termination be performed?
Surgical dilation and suction of uterine contractions
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For less than 15 weeks of pregnancy, how would a termination be performed?
Surgical dilation and evacuation of uterine contents or late medical abortion (induces mini-labour)
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What is the epidemiology of obstetric cholestasis?
Affects 1% of pregnancies in the UK
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Where would pruritis be most intense in obstetric cholestasis?
Palms, soles, abdomen
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What are the features of obstetric cholestasis?
Pruritis - worse around palms, soles and abdomen
Clinically detectable jaundice - 20% of patients
Raised bilirubin in >90%
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What would the management of obstetric cholestasis be?
Induction of labour at 37-38 weeks
Ursodeoxycholic acid
Vitamin K supplementation
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What is oligohydramnios?
Reduced amniotic fluid
Less than 500ml at 32-36 weeks
AFI <5th percentile
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What are the causes of oligohydramnios?
1. Premature rupture of membranes
2. Fetal renal problems e.g. renal agenesis
3. IUGR
4. Post-term gestation
5. Pre-eclampsia
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What is the incidence of multiple pregnancy?
Twins - 1/105
Triplets 1/10,000
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What complications are monoamniotic monozygotic twins associated with?
1. Increased spontaneous miscarriage, perinatal mortality rate
2. Increased malformations, IUGR, prematurity
3. Twin-to-twin transfusions
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What are the predisposing factors for dizygotic twins?
Previous twins
Family history
Increasing maternal age
Multigravida
Induced ovulation and IVF
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What antenatal complications are associated with dizygotic twins?
Polyhydramnios
Pregnancy induced hypertension
Anaemia
Antepartum haemorrhage
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What antenatal complications are associated with dizygotic twins?
Polyhydramnios
Pregnancy induced hypertension
Anaemia
Antepartum haemorrhage
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What are the complications in labour associated with twin pregnancy?
PPH
Malpresentation
Cord prolapse, entanglement
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What are the increased fetal complications in twin pregnancy?
Prematurity
Light-for-date babies
Malformation
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How can twin pregnancy be managed?
Rest
Ultrasound for diagnosis
Additional iron and folate
Weekly antenatal >30 weeks
Precautions during labour - 2 obstetricians
Induction at 38-40 weeks
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When does stage 2 of pregnancy occur?
From full dilation to delivery of fetus
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What is the passive second stage?
Second stage in the absence of pushing
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What is the active second stage of labour?
Active process of maternal pushing
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How long does stage 2 of labour last?
1 hour
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If the second stage of labour does not occur within an hour, what may be considered?
Ventouse extraction
Forceps delivery
Caesarean section
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When would a VTE risk assessment in pregnancy take place?
Upon booking
Any subsequent hospital admission
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What are the risk factors for VTE in pregnancy?
1. Age > 35
2. Body mass index > 30
3. Parity > 3
4. Smoker
5. Gross varicose veins
6. Current pre-eclampsia
7. Immobility
8. Family history of unprovoked VTE
9. Low risk thrombophilia
10. Multiple pregnancy
11. IVF pregnancy
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How many risk factors for VTE in pregnancy requires treatment?
Four or more
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How is VTE in pregnancy prophylactically treated?
LMWH until six weeks postnatal
- If a woman has 3 risk factors LMWH should be initiated from 28 weeks
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Should DOACs and Warfarin be used in pregnancy?
No
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What are the features of hydatidiform mole?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis.
Large uterus for dates
Serum hCG very high
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What are the typical features of vasa praevia?
Rupture of membranes followed immediately by vaginal bleeding.
Fetal bradycardia is classically seen
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What are the causes of bleeding in the 1st trimester of pregnancy?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
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What are the causes of bleeding in 2nd trimester of pregnancy?
Spontaneous abortion
Hydatidiform mole
Placental abruption
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What are the causes of bleeding in the 3rd trimester of pregnancy?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
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What is Group B streptococcus infection?
Most common cause of early-onset severe infection in neonatal period
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What percentage of mothers are carriers for GBS?
20-40%
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What are the risk factors for GBS?
Prematurity
Prolonged rupture of the membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis
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What are the requirements for instrumental delivery?
FORCEPS:
Fully dilated cervix
OA position preferable
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty
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What is the prognosis for endometrial cancer?
Good prognosis
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What is lochia?
Passage of blood, mucus or uterine tissue occurring after puerperium (6 weeks after childbirth)
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When would lochia indicate investigation?
After 6 weeks
- Investigated using USS
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What are the normal laboratory findings in pregnancy?
Reduced urea, reduced creatinine, increased urinary protein loss
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What are the symptoms of fibroid degeneration?
Low grade fever
Pain
Vomiting
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What are the initial investigations for infertility?
Semen analysis
Serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
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What is the cut-off for iron supplementation post-partum?
A cut-off of 100 g/Lshould be used in the postpartum period to determine if iron supplementation should be taken
