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Phase 3a > Women's Health > Flashcards

Women's Health Flashcards

1
Q

What are the signs / symptoms of threatened miscarriage?

A

Painless vaginal bleeding typically around 6-9 weeks

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2
Q

What are the signs / symptoms of missed (delayed) miscarriage?

A

Light vaginal bleeding and symptoms of pregnancy disappear
‘Missed’ refers to the fact that the os remains closed and the gestational sac remains within the uterus.

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3
Q

Painless vaginal bleeding typically around 6-9 weeks would indicate what?

A

Threatened miscarriage

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4
Q

Light vaginal bleeding and symptoms of pregnancy disappear would indicate what?

A

Missed (delayed) miscarriage

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5
Q

What are the two types of inevitable miscarriage?

A

Complete or incomplete - depending on whether all foetal and placental tissue has been expelled

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6
Q

What are the signs / symptoms of an ectopic pregnancy?

A

6-8 weeks of amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later

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7
Q

6-8 weeks of amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later would indicate what?

A

Ectopic pregnancy

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8
Q

What signs / symptoms ‘may’ be present in an ectopic pregnancy?

A

Shoulder tip pain and cervical excitation

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9
Q

What are the signs / symptoms of a hydatidiform mole?

A

Typically bleeding in the first or early second trimester with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG will be abnormally very high

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10
Q

Constant lower abdominal pain. Woman may be more shocked than is expected by visible blood loss. Tender, tense uterus. Foetal heart may be distressed. Would indicate what?

A

Placental abruption

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11
Q

Bleeding in the first or early second trimester with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG will be abnormally very high would indicate what?

A

Hydatidiform mole

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12
Q

What are the signs / symptoms of placental abruption?

A

Constant lower abdominal pain. Woman may be more shocked than is expected by visible blood loss. Tender, tense uterus. Foetal heart may be distressed.

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13
Q

What are the signs / symptoms of placenta praevia?

A

Vaginal bleeding with no pain, the uterus will be non-tender but the presentation and lie may be abnormal.

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14
Q

Vaginal bleeding with no pain, a non-tender uterus but with presentation and lie abnormal would indicate what?

A

Placenta praevia.

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15
Q

What are the signs / symptoms of vasa praevia?

A

Rupture of the membranes followed immediately by vaginal bleeding. Foetal bradycardia is classically seen.

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16
Q

Rupture of the membranes followed immediately by vaginal bleeding and foetal bradycardia would indicate what?

A

Vasa praevia.

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17
Q

What would the options be for an ectopic pregnancy with no foetal heartbeat?

A

Expectant or medical management.

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18
Q

What would the options be for an ectopic pregnancy with a a visible foetal heartbeat?

A

Surgical management.

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19
Q

What would the management be for an ectopic pregnancy with a hCG of <1000?

A

Expectant management

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20
Q

What would the management be for an ectopic pregnancy with a hCG of <1500?

A

Medical management. Can only be done so if the patient is willing to attend a follow up appointment.

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21
Q

What would the management be for an ectopic pregnancy with a hCG of >5000?

A

Surgical management

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22
Q

What would the hCG level need to be for expectant management to be commenced for an ectopic pregnancy?

A

hCG of <1000

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23
Q

What would the hCG level need to be for medical management to be commenced for an ectopic pregnancy?

A

hCG of <1500

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24
Q

What would the hCG level need to be for surgical management to be commenced for an ectopic pregnancy?

A

hCG of >5000?

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25
Q

What is the only intervention of choice for an ectopic pregnancy if there is a ruptured fallopian tube?

A

Surgical management (salplngotomy, salplngectomy)

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26
Q

When should anti-D prophylaxis be given for termination of pregnancy?

A

Anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation

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27
Q

What is the first line investigation for gestational diabetes?

A

Oral glucose tolerance test

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28
Q

At what weeks should an oral glucose tolerance test be performed for gestational diabetes?

A

Screening is offered at 24-28 weeks

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29
Q

At what weeks should an oral glucose tolerance test be performed for gestational diabetes if there are risk factors present?

A

Women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

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30
Q

What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) at fasting?

A

5.3 mmol/l

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31
Q

What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) 1 hour after meals?

A

7.8 mmol/l

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32
Q

What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) 2 hour after meals?

A

6.4 mmol/l

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33
Q

What is the VTE prophylaxis of choice during pregnancy?

A

Low molecular weight heparin

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34
Q

When should VTE prophylaxis be given during pregnancy for those in which it is indicated?

A

From 28 weeks and continued until six weeks postnatal.

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35
Q

What is the management of pre-existing diabetes in pregnancy?

A

Stop oral hypoglycaemic agents, apart from metformin, and commence insulin

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36
Q

What is the management of gestational diabetes with a fasting glucose of > 7 mmol/L?

A

Insulin ±metformin

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37
Q

What is the management of gestational diabetes with a fasting glucose of > 6 mmol/L with Macrosomia or Other Complications?

A

Insulin ±metformin

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38
Q

If the woman declines insulin therapy or cannot tolerate metformin what is second line for gestational diabetes?

A

Glibencalmide (sulfonylurea)

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39
Q

What is the management of gestational diabetes with a fasting glucose of <7mmol/L?

A

Trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

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40
Q

What medication should be given to reduce the risk of developing pre-eclampsia

A

Low dose aspirin from 12 weeks gestation until birth

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41
Q

What is the target blood pressure for gestational hypertension?

A

<135 / 85 mmHg

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42
Q

A diagnosis of gestational diabetes would be made with what levels of blood glucose following an oral glucose tolerance test?

A

Fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L

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43
Q

What type of insulin is gestational diabetes treated with and why?

