Women's Health Flashcards
1
Q
What is cystocele?
A
defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
2
Q
what is a grade 1 cystocele?
A
mild - the bladder droops only a short way into the vagina
3
Q
what is grade 2 cystocele?
A
medium - bladder sunk to reach opening of vagina
4
Q
what is grade 3 cystocele?
A
advances - bladder bulges out through opening of vagina
5
Q
what are 7 risk factors for pelvic organ prolapse?
A
advanced age and post menopause low oestrogen
overweight
childbirth - vaginal delivery
constipation and straining
heavy lifting
chronic cough
previous pelvic surgery
6
Q
What are 6 symptoms of cystocele?
A
pelvic heaviness/fullness
bluge in vagina
aching/pressure in lower belly/pelvis/back that get worse with standing/lifting/coughing
frequent UTIs and LUTS
pain during sex
constipation
7
Q
What are 6 symptoms of pelvic organ prolapse?
A
pelvic heaviness/fullness
bluge in vagina
urinary incontinance
constipation
pelvic/back/abdo pain
sexual dysfunction
8
Q
What is the conservative management for pelvic organ prolapse?
A
physio - pelvic floor exercise
weight loss
lifestyle changes
symptom treatement
vaginal oestrogen cream
9
Q
what are the 5 different types of pessaries that can be used for vaginal prolapse?
A
Ring
shelf/gellhorn - flat disc with stem
Cube
Donut
Hodge - rectangularish
10
Q
what should be given with pessaries to protect from vaginal irritation?
A
oestrogen cream
11
Q
what is the difinitive treatment for pelvic organ prolapse?
A
surgery
12
Q
What is rectocele?
A
defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
particularly associated with constipation
can develop faecal loading and urinary retention
13
Q
what is uterovaginal prolapse?
A
where the uterus +/- the vagina itself descends out of the vagina
14
Q
what is urge incontinence?
A
caused by overactivity of detrusor muscle meaning people feel the sudden need to pass urine
15
Q
what is stress incontinance?
A
due to weakness of the pelvic floor and sphincter muscles urine to leaks at times of increased pressure on the bladder like laughing , coughing or surprise
16
Q
what is overflow incontinence?
A
occurs with chronic urinary retention (more common in men) and without the urge to pass urine can be due to anticholinergic meds, fibroids, pelvic tumours and neuro conditions
17
Q
what are 6 risk factors for urinary incontinance in women?
A
increased age
pregnancy
obesity
pelvic organ prolapse
Neurological disorder
FHx
18
Q
what are 4 investigations for urinary incontinance in women?
A
urinalysis
urodynamic tests
bladder diary
post void residual bladder volume
19
Q
what is the gold standard investigation of urinary incontinence?
A
urodynamic testing
20
Q
what are 3 differential of urinary incontinance?
A
UTI
pregnancy
urogenital fistula
21
Q
what are 4 lifestyle managements of stress incontinance
A
avoid caffine
avoid smoking
weight loss
reduce fluid intake
22
Q
What is the first line medication to manage stress incontinance?
A
Duloxetine
23
Q
What are 3 contra-indications to duloxetine?
A
hepatic impairment
severe renal impairement (<30 creatinine clearance)
Uncontrolled hypertension
24
Q
what are 4 surgeries for stress incontinance?
A
tension-free vaginal tape
autologous sling
colosuspension
intramural urethral bulking
25
what is the management of urge incontinance?
bladder retraining
anticholinergic medication
26
what are 3 examples of anticholinergic medications for urge incontinance?
Oxybutynin
tolterodine
darifenacin
27
what are 4 anticholinergic side effects?
dry mouth and eyes
constipation
urinary retention
cognitive decline
28
what are 4 invasive options for urge incontinance?
Botulinum toxin type A - botox - injection in bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion
29
what is one non-anticholinergic that can be used to treat urge incontinance?
Mirabegron
CAN CAUSE HYPERTENSIVE CRISIS!!
30
Where do renal stones commonly get stuck?
vesico-uteric junction
31
what are 2 key complications of kidney stones?
obstruction => AKI
infection
32
what is the most common composition of kidney stones?
calcium oxalate
33
what are th 2 types of clacium renal stones?
calcium oxalate
calcium phosphate
34
what are 3 non-calcium kidney stones?
struvate - related to UTI
uric acid - fluid loss related
cystine - due to autosomal recessive cystinuria
35
what type of renal stones aren't visible on x-ray?
uric acid stones are radiolucent
36
what are 4 risk factors for renal stones?
dehydration
FHx
obesity and diet
UTIs
37
what are 5 symptoms of renal stones?
acute severe 'loin to groin' pain
nausea/vomiting
urinary frequency/urgency
haematuria
testicular pain
38
what is the gold standard investigation of renal stones?
Non-contrast CT kidneys ureters and bladder (within 24 hours!)
39
what are 4 investigations for renal stones?
Urinalysis - ?haematuria
bloods - ?infection ?hypercalcaemia ?kidney function
abdo X-ray - shows calcium based stones
ultrasound KUB
40
What are the symptoms of hypercalcaemia?
Renal Stones
Painful Bones
Abdominal Groans
Psychic Moans
41
What is the management of renal stones?
NSAIDs - ibruprofen/diclofenac
Antiemetics - metoclopramide
antibiotics - if infective
watchful waiting
tamsulosin - alpha blocker - can aid passage
surgery
42
what size of renal stones require surgery?
>10mm
43
what 4 types of surgical intervention are there for renal stones?
extracorporeal shock wave lithotripsy
uteroscopy laser lithtripsy
percutaneous nepholithotomy
open surgery - rare
44
what are 4 lifestyle changes to prevent further renal stones?
increase fluid intake
add lemon juice to water
reduce salt intake
avoid carbonated drinks
45
what are 2 medications that increase risk of renal stones?
potassium citrate
thiazide diuretics
46
what are 6 risk factors for vaginal fistula?
childbirth
injury
surgery
infection
radiation
IBD
47
what is a vesicovaginal fistula?
urinary bladder and vagina fistula
48
what is an enterovaginal fistula?
opening between small intestine and vagina
49
what are 4 investigations of vaginal fistulae?
Dye test - into bladder and rectum to check for leakage
Imaging - USS, CT, MRI
conoloscopy
cystourethroscopy
50
What is tripple assessment of breat lumps?
clinical assessment - Hx and exam
imaging - USS, mamography
histology - fine needle/core biopsy
each scored 1-5 from normal to malignant
51
what is fibroadenoma?
most common cause of breast mass
normally more likely in early reproductive years
painless, smooth, round, firm, well defined, mobile, usually <3cm
52
what is phyllodes tumour?
can be benign or malignant breast lumps
rapidly growning painless breast lumps
53
what are 8 clinical features of breast cancer?
hard, irregular, painless, fixed lumps
lumps tethered to skin or chest wall
nipple retraction
skin dimpling - peau d'orange
nipple discharge
rash, crusting or scaling around nipple
change in shape/size of breast
auxillary lymphadenopathy
54
what is a fibrocystic breast ?
usually in pre/perimenopausal women
mobile with dystinct borders - lumpy breasts
sometimes tender
fluctuate with mentruation
55
what do breast fat necrosis lumps present with?
hard, fixed masses
very like malignancy and require biopsy
56
what is breast papilloma?
breast lump usually in ducts
usually benign but can be associated with cancer
bloody nipple discharge is typical
57
what are breast abscesses?
breast lump typical in breastfeeding
ruptured sub-areolar ducts leak into periductal space
must be differentiated from inflammatory breast cancer
58
what is breast lipoma?
benign tumours of adipose tissue
soft, painless, mobile, no skin changes
59
what is galactocele?
occur in lactating women often after stopping
breast milk filled cysts due to lactiferous ducts being blocked
firm mobile, painless lump beneath areola
60
what is the most common causative pathogen of infective mastitis?
staphylococcus aureus
61
what is mastitis?
inflammation of breat with or without infection
common with breast feeding
62
what are breast absecesses?
a localised area of infection with a walled off collection of puss - with or without mastitis
63
what are 5 symptoms of mastitis?
fever
decreased milk outflow
breast warmth, tenderness, swelling, redness
breast pain
flu like symptoms
64
what are 3 investigations for breast abscess?
breast ultrasound
needle aspiration drainage
cystology of nipple discharge/aspiration
65
what are 3 investigations for mastitis?
milk/aspirate/discharge/biopsy culture and sensitivity
histopathological exam of biopsy
pregnancy test
66
what lifestyle treatment is there for breastfeeding mastitis?
continue breastfeeding/expressing milk
heat packs
warm showers
simple analgesia
67
what is the treatment of suspected infective mastitis?
Abx - flucloxacillin or erythromyacin (in allergy) for 10 days if still symptomatic 12-24 hours after 1st presentation with lifestyle management
68
what is the treatment of breast abscess?
surgical drainage
69
What are 6 risk factors for breast cancer?
