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Year 4 > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Epidemiology of subfertility/infertility

A

1 in 7 women
50% are due to females
25% due to males
25% are unknown

Increases with age
No family history

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2
Q

Risk factors for subfertility/infertility

A 
Increasing female age
Depression
Stress
STIs
Smoking
Alcohol intake (even moderate)
Overweight or underweight
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3
Q

Causes of infertility (general)

A 
25% ovulatory
20% tubular damage
10% uterine or peritoneal disorders
30% male
25% unknown
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4
Q

What are the 3 WHO classifications for disorders of ovulation

A

Group 1 - hypothalamic-pituitary failure (low oestrogen, low gonadatrophin)

Group 2 - hypothalamic-pituitary-ovarian failure (normal oestrogen, high or low gonadatrophin)

Group 3 - ovarian failure (raised gonadatrophin, low oestrogen)

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5
Q

Causes of ovulatory dysfunction causing infertility

A

PCOS

  • Pituitary tumours
  • Panhypopituitarism (Simmond’s disease)
  • Sheehan’s disease (pituitary infarction following PPH)
  • Hyperprolactinaemia
  • Chromosomal disorders (Turners XO, Klinefelter’s XXY) XXX (increased premature ovarian failure)
  • Premature ovarian failure/ menopause
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6
Q

Role of FSH

A

Follicle stimulating hormone

Stimulates follicle development and oestrogen production

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7
Q

Role of LH

A

Midcycle LH surge causes ovulation.

Maintains corpus luteum and stimulates progesterone and estradiol production

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8
Q

Causes of infertility - tubes/uterus/cervix

A 
STI (PID from chlamydia or gonorrhoea)
Asherman's syndrome (adhesions in uterus and cervix)
Deformity of uterus
Fibroids
Cervical mucus
Endometriosis
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9
Q

What drugs can lead to sub/infertility?

A 
Phenothiazines (antipsychotics)
Metoclopramide
NSAIDs
Immunosuppressants
Spironolactone
Chemotherapy
Neuroleptic drugs
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10
Q

Causes of infertility - male

A

Structural or hormonal

  • Genetic (Klinefelters XXY), Kallman syndrome (hypogonatrophic hypogonadism)
  • Androgen insensitivity
  • Cryptorchidism (testicular dysgenesis)
  • Varicocoele
  • Pituitary causes (tumours)
  • Testicular tumours
  • Severe hyperprolactinaemia
  • Obstruction
  • Erectile dysfunction
  • Hypospadias
  • Retrograde ejaculation
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11
Q

Advice for couple trying to conceive

A

Regular sexual intercourse (2-3x per week)
Preparation for pregnancy (folic acid, rubella check, cervical screening)
Decrease stresses
Smoking and alcohol cessation
BMI between 19 and 25

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12
Q

Investigations for sub/infertility

A

Start if not conceived in 1 year

FEMALE

  • Measure mid-luteal progesterone day 21 of 28 (7 days before period
  • If irregular cycles measure FH and LSH
  • Test thyroid function
  • Measure prolactin
  • Screen for chlamydia and other STIs

MALE
- Semen analysis
- Screen for STIs
Semen sample should be collected after at least 2 days but less than 7 from sexual abstinence

After referral

  • Tubal patency (hysterosalpinography or contrast ultrasonography) HSG
  • If co-morbidities the lap and dye testing
  • Ovarian reserve testing - on day 3 to predict response to stimulation in IVF

Males - further sperm assessment - microbiology, culture
Imaging of tracts

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13
Q

When should sub/infertility be referred

A

Follow local guidelines

  • Under 36 refer after 1 year

Consider early referral if

  • over 36 (6 months)
  • known cause for infertility
  • history of factors that predispose to infertility
  • treatment planned that may result in infertility (chemotherapy)
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14
Q

Management of subfertility/infertility

A

Treat underlying problem

  • Ovulation induction with Clomifene
  • Gonadatrophins if clomifene resistant (pulsatile)
  • If male obstruction, correct surgically
  • Surgical correction of tubes
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15
Q

Different types of assisted conception

A 
Intrauterine insemination
In vitro fertilisation
Intracytoplasmic sperm injection (ICSI)
Donor insemination
Oocyte donation
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16
Q