A

Gestational diabetes is treated with short-acting, but not longer-acting SC insulin due to lower risk of hypoglycaemia, and better post meal blood glucose control

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44
Q

What risk factors will women be screened for during their booking appointment for gestational diabetes?

A

BMI above 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or more
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
An ethnicity with a high prevalence of diabetes

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45
Q

What is eclampsia defined as?

A

Eclampsia may be defined as the development of seizures in association pre-eclampsia.

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46
Q

What is pre-eclampsia defined as?

A

Condition seen after 20 weeks gestation
Pregnancy-induced hypertension
Proteinuria or other organ involvement

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47
Q

What is the first line treatment for magnesium sulphate induced respiratory depression?

A

Calcium gluconate

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48
Q

What is the treatment for patients with severe pre-eclampsia and seizures?

A

Magnesium sulphate - IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

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49
Q

What is severe pre-eclampsia defined as?

A

New onset hypertension: typically > 160/110 mmHg
Proteinuria: dipstick ++/+++
Oedema may be seen

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50
Q

What is the investigation of choice for VTE in pregnancy?

A

Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT

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51
Q

What is the investigation of choice for PE in pregnancy?

A

ECG and chest x-ray should be performed in all patients

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52
Q

What is the first line medication for PE / VTE in pregnancy?

A

Low molecular weight heparin (LMWH)

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53
Q

What is HELPP syndrome?

A

Haemolysis, Elevated liver enzymes and Low platelets

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54
Q

What agent, usually used to treat hyperthyroidism, is contraindicated in pregnancy and why?

A

Carbimazole, may be associated with an increased risk of congenital abnormalities

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55
Q

What is the agent of choice for treatment of hyperthyroidism in pregnancy, what is it associated with?

A

Propylthiouracil, associated with an increased risk of severe hepatic injury

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56
Q

At what blood pressure reading would a pregnant patient be admitted for observation?

A

Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

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57
Q

What signs should be closely monitored following the administration of magnesium sulphate and why?

A

Monitor reflexes + respiratory rate
- Respiratory depression is a recognised complication of magnesium sulphate therapy
- Hyporeflexia is a characteristic sign of hypermagnesaemia, underlining the importance of reflex assessment in evaluating serum magnesium levels

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58
Q

What are the high risk factors for developing hypertensive disorders in pregnancy?

A

(HATCC)
Hypertensive disease in previous pregnancy
Autoimmune diseases
Type 1 or Type 2 diabetes
Chronic hypertension
Chronic kidney disease

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59
Q

What are the moderate risk factors for developing hypertensive disorders in pregnancy?

A

First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
BMI > 35 kg/m² or more at first visit
Family history of pre-eclampsia
Multiple pregnancy

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60
Q

What is the management for patients with pre-existing hypothyroidism during pregnancy?

A

May need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy

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61
Q

What cut-off for haemoglobin should be used to determine when to commence iron tablets in the first trimester?

A

A cut-off of 110 g/L should be used in the first trimester

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62
Q

What cut-off for haemoglobin should be used to determine when to commence iron tablets post-partum?

A

A cut-off of 100 g/L should be used in the postpartum period (6-8 weeks)

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63
Q

What cut-off for haemoglobin should be used to determine when to commence iron tablets in the second trimester?

A

A cut-off of 105 g/L should be used in the second trimester

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64
Q

How long should magnesium sulphate be given for, for eclampsia?

A

Magnesium treatment should continue for 24 hours after delivery or after last seizure

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65
Q

What medication for RA should be stopped when trying to conceive?

A

Methotrexate: must be stopped at least 6 months before conception in both men and women

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66
Q

What is the Bishop scoring system used for?

A

The Bishop score is used to help assess whether induction of labour will be required.

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67
Q

What points are given in the Bishop score for cervical position?

A

0 - Posterior
1 - Intermediate
2 - Anterior

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68
Q

What points are given in the Bishop score for cervical consistency?

A

0 - Firm
1 - Intermediate
2 - Soft

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69
Q

What points are given in the Bishop score for cervical effacement?

A

0 - 0-30%
1 - 40-50%
2 - 60-70%
3 - 80%

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70
Q

What points are given in the Bishop score for cervical dilation?

A

0 - <1 cm
1 - 1-2 cm
2 - 3-4 cm
3 - >5 cm

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71
Q

What points are given in the Bishop score for foetal station?

A

0 - -3
1 - -2
2 - -1,0
3 - +1,+2

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72
Q

What does a Bishop score of <5 indicate?

A

Indicates that labour is unlikely to start without induction

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73
Q

What does a Bishop score of ≥ 8 indicate?

A

That the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour

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74
Q

What would the management be for a Bishop score of ≤ 6?

A
  • Vaginal prostaglandins or oral misoprostol
  • Mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
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75
Q

What would the management be for a Bishop score of >6?

A

Amniotomy and an intravenous oxytocin infusion

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76
Q

What is the definition for the first stage of labour?

A

From the onset of true labour to when the cervix is fully dilated

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77
Q

What is the definition for the second stage of labour?

A

From full dilation to delivery of the foetus

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78
Q

What is the definition of the third stage of labour?

A

From delivery of foetus to when the placenta and membranes have been completely delivered

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79
Q

What is the active management choice for the third stage of labour? and what is the reason for this?

A

10 IU oxytocin by IM injection
Reduce the risk of PPH

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80
Q

Define post-partum haemorrhage?

A

Postpartum haemorrhage is defined as blood loss of 500 ml after a vaginal delivery

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81
Q

What are the causes of PPH?

A

4 T’s
- Tone (uterine atony)
- Trauma
- Tissue (retained placenta)
- Thrombin (clotting / bleeding disorder)

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82
Q

What is the medical management for PPROM?