Female
increased oestrogen exposure - OCP and HRT
more dense breast tissue
obestiy
smoking
FHx
70
What chromosome is BRACA1 on?
chromosome 17
71
what is ductal ectasia?
benign condition of milk duct due to walls thickening and getting blocked
more common in women approaching menopause
often asymptomatic but can cause discharge from breast, lumps under nipple or rarely breast pain
can be surgically treated
72
What is the name of the extention of breast tissue to the axilla?
tail of spence
73
what is the name of a breast milk filled cyst caused by lactiferous duct blockage?
galactocele
74
what chemical has a inhibitory effect on prolactin?
Dopamine
75
what enzyme in adipose tissue converts androgens to oestrogen?
aromatase
76
what type of tumour can cause gynacomastia due to oestrogen secretion?
leydig cell tumour - testicular cancer
77
which common heart meds can cause gynaecomastia?
digoxin and spiro
78
what is intraductal papilloma?
a benign wart like lump that develops in one or more of the milk ducts in the breast
can cause a lump, nipple discharge and pain or discomfort
79
what is bacterial vaginosis?
overgrowth of anaerobic bacteria in vagina that causes unusual fishy smelling, grey-ish white thin discharge
80
what percentage of women with BV have no symptoms?
50%
81
What symtoms are not related to BV?
Soreness or itching
82
What are 4 risk factors for BV?
multiple sexual partners
recent Abx
IUD - copper coil
excessive vaginal cleaning
83
what are 2 complications of BV?
small chance of premature birth/miscarriage
Inceased risk of STI
84
What is the first line antibiotic for BV?
Metronidazole 400mg BD 5-7days
intravaginal gel 0.75% OD 5 days
| Clindamycin gel 2% OD 7 days 2nd choice
SAFE FOR PREGGOS!
85
What is the healthhy bacteria in the vagina?
lactobilli - produce lactic acid and reduce pH of vagina (<4.5)
86
What is the most common cause of BV?
Gardnerella vaginalis
87
what are 3 common pathogenic causes of BV?
gardnerella vaginalis (most common)
Mycoplasma hominis
prevotella species
ALL ANAEROBIC
88
What is normal vaginal pH?
3.5-4.5
89
What is the is the gold standard investigation for BV?
high or low vaginal swab
should also swab for STIs
90
What cells are found under a microscope in BV?
clue cells
91
Which antibiotic shoudl you avoid alcohol whilst on?
Metronidazole - causes nausea, vomiting, flushing and sometimes shock
92
what is the most common cause of vaginal thrush?
Candida albicans
93
What are 4 risk factors for thrush?
increased oestrogen (pregnancy)
poorly controlled diabetes
immunosuppresion
Broad spectrum ABx
94
what are the symptoms of vaginal thrush?
thick white discharge
vulva and vaginal itching and irritation
95
What are 6 complications of vaginal thrush?
erythema
fissures
oedema
pain during sex (dyspareunia)
dysuria
excoriation
96
what is one test that can be used to distiguish between trush and BV/trichomonas?
vaginal pH swab
>4.5 in BV and Trichomonas
<4.5 in candidiasis
97
what swab is used for vaginal MCS?
charcoal swab - for BV, candidiasis, gonorrhoea, trichomonas, other bacteria
98
What is the management for thrush?
antifungal cream - clotrimazole 5g 10% single dose
antifungal pessary - clotrimazole 500mg single dose
Oral antifungal - fluconazole 150mg single dose
99
what should you tell patients using antifungal creams?
can degrade latex condoms and prevent spermacides from working => use other forms of birth control for at least 5 days
100
how is trichomonas spread?
sexual activity
101
what does trichomonas infection increase risk of?
HIV contraction (due to vaginal mucosa damage)
BV
cevical cancer
PID
pregnancy complications
102
What does the discharge look like in trichomonasis?
frothy, yellow-green fishy smelling discharge
103
on pelvic examination what can be found in someone with trichomoniasis?
strawberry cervix (colpitis macularis) caused by inflammation causing tiny haemorrhages on cerviix surface
104
how is trichomoniasis diagnosed?
charcoal microscopy swab from posterior fornix of vagina
vaginal pH >4.5
Urethral or first catch urine in men
105
What is the treatment for trichomoniasis?
refer to GUM for contact tracing
metronidazole 2g single dose (NOT IN PREGGOS)
OR
400-500mg TD 5-7days
106
what are 4 causes of balantitis?
exzema/dermatitis, allergy, psoriasis etc
gonorrhoea
candidosis
penile neoplasm
107
what are 4 risk factors for balantitis
poor hygiene
over washing
HPV
uncircumsised
108
what are 2 investigations for balantitis?
swab for microbiology and PCR
viral swab
109
What bacteria causes chancroid?
coccobacillus haemophilus ducreyi
110
What STI is an important cofactor in HIV transmision?
Chancroid
111
what are 2 symptoms of chancroid?
genital papules/ulcers
lymphadenitis and buboes
112
what STI causes genital ulcers?
chancroid
113
What is the treatment for chancroid?
azithromycin 1g one off dose
114
What bacteria causes chalmydia?
Gram negative chlamydia trachomatis
115
what is the most common STI in the UK?
Chlamydia
116
what percentage f menand women are asymptomatic with chlamydia?
men - 50%
women - 75%
117
what is nucleic acid amplification test swabbing used for?
chlamydia and gonorrhoea
118
what are 5 chlamydia symptoms in women?
Abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding
painful sex
dysuria
119
what are 4 symptoms of chlamydia in men?
urethral discharge/discomfort
painful urination
epididymo-orchitis
reactive arthritis
120
what is the 1st line treatment for chlamydia?
Doxycycline 100mg BD 7 days
NOT IN PREGGOS
121
what are 8 complications of chlamydia?
PID
chronic pelvic pain
infertility
ectopic pregnancy
epididymo-orchitis
conjunctivitis
lymphogranuloma venereum
reactive arthritis
chorioamnionitis
122
what are 5 complication of chlamydia in pregnancy?
preterm deliivery
premature rupture of membranes
low birthweight
post partum endometritis
neonatal infection - conjunctivitis and pneumonia
123
what are the stages of lymphogranuloma venereum?
primary - painless ulcer on genitals
secondary - lymphadenitis
tertiary - inflamation of rectum leading to anal pain, change in bowel, tenesmus and discharge
124
what is the treatment of lymphogranuloma venereum?
Doxycycline 100mg BD 21 days
125
What bacteria causes syphilis?
Treponema pallidum
spirochete
126
what is the incubation period for syphilis?
9-90 days
average 21 days
127
what are the 5 stages of syphilis?
primary
secondary
latent
tertiary
neurosyphilis
128
what are 2 symptoms of primary syphilis?
painless genital ulcer (chancre)
local lymphadenopathy
tends to resolve in 3-8 weeks
129
what are 6 symptoms of secondary syphilis?
maculopapular rash - trunks, palms, soles
condylomata lata - grey warts around genitals and anus
low grade fever and lymphadenopathy
oral lesions - snail trail ulcers
alopecia
3-12 weeks long
130
what are 3 symptoms of tertiary syphilis?
gummatous lesions - granulomatous lesions on skin, organs and bone
aortic aneurysms
neurosyphilis
Argyll-Robertson pupil - accommodates but does not react
131
what are 8 symptoms of neurosyphilis?
headache
altered behaviour
tabes dorsalis - demyelination of posterior columns of spinal cord
ocular syphilis
paralysis
sensory impairment
Argyll-robertson pupil (prostitutes pupil - accommodates but does not react)
132
How do you diagnoses syphilis?
antibody testing for T.pallidum antibodies
dark field microscopy
PCR
rapid plasma reagin - non-specific but sensitive
veneral disease research laboratory test - non-specific but sensitive
133
What is the 1st line treatment for syphilis?
Deep IM benzathine benzylpenicillin 1.8g single dose
SAFE IN PREGGOS
134
What can trichomoniasis in pregnancy cause?
premature birth
low birthweight
135
what can syphilis in pregnancy cause?
congenital syphilis
miscarriage
still birth
early death
136
What is the treatment for chlamydia in preggos?
Azithromycin 1g once then 500mg OD for 2 days
Erythromycin 500mg QD for 7 days
Amoxicillin 500mg TD 7 days
137
what are the complications of chlamydia during pregnancy?
pre-term labour
bleeding in pregnancy
PID + fertility problems
ectopic pregnancy
congenital chlamydia - eye or chest infection
138
what is a complication of spriocete (syphilis) infection after antibiotic treatment that can can cause premature labour?
Jarisch-herxheimer reaction - fever, headach, myalgia, fetal distress
| also lymes + other spirocete
139
Which ganglia is genital herpes usually latent in?
sacral nerve ganglia
140
Which ganglia is genital herpes usually latent in?
sacral nerve ganglia
141
what are 5 manifestations of HSV?
