Women’s Health Flashcards
1
Q
What is the leading cause of direct maternal death in the UK?
A
VTE
2
Q
What is the most common virus transmitted to the foetus during pregnancy?
A
CMV
3
Q
List some causes of direct maternal death
A
- VTE (most common)
- Suicide (2nd most common)
- Sepsis (3rd most common)
- PPH
- Amniotic fluid embolism
- Pre-eclampsia
4
Q
What is the most common gynaecological cancer in the developing world?
A
Endometrial cancer
5
Q
What is the most common and 2nd most common cause of indirect maternal death?
A
- Cardiac disease (1st)
- Neurological conditions (2nd)
6
Q
What is heath promotion?
A
Advising and educating patients about their health, enabling them to increase their control over and improve their health.
7
Q
Outline the organisation of female health services in the United Kingdom including sexual health, genito-urinary medicine, midwifery, obstetrics and gynaecology
A
- Sexual health and GUM clinics.
- Community midwives.
- Antenatal clinics.
- Obs & gynae in-patients and outpatient services e.g. EPAU, abortion services.
8
Q
Identify how the quality of women’s health services is measured at local and national level
A
LOCAL:
- Audits
- QIPs
NATIONAL:
- CQC
- Better births report 2016
- Maternity transformation model
- Shrewsbury and Telford - the Ockenden report 2022
- MBRRACE-UK reports into maternal deaths, stillbirths and infant deaths
9
Q
Outline the relevance of societal, cultural, economic and political issues with regard to the provision of obstetrics, gynaecology and sexual health
A
- Societal: postcode lottery for IVF - how many cycles local CCG allows (NICE recommends 3).
- Cultural: opinions about abortion, LGBTQ+.
- Economic: cost of IVF if not funded by NHS.
- Political: rules on abortion.
10
Q
Outline the aims of the Women’s Health Strategy
A
- Improving health outcomes for women.
- Better education.
- Ensuring the health-care system serves women’s needs across the life course.
- Strengthening research.
- Improve representation of women in clinical trials and medical research - to minimise the ‘gender gap’.
- Ensure women’s voices are heard.
- Improve access to services.
11
Q
Describe the process of antenatal care and the statistical outcomes which are used to measure its benefit
A
ANTENATAL CARE:
- 8 weeks: booking appointment (education, bloods, BMI, urinalysis, BP, risk assessment e.g. gestational diabetes).
- 10 - 13+6 weeks: dating ‘12 week’ scan - accurate gestational age calculated from CRL and no. of foetuses.
- 16 weeks: antenatal appointment (BP, urine dip, SFH, foetal HR, maternal wellbeing, domestic violence).
- 18 - 20+6 weeks: anomaly ‘20 week’ scan.
- 25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks: antenatal appointment.
- Vaccines: whopping cough and influenza.
- Lifestyle advice including folic acid, vitamin D, alcohol, smoking.
STATISTICAL OUTCOMES:
- Pregnancy outcomes - preterm birth and low birth weight.
- Pre-eclampsia.
- Anaemia during pregnancy.
- Stillbirth.
12
Q
Discuss the application of the principles of effective screening to pregnancy
A
- Condition: important health problem (common/severe), epidemiology and natural history understood, detectable risk factor/disease marker/asymptomatic period, all cost effective primary interventions should’ve been implemented as far as possible - pregnancy is common, detectable disease markers e.g. Down’s syndrome screening beta-hCG.
- Test: simple/safe/precise/validated, normal distribution of valves known and cut off agreed, agreed policy on further management of test +ve - blood test are simple, safe and fairly non-invasive.
- Treatment: evidence based, effective intervention that leads to better outcomes if given earlier, cost-effective (lives saved and QALYs) - prepare mothers if child with Down’s syndrome, decision to terminate.
- Programme: effective at decreasing mortality and morbidity, benefit > harm, adequate resources, programme continually reviewed for quality assurance.
13
Q
Describe the screening process for chromosomal abnormalities
A
- Combined test (first line): high beta-hCG, low PAPPA, NT > 6mm.
- Triple test: high beta-hCG, low AFP, low oestradiol.
- Quadruple test: high beta-hCG, low AFP, low oestradiol, high inhibin-A.
- Amniocentesis (later) or chorionic villus sampling (earlier) - cells karyotyped for a definite diagnosis.
- Non-invasive prenatal testing (NIPT): detects cell-free DNA.
14
Q
Outline measurements of pregnancy outcome
A
- Maternal and neonatal mortality/morbidity.
- Stillbirth.
- Preterm birth.
- Birth weight.
- Birth injury.
- Mode of delivery.
- Patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL).
- Mental health.
- Mother-infant bonding.
- Confidence and success with breastfeeding.
- Incontinence.
- Satisfaction with care and birth experience.