A
  • Oral erythromycin / 10 days
  • Antenatal corticosteroids to reduce the risk of respiratory distress syndrome (IM dexamethasone)
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83
Q

When should delivery be considered for PPROM?

A

34 weeks gestation

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84
Q

What is the most common complication of shoulder dystocia?

A

Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia.

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85
Q

What is the most common pattern of shoulder placement due to a complication of shoulder dystocia?

A

Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.

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86
Q

What is the management for intrahepatic cholestasis of pregnancy?

A

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

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87
Q

What is a contraindication of epidural anaesthesia in labour?

A

Coagulopathy

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88
Q

What is the first-line investigation for PPROM?

A

Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault

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89
Q

What is the most common cause of PPH?

A

The most common cause of PPH by far is uterine atony - inadequate uterine contractions

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90
Q

What is the biggest cause of cord prolapse?

A

Artificial amniotomy - around 50% of cord prolapses are due to this

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91
Q

What is the biggest risk factor when performing an artificial amniotomy?

A

Cord prolapse

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92
Q

What is the appropriate management of group B streptococcus infection during pregnancy?

A

Appropriate treatment at time of diagnosis.
Intrapartum antibiotics - IV benzylpenicillin ASAP after labour induction and then 4 hour intervals until delivery.

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93
Q

What is a category 1 caesarean section?

A

An immediate threat to the life of the mother or baby
Delivery of the baby should occur within 30 minutes of making the decision

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94
Q

What is a category 2 caesarean section?

A

Maternal or foetal compromise which is not immediately life-threatening
Delivery of the baby should occur within 75 minutes of making the decision

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95
Q

What is a category 3 caesarean section?

A

Delivery is required, but mother and baby are stable

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96
Q

What is a category 4 caesarean section?

A

Elective caesarean

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97
Q

What are some indications for a category 1 caesarean section?

A

Suspected uterine rupture
Major placental abruption
Cord prolapse
Foetal hypoxia
Persistent foetal bradycardia

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98
Q

What investigation should be performed if there is no amniotic fluid in the posterior vaginal vault following a speculum examination for PPROM?

A

Placental alpha microglobulin-1 protein (PAMG-1)
OR
Insulin-like growth factor binding protein-1

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99
Q

What is the management for PPH secondary to uterine atony?

A

IV oxytocin (syntocinon)
IM ergometrine
IM carboprost
Misoprostol sublingual

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100
Q

What is the surgical management for PPH, secondary to uterine atony, if medical intervention fails?

A

Intrauterine balloon tamponade

B-lynch suture

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101
Q

What is a contraindication for administration of ergometrine for PPH?

A

Hx of hypertension and cardiac diseases

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102
Q

What is a contraindication for administration of carboprost for PPH?

A

Hx of asthma

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103
Q

Describe the McRoberts manoeuvre?

A

Supine with both hips fully flexed and extended

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104
Q

What is the first line investigation for reduced foetal movements at above 28 weeks gestation?

A

Initially, handheld Doppler should be used to confirm foetal heartbeat.

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105
Q

What is the second line investigation for reduced foetal movements at above 28 weeks gestation if a handheld Doppler fails?

A

If no foetal heartbeat detectable, immediate ultrasound should be offered.

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106
Q

What is the definition for latent first stage of labour?

A

0-3 cm dilation, normally takes 6 hours

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107
Q

What is the definition for active first stage of labour?

A

3-10 cm dilation, normally 1cm/hr

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108
Q

What are the risk factors for developmental dysplasia of the hip?

A

Female sex (6x greater)
Breech presentation
Family history
Firstborn children
Oligohydramnios
Birth weight >5kg

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109
Q

What are the investigations of choice for developmental dysplasia of the hip?

A

Ultrasound is generally used to confirm the diagnosis if clinically suspected.
If infant is >4.5 months then X-ray is FIRST LINE

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110
Q

What is potter sequence and what can it be a cause of?

A

Bilateral renal agenesis + Pulmonary hypoplasia
Can cause oligohydramnios

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111
Q

What is the purpose of a 16 and 24 week ultrasound scan for monochorionic twins?

A

Ultrasound examinations performed between 16 and 24 weeks focus on detecting twin-to-twin transfusion syndrome (TTTS)

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112
Q

What is the management for placental abruption when the foetus is alive and <36 weeks and showing no signs of distress?

A

Admit and administer steroids

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113
Q

What are the three types of placenta accetra spectrum?

A

Depends on the degree of invasion.
Accetra - chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis.
Incetra - chorionic villi invade into the myometrium.
Percetra - chorionic villi invade through the perimetrium

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114
Q

What is the management for placental abruption when the foetus is showing distress and >36 weeks?

A

Immediate caesarean

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115
Q

What is the management for placental abruption when the foetus is showing no signs of distress and >36 weeks?

A

Deliver vaginally

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116
Q

What would a grade I placental praevia indicate anatomically?

A

Placenta reaches lower segment but not the internal os

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117
Q

What would a grade II placental praevia indicate anatomically?

A

Placenta reaches internal os but doesn’t cover it

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118
Q

What would a grade III placental praevia indicate anatomically?

A

Placenta covers the internal os before dilation but not when dilated

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119
Q

What would a grade IV placental praevia indicate anatomically?

A

Placenta completely covers the internal os

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120
Q

When would the last ultrasound scan be performed in patients with placental praevia?

A

Final ultrasound at 36-37 weeks to determine the method of delivery

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121
Q

What would a grade I placenta praevia indicate for type of birth?

A

If grade I then a trial of vaginal delivery may be offered

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122
Q

What would a grade III-IV placenta praevia indicate for type of birth?