Cold sores
Genital herpes
aphthous ulcers (in mouth)
herpetic whitlow (painful skin lesions on fingers)
herpes keratitis - inflammation of cornea
142
what are 5 presentations of herpes?
ulcers
neuropathy
flu like symptoms
dysuria
inguinal lymphadenopathy
143
what pathogen causes genital warts ?
Human papillomavirus
HPV6 and 11 most commonly
144
what is the treatment for genital warts?
imiquimod
podephylltoxin
cryotherapy
145
What bacteria causes gonorrhoea?
Neisseria gonorrhoeae
Gram -ve diplococci
146
what are 4 symptoms of gonorrhoea?
odourless purulent discharge (can be green/yellow)
Dysuria
pelvic pain
testicular pain
147
How do you diagnose gonorrhoea?
Nucleic Acid Amplification Test
148
What is the treatment for gonorrhoea?
IM ceftriaxone 1g (also in preggos)
Oral Ciprofloxacin 500mg
Single dose
149
What are 5 complications of gonorrhoea?
PID
Infertility
Prostatitis
Septic arthritis
Conjunctivitis
150
what are 9 risk factors for ectopic pregnancy?
Prev ectopic
tubal surgery
Hx of STD
Smoking
IVF
IUD pregnancy
Black ethnicity
age <18 first intercourse
age >35 at time of presentation
151
when does ectopic pregnancy usually present?
6-8 weeks
152
what hCG level will mean pregnancy is visible on USS?
> 1500 IU/L
153
what is the criteria for expectant management of ectopic pregnancies?
available for follow up
unruptured
mass <35mm
no heart beat
no significant pain
HCG <1500 IU/L
154
what drug is used for medical management of ectopic pregnancies?
IM methotrexate
155
what is the criteria for medical management of ectopic pregnancies?
HCG levels <5000 IU/L
Confirmed absence of intrauterine pregnancy on US
<35mm
minimal pain
no heart beat
156
What embrionic structurre does the female genital system develop from?
paramesonephric (mullerian) ducts
157
what are 4 abnormal female organ formations?
bicornuate uterus - heart shaped
imperforate hymen
transverse vaginal septae - septum in vagina
vaginal hypoplasia and agenesis - abnormally small/absent vagina
158
what is androgen insensitivity syndrome?
a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics despite XY genetics
159
what are the complications of androgen insensitivity syndrome?
slightly taller than average female
no pubic or facial hair
increased risk of testicular cancer unless removed from abdomen
infertility
160
what is the usual presentation of androgen insensitivity syndrome?
inguinal hernias
primary amenorrhoea
161
What is menopause?
no periods for 12 months due to the end of menstruation
162
what is premature menopause?
Menopause before 40 years
163
What cells secrete oestrogen?
ganulosa cells
164
What are 8 perimenopausal symptoms?
Hot flushes
emotional lability/low mood
reduced libido
premenstrual syndrome
irregular periods
joint pain
heavier/lighter periods
vaginal dryness and atrophy
165
What are 4 conditions menopause increases the risk of?
CVD and stroke
osteoporosis
pelvic organ prolapse
urinary incontinance
166
what is the management of perimenopausal symptoms?
HRT
tibolone - synthetic steroid
clonidine - reduces hot flushes
CBT
SSRIs
testosterone gel for libido
vaginal oestrogen/moisturisers
167
what is adenomyosis?
Endometrial tissue inside the myometrium
More common with mutiparous
168
What are 5 presetations of adenomyosis?
Dysmenorrhoea
menorrhagia
dyspareunia (pain in intercourse)
Infertility
Enlarged/tender (boggy) uterus but softer than w/ fibroids
169
what is the 1st line investigation for adenomyosis ?
TV ultrasound
170
What is the gold standard investigation for adenomyosis?
histological exam after hysterectomy
171
what are 2 non-contraceptive treatments for mennhoragia?
Tranexamic acid - when no pain (antifibrinolytic reduces bleeding)
Mefenamic acid - with pain (NSAID - reduced bleeding and pain)
172
What are 3 contraceptive managements options for mennorhagia?
IUS
COCP
cyclical oral progestogens
173
what are 4 specialist managements of menorrhagia?
GnRH analogues to induce meno-pause like state
endometrial ablation
uterine artery embolisation
hysterectomy
174
what are 9 complications of adenomyosis in pregnancy?
infertility
miscarriage
preterm birth
small gestation
preterm premature rupture of membranes
malpresentation
c-section
PPH
175
What is asherman's syndrome?
where adhesions form in uterus following damage
176
What are 3 risk factors for ashermans syndrome?
dilation and curettage (after retained products of conception)
uterine surgery
pelvic infection
177
what are 4 presentations of asherman's syndrome?
secondary amenorrhoea
light periods
dysmenorrhoea
infertility
178
What are 4 investigations for asherman's syndrome?
hysteroscopy
hysterosalpingography
sonohysterography
MRI
179
What is lichen sclerosus?
a chronic inflamatory autoimmune skin condition causing patches of shiny white skin on labia, perineum and perianal skin most commonly as well as axilla and thighs. can also affect men
180
what is lichen planus?
autoimmune condition causing chronic inflammation with shiny purplish flat top raised areas with white lines across surface called wickhams striae
181
what are 7 presentations of lichen sclerosus?
white skin patches
itching
soreness
skin tightness
painful sex
erosions
fissures
182
what is the management for lichen sclerosus?
topical steroids - dermovate - clobetasol propionate 0.05%
emollients
183
what is a key complication of lichen sclerosus?
5% risk of developing squamous cell carcinoma of the vulva
184
what is atrophic vaginitis?
atrophy of the vaginal mucosa due to lack of oestrogen
185
What are 5 presentations of atrophic vaginitis?
itching
dryness
dyspareunia (painful sex)
bleeding (due to inflammation)
recurrent UTIs, Stess incontinance, prolapse
186
what are 6 signs of atrophic vaginitis on examination?
pale mucosa
thin skin
reduced skin foldes
erythema and inflammation
dryness
sparse pubic hair
187
what is the management of atrophic vaginitis?
topical oestrogen - cream, pessaries, ring
estradiol tablets
188
what are the 4 parameters to measure 'normal' menstruation by?
Frequency
regularity
duration
volume
189
what are 4 risk factors for abnormal uterine bleeding?
Extremes of reproductive age
PCOS
endocrine disorders - hypothyroid, hyperprolactinoma
obesity
190
what is the emergency management of excessive uterine bleeding?
1st - hormone therapy - 25mg IM conjugated oestrogens
2nd - Tranexamic acid, Surgery
Blood products and fluids if haemodynamically unstable
191
what type of cancer is 80% of endometrial cancer?
adenocarcinoma
192
which hormone stimulates the growth of endometrial cancer?
oestrogen
193
what is the precancerous version of endometrial cancer?
endometrial hyperplasia
194
what are the two types of endometrial hyperplasia?
hyperplasia without atypia
atypical hyperplasia
195
what is the treatment for endometrial hyperplasia?
progestogens - IUS or continuous oral progestogens
196
what are 9 risk factors for endometrial cancer?
increased age
earlier onset of menstruation
late menopause
oestrogen only hormone replacement
no/few pregnancies
obesity
PCOS
Tamoxifen
Diabetes T2
197
what are 4 protective factors for endometrial cancer?
COCP
MIrena coil
Increased pregnancies
smoking
198
what are 7 presentations of endometrial cancer?
post menopausal bleeding
postcoital and instermenstrual bleeding
menorrhagia
Abnormal discharge
haematuria
anaemia
raised platelets
199
what are 3 investigations for endometrial cancer?
TV USS for endometrial thickness
pipelle biopsy - highly sensitive
hysteroscopy with endometrial biopsy
200
what is a normal endometrial thickness post menopause?
<4mm
201
What are the stages of endometrial cancer?
1 - confined to uterus
2 - invades cervix
3 - invades ovaries, fallopian tubes, vagina or lymph nodes
4 - invades bladder, rectum or beyond pelvis
202
What is the treatment for endometrial cancer?
total abdominal hysterectomy with bilateral salpingo-oophorectomy
Radial hyterectomy
radiotherapy
chemo
progesterone tx
203
what are 5 risk factors for endometrial fibroids?
increasing age
high BMI
hypertension
tamoxifen
HRT (with high oestrogen)
Afro-Caribbean Ancestry
204
what are 7 presentations of uterine fibroids?
Menorrhagia
Prolonged menstruation
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility
205
what are endometriomas seen in the ovaries often called?
chocolate cysts (from endometriosis)
206
what are some possible cause of endometriosis?
retograde menstruation through fallopian tubes into abdomen
embryonic cells
lymphatic spread
metaplasia
207
what are 7 presentations of endometriosis?
cyclical abdomina or pelvic pain
deep dyspareunia
dysmenorrhoea
subfertility
fixed retroverted uterus
palpable mass - endometrioma
painfull pooping
208
what is the gold standard investigation for endometriosis?
laproscopic surgery + biopsy
209
what is the medical management of endometriosis?