15
Q
Discuss the priorities for health promotion in pregnancy and the evidence base for them
A
- Antenatal care - regular appointments with the midwife. Improves maternal and neonatal outcomes. Reduces stillbirths and pregnancy-related complications.
- Lifestyle advice e.g. folic acid, vitamin D, avoid smoking/alcohol, continue moderate exercise, avoid certain foods e.g. shellfish, liver/pate and unpasteurised milk/cheese.
- Education - look out for red flags and maternal health advice.
- Mental health screening.
- Screening: blood tests (e.g. HIV, syphilis, hep B, sickle cell, thalassaemia), Down’s syndrome, gestational diabetes.
16
Q
Access and interpret national fetal, perinatal and maternal mortality and morbidity statistics
A
FOETAL MORTALITY:
- Stillbirths and neonatal death decreasing - due to improvement in general healthcare, midwifery, NICU.
- High number of death in first year, but decreasing due to back to sleep campaign.
- Higher in ethnic minorities, teenage pregnancies, lower SEC.
STILLBIRTHS:
- The stillbirth rate was 3.8 stillbirths per 1,000 births in 2020 - a record low, and in line with previous decreasing trends.
17
Q
Outline the factors that influence maternal mortality
A
- Ethnicity: black x4, asian x2.
- Socioeconomic status: more likely to engage in dangerous behaviours.
- Nutrition.
- Poverty/deprived areas.
- Extremes of age.
- Multiple pregnancies - IVF.
- Obesity.
18
Q
Outline the risk factors for stillbirths
A
- Foetal growth restriction.
- Congenital anomaly.
- Multiple pregnancy.
- Age of extremes of maternity (<25/>40).
- Obesity.
- Smoking.
- Obstetric complications - APH/PPH.
- Geographical variation.
- Ethnicity: Black or Asian have significantly higher rates.
- Lower socioeconomic status.
19
Q
Discuss access to fertility services
A
- NICE recommends 3 cycles of IVF, but it depends on local integrated care board (ICB) allocation of services.
- 3 types of fertility treatment: medication, surgery, assisted reproduction e.g. intrauterine insemination (IUI) and in vitro fertilisation (IVF).
- Funded by NHS and long waiting lists.
- Also depends on eligibility criteria.
- Referral to NHS clinic for initial investigation.
- Can go to private clinics.
20
Q
Outline the importance of risk factors (virology, endocrinology and genetics), pre-cancerous conditions and screening possibilities for gynaecological malignancies
A
- Cervical cancer only routinely screened for in NHS (aged 25-64).
- Cervical cancer: HPV most common cause, HIV, FHx, high number of sexual partners, non-engagement with screening services.
- CIN pre-cancerous stage of cervical cancer (cervical dysplasia).
- Endometrial cancer: prolonged exposure to unopposed oestrogen —> increased age, nulliparity, obesity, PCOs, tamoxifen. HNPCC or Lynch syndrome.
- Endometrial hyperplasia is the pre-cancerous condition.
- Ovarian cancer: BRCA1 & 2 genes, increased number of ovulations (e.g. nulliparity), obesity, smoking.
- Vulval cancer: increased age, HPV, lichen sclerosis.
- Vulval intraepithelial neoplasia (VIN) is pre-cancerous condition.
21
Q
Outline the UK cervical screening programme and HPV vaccination programme
A
CERVICAL SCREENING:
- Smear test to detect pre-cancerous and cancerous changes.
- Sample tested for high-risk HPV (hrHPV).
- hrHPV -ve: return to routine recall.
- hrHPV +ve: cells examined by cytology for dyskaryosis.
- Every 3 years aged 25-49, every 5 years aged 50-64.
- Abnormal cytology —> colposcopy.
HPV VACCINATION:
- Boys and girls aged 12-13 (before they’re sexually active).
- Reduce spread of HPV and reduced risk of cervical cancer.
- Protects against HPV strains 6 & 11 (genital warts), 16 & 18 (cervical cancer).
22
Q
Explain the principle of Multi-Disciplinary Team (MDT) approach to treatment of gynaecological malignancies
A
- Cervical: LLETZ or cone biopsy (CIN and early stage), radical hysterectomy (stage 1B-2A), chemo & radiotherapy (stage 2B-4A), pelvic exenteration (stage 4B).
- Endometrial: total abdominal hysterectomy with bilateral salpingo-oopherectomy, radiotherapy, chemo.
- Ovarian: surgery and adjuvant chemo.
- Vulval: surgery (wide local excision, vulvectomy), chemo and radiotherapy.
- The MDT look at national treatment guidelines or the latest evidence.
- Specialist gynaecological cancer MDT - well-established group of experts with a specialist role in the diagnosis, treatment and management of women with gynaecological cancers.