A

Elective caesarean section for grades III/IV between 37-38 weeks

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123
Q

If a woman with placenta praevia goes into labour prior to the 37-38 week scan what is the management?

A

Emergency caesarean section should be performed due to the risk of post-partum haemorrhage

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124
Q

What does intrahepatic cholestasis of pregnancy increase the risk of?

A

Increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

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125
Q

When is the secondary and tertiary scan when placenta praevia is noted in the 20 week scan?

A

32 weeks and final at 36/37 weeks.

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126
Q

Define vasa praevia?

A

Vasa praevia describes a complication in which fetal blood vessels cross or run near the internal orifice of the uterus.

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127
Q

Painless vaginal bleeding following rupture of membranes and foetal bradycardia would indicate what?

A

Vasa praevia

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128
Q

What are the signs / symptoms of vasa praevia?

A

Painless vaginal bleeding following rupture of membranes and foetal bradycardia

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129
Q

What are the risk factors for placental abruption?

A

A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

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130
Q

When should anti-D immunoglobulins be given to non-sensitised women?

A

28 and 34 weeks

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131
Q

When should anti-D prophylaxis be give to pregnant patients?

A

Once sensitization has occurred it is irreversible

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132
Q

What hormonal therapy should be offered to breast cancer patients who are oestrogen-receptor-positive and are pre- or perimenopausal?

A

Tamoxifen

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133
Q

What is the first line treatment for lactational mastitis if 12-24 hours of effective removal of milk is ineffective?

A

Oral flucloxacillin for 10-14 days

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134
Q

What what type of breast change would you expect to examine a mobile mass?

A

Fibroadenoma

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135
Q

With what type of breast change would you expect to observe a ‘slit like retraction’ and a small amount of cheese like discharge?

A

Duct ectasia - a common alteration in the breast that occurs with ageing

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136
Q

With what breast change would you see a halo sign on a mammogram?

A

Breast cysts compress the underlying fat and produce a radiolucent area (halo sign).

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137
Q

What would an erythematous rash and associated thickening of the nipple indicate?

A

Paget’s disease of the breast

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138
Q

Typically in obese women with large breasts, following trauma, a history of a firm lump which develops into a hard and irregular lump would indicate what?

A

Fat necrosis

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139
Q

What would an intraductal papilloma present with?

A

May present with blood stained discharge.

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140
Q

When should a patient definitely be referred using the suspected breast cancer pathway?

A

Aged 30 and over and have an unexplained breast lump with or without pain or
Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

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141
Q

When should a patient be considered for referral using the suspected breast cancer pathway?

A

Skin changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the axilla

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142
Q

When should a patient be put forward for non-urgent referral for breast changes?

A

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

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143
Q

What is a contraindication for injectable progesterone contraceptives?

A

Breast cancer

144
Q

What is a contraindication for the combined oral contraceptive pill?

A

Smoking >15 cigarettes a day
Migraine with aura

145
Q

What is a contraindication for the IUD and IUS?

A

Unexplained vaginal bleeding

146
Q

By what inheritance pattern is the BRCA gene inherited?

A

Autosomal dominant

147
Q

What is the appropriate management for a patient with suspected Paget’s disease of the nipple?

A

Urgent referral to breast clinic

148
Q

What would the imaging modality of choice be for a breast lump in an under-35-year-old patient?

A

Ultrasound

149
Q

What would the imaging modality of choice be for a breast lump in an over-35-year-old patient?

A

Mammogram

150
Q

What hormonal therapy should be offered to breast cancer patients who are oestrogen-receptor-positive and are post-menopausal?

A

Letrozole / Anastrozole

151
Q

What biological therapy should be offered to breast cancer patients who are HER2 receptor positive? What is a contraindication of this therapy?

A

Trastuzumab (Herceptin)
cannot be used in patients with Hx of heart disorders

152
Q

What is management recommended after a patient has undergone a wide-local excision for breast cancer?

A

Whole breast radiotherapy

153
Q

When is FEC-D chemotherapy used for breast cancer?

A

FEC-D chemotherapy is used for breast cancer that is node +ve

154
Q

When is FEC chemotherapy used for breast cancer?

A

Used for node -ve breast cancer that requires chemotherapy

155
Q

What complication is associated with axillary node clearance?

A

Arm lymphedema and functional arm impairment

156
Q

What age does the breast cancer screening programme start?

A

50-70 years old
After 70 years old patients are ‘encouraged to make their own appointments’

157
Q

How often are women screened for breast cancer under the breast cancer screening programme?

A

Women are offered a mammogram every 3 years.

158
Q

What size would a fibroadenoma have to be for surgical excision?

A

Surgical excision is usual if >3cm

159
Q

What is the most common type of breast cancer?

A

Invasive ductal carcinoma (no special type)

160
Q

What is uterine prolapse?

A

Loss of anatomical support for the uterus, typically surrounding the apex of the vagina.

161
Q

What is a cystocele?

A

Bladder prolapse

162
Q

What is a rectocele?

A

Prolapse of the rectum or large bowel

163
Q

What is an enterocele?

A

Prolapse of the small bowel

164
Q

What grading system is used for uterine prolapse?

A

POP-Q
- Grade 0 - Normal
- Grade 1 - Lowest part is <1cm above introitus
- Grade 2 - Lowest part is within 1cm above or below introitus
- Grade 3 - Lowest part is >1cm below introitus, but not fully descended
- Grade 4 - Full descent with eversion of the vagina

165
Q

What is the management for uterine prolapse?

A

Vaginal pessary

166
Q

What is urge incontinence?

A

Caused by an overactive bladder due to uninhibited detrusor muscles

167
Q

Uninhibited detrusor muscles would be what type of incontinence?