1 - NSAIDs
2 - COCP or Progesterone only, depo, implant or IUS
3 - GnRH analogous
210
what are 4 risk factors for fibrids?
increased patient weight
40+
black ethnicity
low vit D
211
What is a complete mole in a molar pregnancy?
when 2 sperm cells fertalise an ovum with no genetic materium and combine genetically to form a tumour
212
what is a partial mole in a molar pregnancy?
when 2 sperm fertilise a normal ovum at the same time causing a haploid cell (3 sets of chromosomes which divides and multiplies to form a partial mole. there may be csome foetal material
213
what are 6 possible indications of molar pregnancy compared to normal pregncncy?
severe morning sickness
vaginal bleeding
increased enlargement of uterus
abnormally high hCG
thyrotoxicosis
214
what is a sign of molar pregnancy on USS?
snow storm appearance
215
what is the management of molar prregnancy?
evacuation of uterus
histology
referal to gestational trophoblastic disease centre
hCG level monitoring
216
what can be a complication of molar pregnancy?
metastasis
217
what are 6 presentations of prolactinoma?
amenorrhoea/oligomenorrhoea
infertility
galactorrhoea
lowered libido
erectile dysfunction
visual deterioration (bilateral temoral hemianopia)
218
what is the most common type of pituitary tumour in women?
prolactinoma - 50%
219
what is the 1st line medical treatment of prolactinoma?
dopamine agonist - carbergoline 0.5mg once weekly
(2nd line OCP in premeno women)
220
what is the surgical management of prolactinoma?
tras-sphenoidal surgery
221
what is the most common type of ovarian tumour?
epithelial cell tumour
222
what are beingn ovarian tumours?
dermoid cysts
germ cell tumours
teratomas. particularly associated with ovarian torsion
223
what are 6 risk factors for ovarian cancer?
Age (highest incidence >60)
BRACA1 and 2 genes (FHx)
Increased number of ovulations
obesity
smoking
recurrent use of clomifene
224
what factors increase the number of ovulations (and therefore ovarian cancer risk)?
early onset periods
late menopause
no pregnancies
225
what are 4 protective factors for ovarian cancer?
combined oral contraceptive pill
breastfeeding
pregnancy
226
what are 8 presentations of ovarian cancer?
abdominal bloating
early satiety/loss of apetite
pelvic/hip and groin pain
urinary symptoms
weight loss
abdominal/pelvic masses
ascites
227
what is the tumour marker for ovarian cancer?
CA125
228
what are 3 tumour markers for rarer ovarian germ cell tumours?
alpha-fetoprotein
HCG
lactate dehydrogenase
229
What are the 3 diagnostic features for PCOS diagnosis (rotterdam criteria)?
Anovulation/oligoovulation
Hyperandrogenism (hirsutism and acne)
Polycystic ovaries on USS
2 features = diagnosis
230
What are 5 potential presentations of ovarian cysts?
pelvic pain - w/ torsion, rupture or haemorrhage
bloating
fullness in abdomen
palpable pelvic mass (V large cysts)
231
what are functional cysts?
follicular cysts for developing follicles can sometimes fail to rupture and release the egg and therefore persist for a short while
232
what is the most common type of ovarian cyst?
functional (follicular) cysts
233
what type of cysts are often seen in early pregnancy?
corpus luteum cysts - may cause pelvic discomfort pain or delayed menstruation
234
What are 5 types of ovarian cysts?
serous cystadenomas
Mucinous cystadenoma
Endometriomas
dermoid cysts
sex cord stromal tumours (can be benign or malig)
235
what are 2 possible surgical managements of ovarian cysts?
ovarian cystectomy
oophorectomy
236
What is Meig's syndrome?
ovarian fibroma (benign ovarian tumour)
pleural effusion
Ascites
typically in older women. removal of tumour results in complete resolution of symptoms.
237
when is ovarian torsion more likely?
In pregnancy
with a mass >5cm
before menarche and women of reproductive age
238
what are 4 featrue of ovarian torsion?
unilateral sudden onset severe pain
nausea and vomiting
palpable mass
localised tenderness
239
How is ovarian torsion definitively diagnosed?
Laparoscopy
240
what are 3 STDs that can cause PID?
Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma genitalium
241
What are non STDs that can cause PID?
Gardenerella vaginalis (associated with BV)
Haemophilus influenzae
Escheriachia coli
242
what are 6 presentations of PID?
pelvic/low abdomen pain
abnormal discharge
abnormal bleeding
dyspareunia
fever
dysuria
243
what 4 things may be found on a PID examination?
pelvic tenderness
cervical motion tenderness
cervicitis
purulent discharge
244
What are 7 investigations for PID
NAAT swabs for gonorrhoea, chlamydia, mycopasma genitalium
HIV test
Syphilis test
High vag swab for BV, candidiasis, trichomoniasis
Look for pus cells on microscope (absence excludes PID)
Pregnancy test (?ectopic)
Inflammatory markers
245
What are 6 complications of PID?
Se[sis
abscess
infertility
chronic pelvic pain
ectopic pregnancy
Fiz-hugh-curtis syndrome
246
what is fiz-hugh-curtis syndrome?
inflammation and infection of liver cpsule causing adhesions between liver and peritoneum => RUQ pain
247
What is the treatment for PID?
IM Ceftriaxone 1g (for gonorrhoea)
Doxycycline 100mg BD 14 days (chalmidia, MG)
Metronidazole 400mg BD 14 days (anaerobes)
if have coil => leave in unless not responding after 72 hours
248
what are 8 non-diagnostic features that may be present in PCOS?
insulin resistance and diabetes
acanthosis nigricans
CVD
hypercholesterolaemia
endometrial hyperplasia and cancer
Obstructive sleep apnoea
depression and anxiety
sexual problems
249
what are 4 hormonal blood tests for PCOS?
Raised LH
raises LH to FSH ratio
raised testosterone
Raised insulin
250
What can be seen on USS of PCOS?
'string of pearls' appearance
>12 cysts on a single ovary or >10cm3 ovarian volume => diagnostic criteria
251
what test can be used for diabetes in PCOS?
Oral glucose tolerance test
252
What medication can be given for weight loss that impairs lipid absorption?
Orlistat
253
What can be used to reduce risk of endometrial cancer in people with PCOS?
cyclical progesterone or COCP to induce withdrawl bleed
Mirena coil
254
what 2 medications can be used to treat hirsutism?
co-cyprindiol
topical elfornithine
255
What are the baby blues?
transient mood disturbance in the 1st week post partum
crying, fatigue, sensitivity, anxiety, irritability, helplessness, low mood and mood swings
256
What is postnatal depression?
low mood, anhedonia and low energy typically affecting mothers around 3 months post natally
257
what scoring system is used for post natal depression?
Edinburgh postnatal depression scale
258
What is pueperal psychosis?
typically onset 2-3 weeks postnatal with mother experiencing psychotic symptoms (delusions, hallucinations, depression, mania, confusion, thought disorder)
259
what is the treatment for puerperal psychosis?
admission to mother and baby unit
CBT
medications - antidepressants, antipsychotics, mood stabilisers
electroconvulsive therapy
260
what is the surgical management of ectopics?
laproscopic salpingectomy or salpingotomy
when there is pain, mass >35mm, visible heartbeat or HCG >5000
261
what medication do you need to give Rhesus -ve women in surgical ectopic removal?
anti rhesus D
262
What counts as a miscarriage?
<24 weeks gestation
early <12 weeks
late 12-24 weeks
263
what is a missed miscarriage?
when the foetus is no longer alive but no symptoms have occurred
264
what is a threatened miscarriage?
vaginal bleeding with closed cervix and alive foetus
265
what is an inevitable miscarriage?
vaginal bleeding and open cervix
266
what is an incomplete miscarriage?
retained products of conception remain in uterus after miscarriage
267
what is a complete miscarriage?
a full miscarriage has occurred with no products remaining
268
what is anembryonic pregnancy?
a gestational sac is present but contains no embryo
269
what are 3 features looked for on ultrasound to confirm pregnancy?
mean gestational sac diameter
foetal pole and crown rump length
foetal heart beat
270
what is the management of a miscarriage <6 weeks?
expectant management
Repeat urine pregnancy test after 7-10 days
271
what is the management for miscarriage >6 weeks?
referral to eArly pregnancy assessment unit
USS for location and viability
272
what is expectant management of miscarriage?
repeat urine pregnancy test 3 weeks after bleeding and pain settle to confirm complete miscarriage
273
what is medical management of miscarriage?
Misoprostol (prostaglandin analogue to stimulate cervical ripening and uterine contractions)
274
what are 4 side effects of misoprostol?
heavier bleeding
pain
vomiting
diarrhoea
275
what is the surgical management of miscarriage?
manual vacuum aspiration (LA) <10 weeks
electric vacuum aspiration (GA)
+ misoprostol
+ anti D to -ve women
276
what is the management of incomplete miscarriage?
medical - misoprostol
surgical - evacuation under GA
277
What are the 2 legal documents for abortion?