23
Q
Describe the basic epidemiology, pathogenesis and common manifestations of STIs in men and women and demonstrate an understanding of the public health issues for control of spread of infection both locally and globally
A
EPIDEMIOLOGY:
- Most common STIs (in order): chlamydia, gonorrhoea, genital warts, genital herpes, HIV.
- Chlamydia accounted for 46% of all new STI cases.
- Chlamydia and gonorrhoea - bacteria.
- Warts, herpes and HIV - viruses.
- Females more at risk, but overall men have a greater incidence of STIs.
- Age 15-24 most common age.
- Common groups affected: young heterosexuals, black ethnic minorities, gay/bisexual, men who have sex with men.
INFECTION CONTROL:
- Making STI and HIV testing more accessible and less embarrassing. Regular testing.
- Barrier contraception - condoms - to reduce risk of transmission. Consistent and correct use.
- Effective contract tracing/partner notification.
- Effective treatments e.g. antibiotics - to reduce the period of infectiousness in individuals.
- PrEP and PEP for HIV.
- Vaccinations e.g. HPV for genital warts, Hep A/B.
- Reducing the rate of sexual partner exchange/number of sexual partners.
- Abstinence.
- National Chlamydia Screening Programme
24
Q
Identify opportunities for sexual health promotion (ie: opportunities for early diagnosis of HIV, explaining principles of safer sex and risk reduction, be able to demonstrate correct condom use)
A
SEXUAL HEALTH PROMOTION:
- Correct condom use.
- Increased screening.
- Sexual education.
- Remove stigma and normalise testing.
- Target higher risk groups.
- Public education on importance of early detection and diagnosis of HIV.
- Sexual health campaigns.
CONSEQUENCES OF POOR SEXUAL HEALTH:
- Unplanned pregnancies and abortions.
- Psychological consequences from abuse and coercion.
- HIV transmission.
- Cervical cancer.
- Hepatitis.
- Recurrent genital herpes and warts.
- PID impacting on ectopic pregnancy and fertility.
- Poor educational, social and economic opportunities for teenage mothers.
25
Discuss issues in relation to genital mutilation (FGM) in obstetrics and gynaecology
- All procedures that involve full or partial removal of female external genitalia for non-medical reasons.
- FGM practiced in Africa, the Middle East and Asia.
- FGM is a violation of the human rights of girls and women.
- The practice has no health benefits for girls and women and cause severe bleeding and problems urinating, and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.
- Seen as the social norm, religious reasons, controlling sexuality.
FGM Act 2003:
- Illegal in UK.
- Illegal to take child abroad for FGM.
- Offence to aid or abide.
- Reported to police if < 18.
26
Discuss domestic violence issues in obstetrics and gynaecology in relation to safeguarding
- Sexual assault: sexual assault referral centre, forensic physician (pregnancy, suicidal ideation, safeguarding, HIV, Hep B, swabs for criminal evidence), care after sexual assault centres.
- Safeguarding issues for both mother and baby/children.
- National domestic abuse helpline.
- Types of abuse: emotional, threats and intimidation, physical, sexual, financial.
- Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect.
- Domestic abuse is a child protection issue.
27
Discuss welfare of the child issues in relation to subfertility
Designer babies not ethical
28
Dsesscribe the epidemiology, pathophysiology and common presentations of eczematous eruptions, psoriasis, and acneiform eruptions
- Eczema: highest incidence in infants < 1 year, highest prevalence in children aged 2, more common in Asian and black ethnic groups, bimodal distribution (0-17 years then 75+ years), 1 in 5 children, 1 in 10 adults, equal across genders.
- Psoriasis: affects 1.3-2.2% of people in UK, bimodal distribution (20-30 and 50-60), more common in white people, equal gender balance.
- Acne: 20-30% of adolescents are affected by moderate-severe acne, most common age is 12-24 years, males more commonly affected in adolescents, but more common in females in adulthood.
29
Compare and contrast the epidemiology, clinical features and management of the following benign lesions: Viral warts, Epidermoid and pilar cysts, Seborrhoeic keratosis, Dermatofibroma, Lipoma, and Common vascular lesions
- Viral warts: 7-12% prevalence, 10-20% in school aged children.
- Epidermoid cysts: most common in 30-40s, more common in men.
- Pilar cysts: 5-10% prevalence, most commonly affect scalp.
- Seborrhoeic keratosis: most common human tumours, more common in >70 years.
- Dermatofibroma: more common in women, most common in young adults, more common with immunosuppression.
- Lipoma: any age, but usually first appear between 40-60 years, solitary lipomas more common in women, multiple more common in men, annual incidence of 1 per 1,000.
- Vascular lesions: Hemangiomas, Vascular Malformations, and Pyogenic Granulomas.