A

Urge incontinence

168
Q

What is stress incontinence?

A

Urine leaks out due to a high abdominal pressure

169
Q

Urine leaking out due to a high abdominal pressure would be what type of incontinence?

A

Stress incontinence

170
Q

What is mixed incontinence?

A

A mixture of both stress and urge incontinence

171
Q

What is overflow incontinence?

A

AKA neurogenic bladder - the bladder doesn’t empty completely which leads to an eventual leak

172
Q

If the bladder doesn’t completely empty and causes an eventual leak, what type of incontinence is this?

A

Overflow incontinence - AKA neurogenic bladder

173
Q

What is the main cause of overflow incontinence?

A

Damage to the peripheral nerves or nerves of the brain and spinal cord

174
Q

What are the classic signs/symptoms of urge incontinence?

A

Frequent urination, especially at night

175
Q

Frequent urination, especially at night, would indicate what type of incontinence?

A

Urge incontinence

176
Q

What are the classic signs/symptoms of stress incontinence?

A

Urinary leakage when coughing, sneezing, or laughing

177
Q

Urinary leakage when coughing, sneezing, or laughing would be what type of incontinence?

A

Stress incontinence

178
Q

What are the classic signs/symptoms of overflow incontinence?

A

There is a weak or intermittent stream / hesitancy

179
Q

If there is a weak or intermittent stream / hesitancy when urinating, what type of incontinence is this?

A

Overflow incontinence

180
Q

What is the first line intervention for urge incontinence?

A

Bladder retraining for 6 weeks

181
Q

What type of medications are used for urge incontinence?

A

Anticholinergic (antimuscarinic)

182
Q

What is the first line pharmacological agent for urge incontinence?

A

Oxybutynin

183
Q

What is a contraindication of using oxybutynin for urge incontinence?

A

Being elderly due to an increased risk of falls

184
Q

What is the second line pharmacological intervention for urge incontinence?

A

Tolterodine or Solifenacin

185
Q

What is a contraindication for Tolterodine or Solifenacin for urge incontinence?

A

Closed-angle glaucoma

186
Q

If a patient is elderly with closed angle glaucoma, what is the pharmacological agent which can be given?

A

Mirabegron

187
Q

What is the first line management for stress incontinence?

A

Pelvic floor exercises for at least three months.

188
Q

What is the pharmacological management for stress incontinence if a patient declines surgery?

A

Duloxetine (SNRI)

189
Q

What is the management for overflow incontinence?

A

Re-establish a clear pathway for urine flow e.g. catheterisation or medications like alpha blockers, which relax smooth muscle e.g. Tamsulosin

190
Q

What are the most common type of renal stones?

A

80% of stones are composed of calcium oxalate or phosphate stones

191
Q

What is the gold standard investigation for renal / urinary stones?

A

Non-contrast CT within 24 hours of presentation

192
Q

What would the management be for renal stones that are less than less than 5mm?

A

Watchful waiting

193
Q

In what case would you use watchful watching for the management of renal stones?

A

If they are less than 5mm

194
Q

What would the management be for renal stones that are less than more than 10mm?

A

Surgical management

195
Q

In what case would you use surgical intervention in the management of renal stones?

A

If they are more than 10mm.

196
Q

What pharmacological agent may aid in the passage of renal stones?

A

Alpha blocker e.g. Tamsulosin

197
Q

What is androgen insensitivity syndrome?

A

X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.

198
Q

What is the inheritance pattern of androgen insensitivity syndrome?

A

X-linked recessive

199
Q

What are the classical signs/symptoms of androgen insensitivity syndrome?

A

Primary amenorrhoea with little or no axillary or public hair.
Undescended testes may be felt in the suprapubic region.

200
Q

Primary amenorrhoea with little or no axillary or public hair. Alongside
undescended testes felt in the suprapubic region would indicate what?

A

Androgen insensitivity syndrome

201
Q

What is the management for androgen insensitivity syndrome?

A

Raise the child as a female
Bilateral orchidectomy
Oestrogen therapy

202
Q

What is the normal endometrial thickness in pre-menopausal women during menstruation?

A

2-4mm

203
Q

What is menarche?

A

Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans.

204
Q

Why is a bilateral orchidectomy performed in patients with androgen insensitivity syndrome?

A

There is an increased risk of testicular cancer due to undescended testes.

205
Q

What is the normal endometrial thickness in pre-menopausal women during the early proliferative phase (day 6-14)?

A

5-7mm

206
Q

What is the normal endometrial thickness in pre-menopausal women during the late proliferative phase (day 14-18)?

A

Up to 11mm

207
Q

What is the normal endometrial thickness in pre-menopausal women during the secretory phase (day 18-28)?

A

7-16mm

208
Q

A endometrial thickness of 2-4mm would indicate a woman is in what part of their cycle?

A

Menstruation

209
Q

A endometrial thickness of 5-7mm would indicate a woman is in what part of their cycle?

A

Early proliferative phase (day 6-14)

210
Q

A endometrial thickness of up to 11mm would indicate a woman is in what part of their cycle?

A

Late proliferative phase (day 14-18)

211
Q

A endometrial thickness of 7-16mm would indicate a woman is in what part of their cycle?

A

Secretory phase (day 18-28)

212
Q

When can menopause be diagnosed?

A

Cessation of menses for at least 12 consecutive months

213
Q

When does menopause usually occur in women, what is the average age?

A

40-60 years old. Average age is 51 years.

214
Q

What is considered to be pre-menopausal?

A

Menopause before the age of 40 years.

215
Q

What are some contraindications of HRT?