1967 abortion act
1990 human fertilisation and embryology act
278
what are the legal requirements for abortion?
2 medical practitioners sign to agree abortion is indicated
must be carried out by registered medical practitioner in NHS hospital or approved premise
279
what are 3 indications for abortion post 24 weeks?
continuing pregnancy risks life of woman
Termination prevents grave permanent injury to physical or mental health of the woman
substantial risk of physical or mental abnormalities in the child
280
what 2 medications are used in a medical abortion?
mifepristone (anti-progestogen)
misoprostol (prostaglandin analogue) 1-2 days later
281
What is an USS signs of diamniotic dichorionic twins?
lambda or 'twin peak' sign
282
what is an USS sign of monochorionic diamniotic twins?
T sign
283
what are 7 risks to the mother with multiple pregnancy?
anaemia
polyhydramnious
HTN
malpresentations
spont preterm labour
instrumental delivery/caesarian
PPH
284
what are 7 risks to the foetuses in multiple pregnancy?
Miscarriage
Stillbirth
foetal growth restriction
prematurity
twin-twin transfusion syndrome
twin anaemia polycythaemia sequence
congenital abnormalities
285
what is twin-twin transfusion syndrome?
only monochorionic multiples
Abnormal connection between blood supply of babies causing shunting of blood to one foetus (recipient) and away from the other (donor)
The recipient gets overloaded and therefore HF and polyhydramnios.
The donor gets growth restricted, anaemic and oligohydramnios
Tx - laser seperation
286
what is twin anaemia polycythaemia sequence?
similar to twin to twin but less acute
one twin becomes anaemic whilst the other develops polycythaemia
287
whenis the monitoring for anaemia in multiple pregnancy?
booking
20 weeks
28 weeks
288
what is the scan monitoring for monochorionic twins?
every 2 weeks from 16 weeks
289
what is the scan monitoring for dichorionic twins?
every 4 weeks from 16 weeks
290
when is birth planned for monochorionic monoamniotic twins?
32-34 weeks
Must be sectioned
291
when is birth planned for monochorionic diamniotic twins?
36-37 weeks
292
when is birth planned for dichorionic diamniotic twins?
37-38 weeks
293
when is birth planned for triplets?
before 35+6 weeks
294
What are 6 things obesity increases risk of in pregnancy?
Gestational diabetes (screen BMI >30)
Pre-eclampsia and HTN (BMI >35)
VTE (BMI > 30)
mental health problems
inaccurate symphysis fundal height measurements
PPH
295
what causes gestational diabetes?
due to insulin resistance and relative glucose intolerance in pregnancy
296
what are 7 risk factors for gestational diabetes?
prev. gestational diabetes
prev. macrosomic baby
BMI>30
Ethnic origin
FHx of diabetes (1st degree relative)
Advanced maternal age
PCOS
297
what counts as a macrosomic baby?
>4.5kg (9lb 12oz)
298
what test is use for gestational diabetes?
glucose tolerance test between 24-28 weeks
299
what are 3 indications of gestational diabetes?
large for date foetus
polyhydramnios
Glu on dipstick
300
what is a normal fasting GTT level?
<5.6 mol/L
301
what is the normal 2 hour GTT level?
<7.8 mmol/L
302
what is the initial management of gestational diabetes?n (3)
1 - diet and exercise
2 - metformin (if not under control after 2 weeks)
3 - Insulin
(fasting >7 mmol/L)
303
what is the fasting glucose target for pregnant women?
<5.6 mmol/L
304
what is the 1 and 2 hour post prandial glucose target for pregnant women?
1 hour - 7.8mmol/L
2 hours - 6.4 mmol/L
305
when is delivery planned for those with complicated diabetes in pregnancy?
between 37-38+6 weeks
306
what is the maximum gestation diabetic women can give birth up to?
40+6 weeks
307
when is retinal screening performed for diabetics in pregnancy?
at booking and at 28 weeks
308
what is the post-natal management of mothers with gestational diabetes?
HbA1c at 13 weeks then annually
309
what is the maternal risk in pre-existing diabetes?
miscarriage
pre-eclampsia risk increased
infection - uti, resp, endometrial. andwound
increased c-section rate
310
what are 6 risks to the baby of a diabetic mother?
neonatal hypoglycaemia
neonatal jaundice
congenital abnormalities - heart, skeletal, neural tube
shoulder dystocia
polycythaemia
childhood obesity
311
When is a variable rate insulin infusion (sliding scale) started intrapartum?
with 2 BMs >7
312
What is the target intrapartum blood glucose level?
4-7 mmol/L
313
what is given preconception. to pregnant women. to prevent neural tube defects?
Folic acid 400microg till 12 weeks unless there are risk factors for neural tube defects or obesity
314
can ACEI or ARBs be taken in pregnancy?
NO
cause oligohydramnios, miscarriage, hypocalvaria (malformation of skull), renal failure in neonate, hypotension in neonate
315
what is the 1st line management of severe hypertension in pregnancy <37 weeks?
labetalol (>160 systolic but also for consideration >140)
316
what is the management of gestational hypertension >37 weeks?
delivery (+labetalol if >160/110)
317
what is pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of proteinuria
or organ involvement
318
what are 5 high risk factors for pre-eclampsia?
pre-existing HTN
Prev. HTN in pregnancy
autoimmune consitions
diabetes
CKD
319
what are 6 moderate risk factors for pre-eclampsia?
>40 years
BMI >35
10+ years since prev. pregnancy
multiples
first pregnancy
FHx of pre-eclampsia
320
what are 8 symptoms of pre-eclapsia?
headache
visual disturbance/blurring
nausea and vomiting
upper abdo/epigastric pain
oedema
reduced urine output, proteinuria
brisk reflexes
RUQ/Epigastric pain
321
what is needed for a diagnosis of pre-eclampsia?
blood pressure >140/90
+
Proteinuria OR
Organ dysfunction (^creatinine, ^liver enzymes,seizures, thrombocytopenia, haemolytic anaemia) OR
Placental dysfunction (foetal growth restriction or abnormal dopplers)
322
what blood test can be used to test for pre-eclapsia?
placental growth factor (between 20-35 weeks)
323
what is the prophylaxis treatment for pre-eclampsia?
Aspirin from 12 weeks-birth
women with 1 high risk or 2 moderate risk factors
324
what is the management for gestational hypertension?
aim 135/85 mmHg
Urine dip every week
bloods weekly - FBC U+E LFTs
Serial growth scans
PlGF test once (20-35 weeks)
Admit if >160/110 mmHg
325
How often are scans with pre-eclapsia?
every 2 weeks
326
what is the medical management of pre-eclapsia?
1st line - labetalol
2nd line - nifedipine
3rd line - methyldopa
327
what can be given in severe pre-eclampsia or eclapsia?
IV hydralazine
328
what is the management in labour of pre-eclamptics?
IV magnesium sulphate (prevent seizures)
Fluid restriction to avoid fluid overload
329
what is the post delivery management of pre-eclampsia?
1st line - enalapril
1st line in black afro or Caribbean people - Nifedipine/amlodipine
3rd line labetolol or atenolol
330
what is HELLP syndorme?
complication of pre-eclapsia and eclapsia
Haemolysis
Elevated liver enzymes
Low Platelets
331
what are 8 complications of pre-eclampsia?
foetal growth restriction
eclampsia
pulmonary oedema
stroke
placental abruption
CVD
renal failure
still birth
332
what are the levels for anaemia in pregnacy?
<110 g/L 1st trimester
<105 g/L 2nd/3rd trimester
333
why does anaemia occur in pregnancy?
blood volume increases naturally in pregnancy to a greater extent than red cell mass
334
What are 12 risk factors for VTE in pregnancy?
smoking
Para >3
Age >35
BMI >30
reduced mobility/immobility
Multiples pregnancy
pre-eclampsia
gross varicose veins
FHx of VTE
Thrombophilia
IVF pregnancy
335
what are the guidelines for starting VTE prophylaxis in pregnancy?
from 28 weeks with 3 risk factors
from booking with 4+ risk factors
336
what prophylaxis is given for VTE in pregnancy?
LMWH - Dalteparin (5000 units)
also enoxiparin or tinzaparin
Given until 6 weeks postnatal
337
what are 5 presentations of DVT?
unilateral calf/leg swelling (>3cm difference)
dilated superficial veins
tender calf
oedema
colour changes to leg
338
what are 8 presentations of PE?
SOB
cough/haemoptysis
pleuritic chestr pain
hypoxia
tachycardia
tachypnoea
low-grade fever
haemodynamic instability
339
what is the gold standrd investigation for DVT?
doppler uss
340
what is the gold standard investigation for PE?
CT pulmonary angiogram (CTPA)
341
what are 3 conditions that group b strep infection of the newborn can cause?
meningitis
sepsis
pneumonia
342
what increases baby's risk of GBS infetion from mother?
preterm birth
previous baby with GBS
signs of infection during labour
+ urine or GBS swab in pregnancy
ROM >24 hours before birth
343
which antibiotic is used for intrapartum antibiotic prophylaxis in group B strep?