30
Describe the epidemiology and pathophysiology of benign, premalignant and malignant melanocytic lesions
- Melanoma is the 5th most common cancer.
- 16,000 new cases per year.
- More common in men.
- 2,300 deaths per year in the UK.
- 86% cases preventable.
31
Describe the epidemiology and pathophysiology of premalignant lesions: actinic keratosis and Bowen’s disease
- Actinic keratosis: affects ~20% population >60 years, more common in individuals with fair skin, blonde hair and blue eyes, prevalence increases with age, immunosuppressed, UV light exposure, more common in men.
- Bowen’s disease: can develop into SCC, more common in immunocompromised, more common in women, incidence of 15 in 100,000 per year, most common in 60-70 years, UV light exposure, Caucasians.
32
Describe the epidemiology and pathophysiology of non melonoma skin cancers (inc BCC and SCC)
- BCC: most common form of skin cancer, affects middle aged/elderly.
- SCC: second most common type of skin cancer.
- 156,000 new cases of non melanoma skin cancer in uk every year.
33
Counsel patients on appropriate sun protection behaviours with the correct use of sunscreens (protecting for both UVA and UVB)
- Suncream, hats, sunglasses, cover ups.
- UVA: present during all daylight hours, deeply penetrating, causing more long-term damage.
- UVB: responsible for sunburn and skin reddening, develop towards skin cancer.
- The lowest recommended star rating for UVA protection is 4.
- SPF: ‘sun protection factor’ indicates the level of protection a sun cream provides against burning rays.
- SPF 50+ offering the most protection against UVB.
- Reapply suncream every 2 hours.
34
Explain the two-week-wait pathway and the role of the skin cancer multidisciplinary team to patients and their carers
Urgently refer (appointment within two weeks) if:
- A person presents with a suspicious pigmented skin lesion that has a weighted 7-point checklist score of 3 or more. OR…
- A dermoscopy suggests malignant melanoma of the skin.
Consider urgent referral (appointment within two weeks) for melanoma in people with a pigmented or non-pigmented skin lesion that suggests nodular melanoma.
The seven-point weighted checklist:
- Major features (scoring two points each): change in size, irregular shape, irregular colour.
- Minor features (scoring one point each): largest diameter of 7mm or more, inflammation, oozing, change in sensation.
Only consider urgent referral (appointment within two weeks) if a person has a skin lesion that raises the suspicion of a basal cell carcinoma and there’s concern a delay may have an unfavourable impact, because of the location or size of the lesion.
Consider urgently referring (appointment within two weeks) if a person has a skin lesion that raises the suspicion of squamous cell carcinoma.
Melanoma MDT:
- Oncologist: a cancer doctor who specialises in treating people with cancer using targeted and immunotherapy drugs, radiotherapy and chemotherapy.
- Skin cancer nurse specialist: a nurse who gives information about skin cancer, and support during treatment.
- Dermatologist: a doctor who treats skin problems.
- Plastic surgeon: a doctor who does operations (surgery) to repair or reconstruct tissue and skin.
- Pathologist: a doctor who looks at cells or body tissue under a microscope to diagnose cancer.
- Radiologist: a doctor who looks at scans and x-rays to diagnose problems.
35
What is the most common gynaecological procedure performed in NHS?
Abortion
36
Do women and pregnant people have a legal right to abortion in mainland UK?
No - there is no legal right to abortion. It is a criminal offence, however the 1967 Abortion Act permitted abortion under certain conditions.
37
What are the rules in Northern Ireland on abortion?
Decriminalised in October 2019 (made it part of healthcare). Legal right to abortion up to 12 weeks. Conditions similar to 1967 Abortion Act from 12 weeks imposed by government regulations.
38
How many doctors are required to agree to an abortion?
Two
39
Which circumstances is there no time limit for abortion?
- Serious foetal abnormality.
- To save a women’s life or prevent grave permanent injury - only requires one doctors authorisation.
40
Describe the 5 grounds for abortion
A. To save the woman's life (no limit).
B. To prevent grave permanent injury to the woman's physical or mental health (no limit).
C. Abortion less risk to the physical or mental health of the woman than continuing the pregnancy (< 24 weeks).
D. Abortion less risk to the physical or mental health of existing children than continuing the pregnancy (< 24 weeks).
E. Child likely to be severely physically or mentally disabled (no limit).
41
What happens if a doctor has a conscientious objection to abortion?
Doctors have a legal and professional right to opt out of participating in direct abortion care (unless it’s an emergency to save a women’s life or prevent grave permanent harm). However, they still have a duty of care, therefore they must ensure that the patient still receives access to an abortion, by providing the patient with the correct information to access abortion care - i.e. it is a self-referral service in the UK.
42
Impact of conscientious objection to a patient requesting abortion care
- Feeling stigmatised/judged
- Distrust between doctor patient relationship