A

Current or past breast cancer.
Any oestrogen sensitive cancer.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.

216
Q

Unopposed oestrogen HRT can be given to women under what conditions?

A

If they do not have a uterus.

217
Q

Combined HRT should be given to women who have what?

A

A uterus

218
Q

What is a complication of oral HRT?

A

Increased risk of VTE, no increased risk with transdermal

219
Q

Which two cancers are associated with an increased risk due to HRT use?

A

Ovarian and breast

220
Q

What pharmacological agent can be given for women suffering from vasomotor symptoms (non-HRT)?

A

Fluoxetine

221
Q

What is oestrogen HRT called when it is given in oral form?

A

Estradiol

222
Q

What is progesterone HRT called when given in oral form?

A

Utrogestan (micronised progesterone)

223
Q

What is the most common cause of vulval itching?

A

Contact dermatitis

224
Q

What would the classical signs/symptoms of lichen sclerosis be?

A

Intense itching, especially worse at night, and presents with white, shiny patches, thinning of the vulvar skin, and areas of atrophy.

225
Q

What demographic is lichen sclerosus most common in?

A

Elderly females

226
Q

What is the first line management for lichen sclerosus?

A

Gold standard - Clobetasol proprionate 0.05%

227
Q

What is the second line management for lichen sclerosus?

A

Topical calcineurin inhibitors e.g. Tacrolimus 0.1%
Topical retinoids e.g. Tretinoin 0.025-0.1%

228
Q

Why is there a need for follow up in patients with lichen sclerosus?

A

There is an increased risk of vulval cancer

229
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinoma

230
Q

What are the risk factors for vulval cancer?

A

Increased age
HPV infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus

231
Q

What are the classical features of vulval cancer?

A

Lump or ulcer on the labia majora
Inguinal lymphadenopathy
May be associated with itching, irritation

232
Q

What is the management of vulval cancer?

A

Wide local excision to remove the cancer
Chemotherapy - Erlotibib

233
Q

Atrophic vaginitis most commonly occurs in women at what stage in life?

A

Post-menopausal

234
Q

What is the management of atrophic vaginitis?

A

Vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.

235
Q

What are the risk factors for urinary incontinence?

A

Advancing age
Previous pregnancy and childbirth
High BMI
Hysterectomy
Family history

236
Q

What are the different types of urinary incontinence?

A

Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence

237
Q

What is an urge incontinence and what is it caused by?

A

The urge to urinate quickly followed by an uncontrollable leakage ranging from a few drops to complete emptying
Due to detrusor muscle overactivity

238
Q

What is an urge incontinence and what is it caused by?

A

Leaking small amounts when coughing or laughing

239
Q

The urge to urinate quickly followed by an uncontrollable leakage ranging from a few drops to complete emptying would be what?

A

Urge incontinence

240
Q

Leaking small amounts when coughing or laughing would be what?

A

Stress incontinence

241
Q

What is mixed incontinence?

A

Both urge and stress incontinence

242
Q

What is overflow incontinence?

A

Due to bladder outlet obstruction e.g. prostate enlargement

243
Q

What is functional incontinence?

A

Comorbid physical conditions impair the patient’s ability to get to a bathroom in time

244
Q

What are some causes of functional incontinence?

A

Dementia
Sedating medication
Injury / illness resulting in decreased ambulation

245
Q

Incontinence due to bladder outlet obstruction e.g. prostate enlargement would be what?

A

Overflow incontinence

246
Q

Incontinence due to comorbid physical conditions impair the patient’s ability to get to a bathroom in time would be what?

A

Functional incontience

247
Q

What are the initial investigations for urinary incontinence?

A

Bladder diaries for a minimum of 3 days
Vaginal examination
Kegel exercises
Urine dipstick and culture
Urodynamic studies

248
Q

What is the first line management for urge incontinence?

A

Bladder retraining for a minimum of 6 weeks

249
Q

What is the first-line pharmacological management for urge incontinence?

A

Oxybutynin (immediate release)

250
Q

What are the second line pharmacological agents used for urge incontinence?

A

Tolterodine (immediate release)
Darifenacin (once daily preparation)

251
Q

What class of drugs are used first line in urge incontinence?

A

Antimuscarinics (anticholinergics)

252
Q

In what demographic should oxybutynin be avoided?

A

Frail older women due to anticholinergic side-effects

253
Q

What pharmacological agent should be used in ‘frail older women’ in urge incontinence?

A

Mirabegron

254
Q

What class of drug is mirabegron?

A

A beta-3-agonist

255
Q

What is the first line management for stress incontinence?

A

Pelvic floor retraining (Kegel exercises)

8 contractions performed 3 times per day for a minimum of 3 months

256
Q

What is the second line management for stress incontinence?

A

Surgical procedures: e.g. retropubic mid-urethral tape procedures

257
Q

What is the second line management for women for stress incontinence if they decline surgical procedures?

A

Duloxetine

258
Q

What class of drug is duloxetine?

A

A combined noradrenaline and serotonin reuptake inhibitor

259
Q

What is the mechanism of action of duloxetine?

A

Increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

260
Q

Define adenomyosis?

A

Adenomyosis is characterised by the presence of endometrial tissue within the myometrium

261
Q

What are the classical features of adenomyosis?

A

Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus

262
Q

What is the first-line investigation for adenomyosis?

A

Transvaginal ultrasound

263
Q

What is the management for adenomyosis?

A

Tranexamic acid to manage ammenhorea
GnRH agonists
Uterine artery embolisation

264
Q

What is the definitive treatment for adenomyosis?

A

Hysterectomy

265
Q

What is Asherman’s syndrome?