IV benzylpenicillin 3g (+1.5g 4 hourly until delivery)
344
which antibiotic is given intrapartum for GBS in women with penicillin allergy?
Vamcomycin 1g every 12 hours (in severe beta-lactam allergy)
Cephlasporins can be used in non sever penicillin allergy
345
What test is used for Group B strep in pregnancy?
enriched culture medium test at 35-37 weeks
346
what is the treatment for BV in pregnANCY?
oral metronidazole 400mg BD 5-7 days
OR
Intravaginal metronidazole gel 0.75% OD 5 days
347
what are the 3 different types of puerperal infection?
endometritis (most common)
myometritis
parametritis (supporting tissue around uterus)
348
what are 6 signs of puerperal infection?
pain below waist/in pelvic area
pale clammy skin due to blood loss
foul smelling vaginal discharge
raised HR
fever/chills/aches
Loss of appetite
349
what bacteria most commonly causes puerperal infection?
Group B strep (or other streps)
350
what are 5 risk factors for puerperal infection?
caesarean
many VEs
delay of birth after ROM
retained tissues
meconium in liquor
use of balloon for induction
351
what is the treatment for trichomonas in pregnancy?
metronidazole 400-500mg TD 5-7days
CANNOT DO 2g SINGLE DOSE
352
What does UTI in pregnancy increase the risks of ?
preterm delivery
posibly - low birth weight, pre-eclampsia
353
what would be seen on a dipstick of someone with a UTI?
Nitrites
Leukocytes
?blood
354
what is the management of uti in pregnancy?
Nitrofurantoin (trimester 1+2)
Amoxicillin
Cefalexin
355
can nitrofurantoin be used in pregnancy?
Yes but NOT IN THIRD TRIMESTER
Risk of neonatal haemolysis
356
Can trimethoprim be used in pregnancy?
NOT IN FIST TRIMESTER
folate antagonist => risk of neural tube defects and congenital malformations
357
what 4 things can congenital rubella cause?
deafness
congenital cataracts
congenital heart disease
learning disabilities
358
Can pregnancy women get the MMR vaccine?
NO - live vaccine
359
what complications can varicella zoster cause in pregnant mothers?
varicella pneumonitis
hepatitis
encephalitis
360
what are 5 features of congenital varicella syndrome?
foetal growth restriction
microcephaly, hydrocephalus and learning disability
limb hypoplasia
cataracts and eye inflammation
361
what kind of bacteria is listeria?
gram pos bacilli
362
what can listeria cause in pregnancy?
miscarriage or foetal death
sever neonatal infection
363
what are 6 complications of congenital cytomegalovirus?
foetal growth restriction
microcephaly
hearing loss
vision loss
learning disability
seizures
364
where does toxoplasma gondii come from?
parasite from cat poo
365
what is the classical triad of congenital toxoplasmosis?
intracranial calcification
hydrocephalus
chorioretinitis (eye inflamation)
366
what are the complications of parovirus B19 in pregnancy?
miscarriage or foetal death
severe fetal anaemia
hydrops fetalis (foetal heart failure)
maternal pre-eclampsia like syndrome
367
what are 3 signs of congenital zika syndrome?
microcephaly
foetal growth restriction
intracranial abnormalities
368
what is the management of varicella zoster in pregnancy?
IV varicella immunoglobulins as prophylaxis after exposure in unexposed mother
369
what hormone causes uterine contraction?
oxytocin
370
what are 6 risk factors for atonic uterus?
primiparity/grand multiparity
Multiples
high BMI
foetal macrosmia
polyhydramnios
uterine fibroids
371
what is oligohydramnios?
too little amniotic fluid below the 5th centile
372
what is the aprox average amount of amniotic fluid at term?
500ml
373
what are 7 causes of oligohydramnios?
preterm ROM
placental insufficiency (too much blood to brain rather than abdo and kidneys)
renal agenesis
non-functional foetal kidneys
obstructive uropathy
genetic/chromosomal abnormalities (neuropathies)
viral infections
374
what are 7 causes of polyhydramnios?
conditions stopping foetal swallowing
anaemia or foetal hydrops
twin-twin transfusion
maternal DM
maternal lithium ingestion (causes foetal DI)
macrosomia
idopathic (most common)
375
what are 5 complications of polyhydramnios?
congenital malformations or abnormalities
increased risk preterm labour
increased risk atony and PPH
increased risk malpresentations
increased risk cord prolapse
376
what are the 3Ps of labour?
Power (uterine contractions)
Passenger (size/position/presentation of baby)
Passage (shape/size of pelvis)
377
what is the latent phase of labour?
from 0-3cm dilation
irregular contractions
378
is the active phase of labour?
4-10cm dilation
Strong regular contractions
379
What is. the second stage of labour?
from 10cm to delivery
380
what is the 3rd stage of labour?
delivery of baby to delivery of placenta
381
How long should delivery of the placenta take with active management?
30 mins
382
how long should delivery of the placenta take without intervention?
60 mins
383
what is active management of the 3rd stage of labour?
IM oxytocin
Controlled cord traction
384
what are the 3 different types of breech presentation?
extended breech
flexed breech
footling breech
385
what are 6 risk factors for malpresentation?
multparity
uterine malformations/fibroids
placenta praevia
macrosomia
polyhydramnios
multiples/prematurity
386
what are 5 complications. of malpresentation?
foetal head entrapment
premature ROM
birth asphyxia
intracranial haemorrhage
cord prolapsd
387
what are 7 risk factors for uterine rupture?
prev c section
prev uterine surgery
increased BMI
High parity
increased age
Induction of labour
use of oxytocin
388
what are 5 signs of uterine rupture?
abdo pain
vag bleeding
ceasing of contractions
hypotension
tachycardia
collapse
389
what is. an incomplete uterine rupture?
when. the perimetrium remains intact
390
what is classed as premature?
<37 weeks
391
what are 2 prophylaxis for preterm labour?
vaginal progesterone
cervical cerclage (stitch)
(<25mm on TV USS 16-24 weeks)
392
what 2 proteins can be tested for to check ROM?
insulin like growth factor binding protein 2
Placental alpha-microglobin-2
393
what is the management of preterm ROM?
prophylactic Erythromycin 250mg QDS for 10 days/until labour
induction of labour from 34 weeks
394
what are 5 management options for preterm labour?
foetal monitoring
Suppression of labour with nifedipine or terbutaline
maternal corticosteroids (<35 weeks)
IV Mag sulphate (<34 weeks for brain protection)
Delayed cord clamping and milking
395
what are 3 signs of magnesium toxicity?
reduced resp rate
reduced BP
absent reflexes
396
what is the management for cord prolpase?
emergency caesarean section
397
what are the 2 causes of foetl hypoxia in cord prolapse?
cord compression
arterial vasospasm (cold air)
398
what are 5 risk factors for cord prolapase?
breech
unstable lie
artificial rupture of membranes
polyhydramnios
prematurity
399
what are 4 indications for instrumental delivery?
failure to progress
foetal distress
maternal exhaustion
control of head position
400
what are 5 risks of instrumental delivery to the mother?
PPH
episiotomy/tears
injury to anal sphincter
incontinance of bladder/bowel
nerve injury
401
what 2 nerves can be damaged in instrumental delivery?
obturator or femoral
402
what are 5 risks of instrumental delivery to the baby?
cephalohaematoma w/ ventouse
facial nerve palsy w/ foreceps
skull fracture
subgaleal haemorrhage
spinal cord injury
403
what is obstructed labour?
when a physical blockage prevents childbirth - too small pelvis, too big baby, fibroids, malpresentation
more common in asia and africa
404
what is placenta accreta?
where placenta implants into the myometrium but not beyond
405
what is placenta increta?
where the placenta attaches deeply into the myometrium
406
what is placenta percreta?
when the placenta invades past the myometrium and perimetrium into the abdomen
407
what are 6 risk factors for placenta accreta?
prev accreta
prev endometrial curettage
prev c-section
multigravida
increased maternal age
low lying/placenta praevia
408
how does placenta accreta present?
bleeding in 3rd trimester
antenatal uss
At birth
409
when is a baby with placenta accreta induced?
35 to 36+6 weeks
reduce risk of spont labour
given steroids antenatally
410
what are 3 options for placenta accreta management?
hysterectomy
uterus preserving surgery
expectant management
411
what are 4 causes of antepartum haemorrhage?
placenta praevia
placental abruption
vasa praevia
placenta accreta
412
what are 3 possible causes of minor pv spotting in pregnancy?
cervical ectropian
infection
vaginal abrasion
413
what are 6 complications of placenta praevia?
antepartum haemorrhage
emergency c-section
emergency hysterectomy
maternal anaemia and transfusions
preterm birth and low birth weight
still birth
414
what is classed as a low lying placenta?
within 20mm of internal cervical os
415
what are 6 risk factors for placenta praevia?
prev c-section
prev placenta previa
IVF
older maternal age
maternal smoking
structural uterine abnormalities
416
what is the management for placenta praevia?
elective c-section at 36-37 weeks
417
what are 10 risk factors for placental abruption?
prev. placenta abruption
pre-eclampsia
bleeding in early pregnacy
trauma
multiples
foetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine use
418
what is the presentation of placental abruption?
sudden onset sever continuous abdo pain
vaginal bleeding
shock
CTG abnormality
woody uterus on palpation
419
what is classed as a minor antepartum haemorrhage?