A

also referred to as intrauterine adhesions or intrauterine synechiae, occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix

266
Q

How is Asherman’s syndrome diagnosed?

A

Hysteroscopy - Gold standard

267
Q

What is the management for Asherman’s syndrome?

A

Dissection of adhesions during hysteroscopy

268
Q

What is endometrial hyperplasia?

A

Defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle

269
Q

What is the management for simple endometrial hyperplasia without atypia?

A

High dose progestogens with repeat sampling in 3-4 months
The levonorgestrel intra-uterine system may be used

270
Q

What is the management for endometrial hyperplasia with atypia?

A

Hysterectomy is usually advised

271
Q

What are the risk factors for endometrial cancer?

A

Nulliparity
More periods - early menarche, late Menopause
Unopposed oestrogen
Tamoxifen
HNPCC

272
Q

What are some protective factors against endometrial cancer?

A

Multiparity
COCP
Smoking

273
Q

What is the classic symptom of endometrial cancer?

A

Postmenopausal bleeding

274
Q

What are some axillary features of endometrial cancer?

A

Pain (uncommon - signifies extensive disease)
Vaginal discharge - unusual

275
Q

How may endometrial cancer present in premenopausal women?

A

Premenopausal women may develop menorrhagia or intramenstrual bleeding
pain is not common and typically signifies extensive disease

276
Q

What should happen for all women > 55 years old who present with post-menopausal bleeding?

A

All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway

277
Q

What is the first line investigation for endometrial cancer?

A

First-line investigation is trans-vaginal ultrasound

278
Q

What is the management for endometrial cancer?

A

Surgery - total abdominal hysterectomy with bilateral salpingo-oophorectomy

High-risk - posteroperative radiotherapy

279
Q

Define endometriosis?

A

Characterised by the growth of ectopic endometrial tissue outside of the uterine cavity

280
Q

What are the features of endometriosis?

A

Chronic pelvic pain
Secondary dysmennhorea - starts before bleeding
Dysparenuria

281
Q

What is the investigation of choice for endometriosis?

A

Laparoscopy is the gold-standard investigation

282
Q

What is the first-line management for endometriosis?

A

NSAIDs and/or paracetamol

283
Q

What is the second line management for endometriosis?

A

Combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate

GnRH analogues CAN be tried

284
Q

What is the management for endometriosis for patient who are trying to conceive?

A

Laparoscopic excision or ablation of endometriosis plus adhesiolysis

285
Q

What are uterine fibroids?

A

Fibroids are benign smooth muscle tumours of the uterus

286
Q

What demographic are uterine fibroids most common in?

A

More common in Afro-Caribbean women

287
Q

How are uterine fibroids diagnosed?

A

Transvaginal ultrasound

288
Q

What is the management for asymptomatic uterine fibroids?

A

No treatment is needed other than periodic review to monitor size and growth

289
Q

What are some management options of menorrhagia secondary to uterine fibroids?

A

Levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
Tranexamic acid
Combined oral contraceptive pill
Oral progestogen
Injectable progestogen

290
Q

What are some management options for shrinking / removal of uterine fibroids?

A

GnRH analogues
Myomectomy
Endometrial ablation
Hysterectomy

291
Q

Why are GnRH analogues only used short-term?

A

Due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density

292
Q

What is the most common cause of postmenopausal bleeding?

A

Vaginal atrophy

293
Q

What is a hydatidiform mole?

A

Molar pregnancies (hydatidiform moles) are chromosomally abnormal pregnancies that have the potential to become malignant

294
Q

What is a complete hydaitdiform mole?

A

Complete hydatidiform moles have a 46 XX or 46 XY karyotype that is derived entirely of paternal DNA.

295
Q

What is an incomplete hydatidiform mole?

A

Partial hydatidiform moles contain a karyotype of either 69 XXX or 69 XXY, and contain both maternal and paternal genetic material

296
Q

What are the classical features of complete hydatidiform mole?

A

Vaginal bleeding
Uterus size greater than expected for gestational age
Abnormally high serum hCG

297
Q

What would a complete hyaditidiform mole show on ultrasound?

A

‘snow storm’ appearance of mixed echogenicity

298
Q

A ‘snow storm’ appearance of mixed echogenicity would indicate what?

A

Complete hyatidiform mole

299
Q

What is a prolactinoma?

A

A type of pituitary adenoma, a benign tumour of the pituitary gland.

300
Q

What are the size ranges for a pituitary micro- and macroadenoma?

A

Microadenoma is <1cm and a macroadenoma is >1cm

301
Q

What is the management for a prolactinoma?

A

Dopamine agonists (e.g. cabergoline, bromocriptine) they inhibit the release of prolactin from the pituitary gland

302
Q

What type of drugs are cabergoline and bromocriptine?

A

Dopamine agonists

303
Q

What is the management for patients with a pituitary gland who cannot tolerate or fail therapy?

A

A trans-sphenoidal surgery

304
Q

Why does ovarian cancer carry a poor prognosis?

A

Poor prognosis due to late diagnosis.

305
Q

What are the risk factors for ovarian cancer?

A

BRCA1 and BRCA2
Many ovulations - early menarche, late menopause, nulliparity

306
Q

What are the investigations for ovarian cancer?

A

CA125 - if above 35IU/mL then urgent ultrasound of abdomen and pelvis

307
Q

How is ovarian cancer diagnosed?

A

Diagnostic laparotomy

308
Q

What is the management for ovarian cancer?

A

Usually a combination of surgery and platinum-based chemotherapy

309
Q

Define ovarian torsion?

A

Ovarian torsion may be defined as the partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply

310
Q

What are the classical features of ovarian torsion?

A

Sudden onset of deep-seated colicky abdominal pain
Associated with vomiting and distress
Adenexal tenderness

311
Q

What will ovarian torsion show on ultrasound?

A

Whirlpool sign

312
Q

What would whirlpool sign on an ultrasound be suggestive of?

A

Ovarian torsion

313
Q

Define pelvic inflammatory disease?

A

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum

314
Q

What are the causative organisms for PID?

A

Chlamydia trachomatis - most common
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

315
Q

What is the first line management for PID?

A

Stat IM ceftriaxone +
14 days of oral doxycycline + oral metronidazole

316
Q

What is the second line management for PID?

A

Oral ofloxacin + oral metronidazole

317
Q

What are the features of PCOS?

A

Subfertility and infertility
Senstrual disturbances: oligomenorrhoea and amenorrhoea
Hirsutism, acne (due to hyperandrogenism)
Obesity
Acanthosis nigricans

318
Q

What are the investigations for PCOS?

A

Pelvic ultrasound
Various bloods
Glucose tolerance test

319
Q

What bloods should be checked in PCOS and what would they show?

A

LH:FSH will be raised
Prolactin - raised
Testosterone - Normal / mildy elevated
SHGB (sex hormone-binding globulin) normal

320
Q

What is the Rotterdam criteria used for?

A

To confirm a diagnosis of PCOS.

321
Q

What are the Rotterdam criteria?

A

Diagnosis can be made if 2/3:

Infrequent or no ovulation
Clinical / biochemical signs of hyperandrogenism
Polycystic ovaries on ultrasound (≥12) in one or both

322
Q

What are the two types of cervical cancer?

A

Squamous cell cancer (80%)
Adenocarcinoma (20%)

323
Q

What serotypes of HPV are associated with increased risk of cervical cancer?

A

16,18 & 33

324
Q

What oncogenes do HPLC contain and what do they do?

A

E6 oncogene inhibits p53 tumour supressor gene
E7 inhibits RB tumour supressor gene

325
Q

What staging system is used for cervical cancer?

A

FIGO staging

326
Q

What is stage IA cervical cancer classified as?

A

Confined to cervix, only visible by microscopy and less than 7 mm wide

327
Q

What is stage IB cervical cancer classified as?

A

Confined to cervix, clinically visible or larger than 7 mm wide

328
Q

What is stage II cervical cancer classified as?

A

Extension of tumour beyond cervix but not to the pelvic wall

329
Q

What is stage III cervical cancer classified as?

A

Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall

330
Q

What is stage VI cervical cancer classified as?

A

Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis

331
Q

What is the gold standard treatment for stage IA cervical cancer?

A

Hysterectomy +/- lymph node clearance

332
Q

What is the management option for patients with stage IA cervical cancer and wanting to preserve fertility?

A

Cone biopsy with negative margins

333
Q

What are the management choices for stage II and above cervical cancer?

A

Chemotherapy - cisplatin
Radiotherapy

334
Q

What type of cervical cancer is frequently not detected in cervical cancer screening?

A

Adenocarcinoma

335
Q

At what age are women offered cervical smears?

A

All women between the ages of 25-64 years

336
Q

At what ages is 3 yearly screening performed for cervical cancer screening?

A

25-49 years: 3-yearly screening

337
Q

At what ages is 5 yearly screening performed for cervical cancer screening?

A

50-64 years: 5-yearly screening

338
Q

Explain how cervical cancer screening works?

A

HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive

339
Q

When is cervical cancer screening performed during pregnancy?

A

Usually delayed until 3 months post-partum unless missed screening or previously abnormal smears

340
Q

What is the protocol in cervical cancer screening if there is a negative result for high-risk HPV?

A

Return to normal recall

341
Q

What is the protocol in cervical cancer screening if there is a positive result for high-risk HPV?

A

Samples are examined cytologically

342
Q

If cytological samples are normal following a positive high-risk HPV sample in cervical cancer screening, what is the protocol?

A

Test is repeated in 12 months

343
Q

If cytological samples are normal following 2 x positive high-risk HPV sample after 12 months in cervical cancer screening, what is the protocol?

A

Test is repeated in 12 months

344
Q

If cytological samples are normal following 3 x positive high-risk HPV sample after 12 months in cervical cancer screening, what is the protocol?

A

If positive after 24 months = Colposcopy

345
Q

If cytological samples are abnormal following a positive high-risk HPV sample in cervical cancer screening, what is the protocol?

A

Colposcopy

346
Q

What is the treatment for cervical intraepithelial neoplasia?

A

Large loop excision of transformation zone (LLETZ)

347
Q

What score is used to assess postpartum mental health problems in pregnancy?

A

The Edinburgh Postnatal Depression Scale may be used to screen for depression

348
Q

What score in the Edinburgh Postnatal Depression Scale would indicate a ‘depressive illness of varying severity’

A

Score of > 13

349
Q

A score of > 13 in the the Edinburgh Postnatal Depression Scale would indicate what?

A

A ‘depressive illness of varying severity’

350
Q

When is ‘baby-blues’ most likely to occur?

A

Typically seen 3-7 days following birth

351
Q

When is post-natal depression most likely to occur?

A

Most cases start within a month and typically peaks at 3 months

352
Q

When is puerperal psychosis most likely to occur?

A

Onset usually within the first 2-3 weeks following birth

353
Q

What is the management for ‘baby blues’?

A

Reassurance and support, the health visitor has a key role

354
Q

What is the management for postnatal depression?

A

Reassurance and support are important
CBT may be beneficial
Paroxetine SSRI may be used if severe

355
Q

What is the management for puerperal psychosis?

A

Admission to hospital is usually required, ideally in a Mother & Baby Unit

Phase 3a (7 decks)

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