<500ml
420
what is classed as a major antepartum haemorrhage?
500-1000ml loss
421
what is classed as a massive antepartum haemorrhage?
>1000ml blood loss
OR
signs of shock
422
what is the management of massive antepartum haemorrhage?
senior review
2x grey canula
blods - FBC, UE, LFT. Coag
cross match 4 units of blood
Flood and blood resus as required
CTG monitor foetus
close monitoring. ofmother
423
what connective tissue in the umbilical cord protects the blood vessels?
whartons jelly
424
what are the two types of vasa praevia?
1 - foetal vessels exposed as cord inserts into membranes outside placenta
2 - vessels exposed as travel to accessory placental lobe from placenta
425
what are 3 risk factors for vasa praevia?
low lying placenta
IVF
multiples
426
what are 3 presentations of vasa praevia?
antenatal scan
antepartum haemorrhage in 2nd/3rd trimester
bright red blood on ROM in labour or foetal vessals seen on VE
427
what is the management for vasa praevia?
corticosteroids from 32 weeks
elective c-section 34-36 weeks
428
what is classed as a minor PPH?
500-1000ml
429
what is classed as a major PPH?
1000ml+
430
what is a primary PPH?
bleeding within 24 hours of birth
431
what is a secondary PPH?
24 hours -12 weeks after birth
432
what are the 4 Ts of PPH?
tone (atony)
trauma (tears)
tissue (retained placenta)
thrombin (bleedin gdisorder)
433
what are 12 risk factors for PPH?
previous PPH
grandmultiparity
obesity
macrosomnia/polyhydramnios
prolonged labour
pre-eclampsia
placenta accreta
placenta praevia
retained placenta
instrumental delivery
pre-existing anaemia
induction
434
what are 4 preventative measures for PPH?
Tx anaemia antenatally
give birth with empty bladder
active management of 3rd stage
IV tranexamic acid during section in high risk patients
435
what are 2 mechanical managements of PPH?
fundal massage
catheterisation
436
what are 5 medical managements of PPH?
IV/IM oxytocin
IV/IM ergometrine (without Hx hypertension)
IM carboprost (without Hx asthma)
Misoprostol sublingual
Tranexamic acid
437
what are 4 surgical managements of PPH?
interuterine balloon tamponade
B-lynch suture (braces)
Uterine artery ligation
Hysterectomy
438
what is antepartum haemorrhage?
bleeding PV from 24 weeks
439
what does rhesus disease cause in the new born?
haemolysis
440
what is the prophylaxis for rhesus disease of the newborn?
anti-D IM injection in negative mothers
prevents sensitasation in the mother given at 28 weeks
441
when is anti-d given?
28 weeks
Birth (if baby +ve)
sensitisation events
442
what test is used to titrate the dosage of anti-D?
Kleinhauer test
443
what does the kleinhauer test check?
how much foetal blood has passed into the maternal circulation during a sensitisation event after 20 weeks
444
what is low birth weight?
<2500g
445
what is placental insufficiency?
when o2 and nutrients cannot sufficiently supplu placenta and foetus due to insufficient spiral arteries
446
what are 6 risk factors for placental insufficiency?
Pre-eclampsia/hypertension
smoking, drinking, drugs
Advanced maternal age
primiparity
prev IU growth restriction baby
medications - cancer, antiepileptics
447
what 2 medications can be given for placental insufficiency?
aspirin
heparin
448
what is the combined test?
11-14 weeks gestation
uss - nuchal translucency >6cm
bloods - bHCG and PAPPA - increased HCG and low PAPPA
Screening for downs
449
what physiological changes in pregnancy are there in relation to maternal fluid retention?
Increased total plasma volume (30-50%)
Decreased plasma oncotic pressure
450
How long does the corpus luteum produce progesterone for in pregnancy?
10 weeks
451
what are 6 physiological hormonal changes in pregnancy?
Increased ACTH which causes an increase in steroid hormones (cortisol and aldosterone)
Increased prolactin - suppresses FSH and LH
Increased melanocyte stimulating hormone causes hyperpigmentation - linea nigra, melasma
Increase in T3 and T4
Increase in progesterone and oestrogen
increase then slow fall in HCG after 12 weeks
452
what is the change in the size of the uterus in pregnancy?
from around 100g to around 1.1kg
453
what hormone allows break down of collagen in the cervix to prepare for effacement?
prostaglandins
454
what are 7 physiological cardiac changes in pregnancy?
Increased blood volume
increased plasma volume
increased cardiac output - increased stroke volume and HR
decreased peripheral vascular resistance
decreased BP (early and mid pregnancy)
varicose veins
peripheral vasodilations (can cause flushing and hot sweats)
455
what are 2 physiological respiratory changes in pregnancy?
increased tidal volume
increased resp rate
456
what are 5 physiological renal changes in pregnancy?
increased blood flow to kidneys
increased GFR
increased aldosterone => increased Na+ and water
increased protein excretion
dilation of the ureters and collecting system - physiological hydronephrosis (R>L)
457
what are 3 nutrients that are in higher demand in pregnancy?
iron
folate
B12
458
what are the side effects of tamoxifen and aromatase inhibitors?
hot flushes
nausea
vaginal bleeding
thrombosis
endometrial cancer
459
what medication can be used in pre-menopausal woman with ovarian sensitive breast cancer?
GNFR inhibitors
460
what is the name of 3 HER2 receptor blocker medications?
trastuzumab
pretuzumab
Neratinib
461
what medications can be used in tripple negative breast cancer?
immunomodulators
462
what medications can be used in braca1 and 2 cancers?
PARP inhibitors
463
what is the first line management of cholestasis of pregnancy?
1 - emmolients and antihistamines
2- ursodeoxycholic acid
464
what are 4 risk factors for shoulder dystocia?
macrosomia
High maternal BMI
Diabetes
Prolonged labours
465
what is the 1st line management of shoulder dystocia?
McRoberts manoeuvre
466
what is the management of one missed COCP?
take missed pill even if have to take two in one day
no additional contraceptive needed
467
what is the management if 2+ OCPs are missed?
take yesterdays and todays dose then continue taking normally
Use condoms for 7 days
468
what is the management of unprotected sex on OCP with missed pills in week 1?
emergency contraception
469
what is the management of unprotected sex on OCP with missed pills in week 2?
no need for additional contraception
470
what is the management of unprotected sex on OCP with missed pills in week 3?
finish pills in current pack and start new pack immediately no need for pill free interval
471
where is the most common site of ectopic pregnancy?
ampulla of fallopian tubes
472
what are 4 risk factors for hyperemesis gravidum?
increased levels of beta-hCG - multiple pregnancies, trophoblastic disease
nulliparity
obesity
family or personal history of NVP
473
what is associated with decreased levels of hyperemesis gravidum?
smoking
474
what is the triad of hyperemesis gravidum?
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
475
what is the first line management of hyperemesis gravidum?
antihistamines: oral cyclizine or promethazine
phenothiazines: oral prochlorperazine or chlorpromazine
476
what is the second line management of hyperemsis gravidum?
oral ondasetron
oral metoclopramide or domperidone
477
what complication can ondansetron use in pregnancy cause?
cleft lip and palate
478
what are 4 complications of hyperemesis gravidum?
acute kidney injury
Wernicke's encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism
479
what are 7 features of fibroids?
asymptomatic
menorrhagia - may result in iron-deficiency anaemia
bulk-related symptoms
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
480
how are fibroids diagnosed?
TV USS
481
what is the management of menhorrhagia in fibroids?
levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
482
what is the management to treat fibroids?
GnRH analogues
surgery - myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation
483
what can be a cause of thick green nipple discharge most common in postmenopausal smokers?
Mammary duct ectasia
484
what type of contraception can be used in trans men?
Progesterone only
non-hormonal
485
How long after UPSI can Levonorgestrel (Levonelle) be taken?
72 hours
486
How long after UPSI can Ulipristal (ella one) be taken?
120 hours
487
what patients should Ulipristal use be cautioned in?
Asthmatics
488
How long after taking Ulipristal do you need to wait to start hormonal contraception?
5 days
489
How long after UPSI can the copper IUD be fitted?
5 days
490
what is the most common ovarian cyst?
follicular cyst - due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
491
what is the most common benign ovarian tumour in women <30?
Dermoid cyst - torsion in more likely
492
what is amniotic fluid embolism?
when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
493
what antibiotics should be avoided in breast feeding?
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
494
what psychiatric drugs should be avoided in breast feeding?
lithium, benzodiazepines
495
What are 6 drugs that should be avoided in breast feeding?
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
496
what medication can be used to suppress lactation?
cabergoline
497
what are 5 risk factors for breech presentation?
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
498
when should external cephalic version (ECV) be offered in breech presentation?
37 weeks (can be 36 in primies)
499
what are 5 reasons for a Cat 1 section?
suspected uterine rupture
major placental abruption
cord prolapse
fetal hypoxia
persistent fetal bradycardia
500
how quick should a cat 1 section be?
within 30 mis
501
How quick should a cat 2 section be?
within 75 mins
502
what is the results of a positive combined test?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency => Downs likely
503
what tests are included in the quadruple test?
alpha-fetoprotein
unconjugated oestriol
human chorionic gonadotrophin
inhibin A
504
what is the quadruple test result for downs?
alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - HIGH
inhibin A - HIGH
505
what is the quadruple test result for edwards?
alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - LOW
inhibin A - NORMAL
506
what is the quadruple test result for neural tube defects?
alpha-fetoprotein - HIGH
unconjugated oestriol - NORMAL
human chorionic gonadotrophin - NORMAL
inhibin A - NORMAL
507
what is the management of eclampsia in pregancy?
IV magnesium sulphate
508
How long should magnesium sulfate continue after delivery in eclampsia?
24 hours
509
what is the first line management for mag sulfate induced respiratory depression in eclampsia?
calcium gluconate
510
what folic acid supplementation should pregnant women take?
400mcg of folic acid until the 12th week of pregnancy
511
What risk factors mean women should take 5mg of folic acid pre-pregnancy?
Personal or FHx of neural tube defect
anti-epileptic drugs
coeliac disease, diabetes, or thalassaemia trait
BMI >30 kg/m2
512
what is the diagnostic threshold for gestational diabetes?
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
5,6,7,8
513
what is the fasting glucose target in pregnancy for those with diabetes?
5.3 mmol/L
514
what is the 1 hour post meal glucose target in pregnancy?
7.8 mmol/L
515
what is the 2 hour post meal glucose target in pregnancy?
6.4 mmol/L
516
what are 6 indications for induction?
Overdue >41 weeks
PPROM/PROM
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis
intrauterine fetal death
517
what score is used to assess whether induction of labour is necessary?
Bishop score
518
what is the bishop score that indicates need for induction?
<5
519
what is the bishop score that indicates no need for induction?
>8 inclusive
520
what is the management of bishop score <6 inclusive?
vaginal prostaglandins or oral misoprostol
balloon catheter if higher risk of hyperstimulation or prev c-sections
521
what is the management of bishop score >6?
amniotomy and an intravenous oxytocin infusion
522
what is the main complication of induction of labour?
uterine hyperstimulation
523
what are 4 complications of PROM?
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
524
what can be seen on sterile speculum exam in PROM?
pooling of amniotic fluid in the posterior vaginal vault
525
How can PROM be tested for if fluid pooling not seen?
testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein‑
526
what medication should be given in PROM?
Oral erythromycin 10 (TEN) days
Corticosteroids (<34 weeks)
527
What are 8 situations where anti-D should be given ASAP?
delivery of Rh +ve infant - live or stillborn
termination of pregnancy
miscarriage > 12 weeks
ectopic pregnancy - surgically managed
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
528
what tests should be done on the cord blood of any baby born to Rh -ve mother?
FBC
Blood group and save
Direct coombs test
529
what are the 3 stages of postpartum thyroiditis?
Thyrotoxicosis
hypothyroid
return to normal
530
what is the management of the thyrotoxic phase of postpartum thyroiditis?
propanalol - to treat symptoms
531
what is the management for fibroids <3cm?
1 - Mirena coil
symptomatic - tranexamic and mifenamic acid
2 - COCP, cyclical progestogens
Surgical - Endometrial ablation, resection of submucosal fibroids during hysteroscopy, Hysterectomy
532
what is the management of fibroids >3cm?
refer to gynae - options as <3cm +
Uterine artery embolisation
Myomectomy
Hysterectomy
+ GnRH analogues to shrink before myomectomy
533
what are 8 complications of fibroids?
iron deficiency anaemia
Reduced fertility
Pregnancy complications
Constipation
Urinary outflow obstruction + UTI
Red degeneration
Torsion of the fibroid
Malignant change to a leiomyosarcoma - very rare (<1%)
534
what is red degeneration of fibroids?
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply usually in pregnancy
Presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
535
when should induction be offered in cholestasis of pregnancy?
37-38 weeks
536
what other than ovarian cancer can cause a raised Ca125?
adenomyosis
ascites
endometriosis
menstruation
breast cancer
ovarian torsion
endometrial cancer
liver disease
metastatic lung cancer
537
what are 8 things that increase risk of IUGR?
Maternal age of <16 or >35
low BMI or a pre-pregnancy weight of >75kg. interpregnancy interval < 6 months or >10 years
Pre-eclampsia
smoking, drugs and alcohol
clotting disorders
diabetes
congenital abnormalities
538
what are 4 features of congenital syphilis?
Generalised lymphadenopathy
Hepatosplenomegaly
Rash
Skeletal malformations
539
what are 4 causes of retrograde ejaculation?
Bladder neck surgery
Congenital abnormality
Diabetic autonomic neuropathy
Transurethral resection of the prostate
540
which cells does HIV affect?
CD4 T-Helper cells
541
What are 6 Aids defining infections
Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis
542
what is the normal CD4 count?
500-1200 cells
543
What is the treatment of HIV?
Antiretroviral therapy (ART)
544
what medication can be given people with a very low CD4 count in HIV to prevent pneumocystis jirovecii infection?
Prophylactic co-trimoxazole
545
How often do people with HIV get cervical smears?
Yearly
546
what infectious disease screening is offered in pregnancy?
HIV
syphilis
hepatitis B
547
when does the dating scan happen?
11+2-14+1 weeks
548
when is the booking visit and what happens?
<10 weeks
Ht and Wt
screening offered
BP and urinalysis
risk assessed
vaccines offered
549
when does the anatomy scan occur?
18-20+6 weeks
550
when is Anti-D given in normal pregnancy?
28 weeks and 34 weeks
551
what are 11 risk factors for small for gestational age baby?
Maternal age >40
Smoker
Maternal cocaine use
Maternal daily vigorous exercise
Previous SGA baby
Previous stillbirth
FHx SGA
Chronic hypertension
Diabetes with vascular disease
Renal impairment
Antiphospholipid syndrome
552
what are 6 foetal surveillance techniques?
Symphyseal fundal height Foetal abdominal circumference.
Femur length.
Head circumference / biparietal diameter.
Liquor volume / amniotic fluid index (normal = 5-25cm)
umbilical/MCA artery Doppler
553
what level is raised bile acids in pregnancy?
>19 micromol/L
554
what are 3 analgesias used in labour?
Entonox
IM opioids - diamorphine or morphine
Epidural - bupivacaie and fentanyl
555
what counts as delay in the first stage of labour?
cervical dilation <2cm in 4 hours
556
what counts as delay in the second stage of labour?
nuliparous > 2 hours
multiparous >1 hour
557
what are 6 contraindications to the copper IUD and the IUS?
1. PID
2. Gonorrhoea or chlamydia
3. Unexplained vaginal bleeding / endometrial cancer
4. Postpartum / post-abortion septicaemia
5. Gestational trophoblastic disease
6. Purulent cervicitis, pelvic TB
558
at what crown rump length should a foetus have a heart beat?
>7 mm
559
what is the normal positioning of the baby throughout birth?
Descent, engagement, flexion, internal rotation, crowning, extension of presenting part, external rotation of head, delivery
560
what is the management of asymptomatic bacteriuria in pregnancy?
Confirm presence of bacteriuria with second culture and begin culture dependent antibiotic
561
What counts as polyhydramnious?
AFI of >24cm (or 2000ml+)
562
what counts as oligohydramnious?
AFI of <5cm (or under 200ml)
563
what are 4 neonatal complications due to anti-epileptic use in pregnancy?
Orofacial defects
neural tube defects
congenital heart defects
haemorrhagic disease of the new born
564
what are 6 causes of hydrops fetalis?
severe anaemia
cardiac abnormalities
chromsomal abnormalities (turners, downs, edwards, pataus)
Infection (toxoplasmosis, rubella, CMV, varicella, parvovirus)
twin-twin trasnfusion syndrome
chorioangioma
565
what is the Hb monitored in pregnancy?
booking and 28 weeks
566
How do you read CTGs?
DR C BRAVADO
DR - Define risk
C - contractions - <5 in 10 inclusive
BRa - Baseline rate - 110-160 BPM
V - Variability - 5 -25 bpm variability
A - Accelerations - rise of 15bpm for >15s, should be 2 every 15 mins
D - Decelerations - drop of 15bpm for >15s
O - overall impression
567
obs
gynae