Describe intrauterine insemination

A

15% success in under 35s
Prepared sperm placed into uterine cavity at ovulation (induced or spontaneous)

Used when

  • difficult to have intercourse (unable, disability, psychological)
  • HIV+ male (sperm washing)
  • Same sex relationships
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17
Q

Describe IVF

A

33% success in under 35s
25% of treatments result in live births

Offered after 2 years

  • Ovarian stimulation prior to IVF with US measured response
  • Embyro inserted into uterus
  • Progesterone given after embryo for luteal phase support
  • transfer single embryo

Under 40s up to 3 cycles - stop once reach 40
Over 40s, 1 cycle if never had IVG, no evidence of low ovarian reserve

Some CCGs in addition
- No previous children, or partner with any children, healthy weight, non-smoker

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18
Q

Describe Intracytoplasmic sperm injection (ICSI)

A

Single sperm injected into oocyte

Used when severe deficits in sperm or after failed IVF

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19
Q

When can donor insemination be used

A

Azoospermia
Severe deficits in sperm quality and don’t want ICSI
High risk of transmitting genetic disorder
High risk of transmitting infectious disease to child/partner

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20
Q

Complications of assisted conception

A

OVARIAN HYPERSTIMULATION SYNDROME (OHSS)

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21
Q

Symptoms of ovarian Hyperstimulation syndrome

A 
lower abdo discomfort
nausea and vomiting
diarrhoea
abdo distension
ascites
rapid weight gain
tachycardia
hypotension
oliguria
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22
Q

What factors should be considered when prescribing contraception?

A 
Womens preference and choice
Education - must be fully informed
Co-morbidities
Medications
Age and parity
Smoking history
Weight
Family plans (long vs short term)
Protection from STIs
Exclude pregnancy
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23
Q

MOA of COCP

A

Prevents conception by acting on hypothalamic-pituitary-ovarian axis to suppress synthesis and secretion of FSH and LH

Inhibits development of ovarian follicles and ovulation
Cervical mucus to prevent sperm penetration
Endometrium to inhibit blastocyst secretion of LH and LSH

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24
Q

Advantages and disadvantages of COCP

A

Advantages:
Non invasive
Regular and lighter periods, decrease pain
Control time of periods
Can improve acne
Decreases ovarian, endometrial and colorectal cancer
Decrease PMS symptoms

Disadvantages:
User dependent
Less effective than long acting
Side effects
VTE risk
No protection from STIs
Breakthrough bleeding in first few months
Increased breast and cervical cancer
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25
Q

When prescribing contraception - what criteria should be checked?

A 
UKMEC - UK Medical Eligibility Criteria
1 - no restriction for use
2 - advantages > disadvantages
3 - risks outweigh advantage - not recommended
4 - use is unacceptable
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26
Q

What questions must be asked before prescribing COCP

Advice to give

A 
Migraine
Smoker
HTN
Thrombophilia
Previous VTE
FHx of VTE
Hyperlipidaemia
BP
BMI
Exclude pregnancy

Start on first day of bleeding (or within 5 days)
Drug interactions
D&V advice - use alterative protection
Need alternative protection for first 7 days

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27
Q

MOA of progestogen only pill POP

A

Ovulation is inhibited by varying degrees depending on the drug

Delays transport of ovum
Cervical mucus thickens
Endometrium becomes unsuitable for implantation

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28
Q

Advantages and disadvantages of POP

A 
A
Non invasive
Easily reversible
Avoids CV risk of COCP
Less restriction
Can be used up to 55 and while breastfeeding

D

  • Amennorhoea and breakthrough bleeds
  • narrower window
  • increase risk of cysts
  • increased risk of ectopic pregnancy if become pregnant
  • Irregular periods
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29
Q

Describe depot progesterone injections and MOA

A

Every 12 weeks
Long acting reversible progesterone only
Failure rate 2 in 1000

Thickens mucus
Endometrium unsuitable for implantation

Can be used 4 weeks post partum

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30
Q

Advantages and disadvantages of POP

A

A

  • Reliable
  • Infrequent
  • Low risk
  • Low failure rate
  • Decreases bleeding
  • Used in breast feeding

D

  • not quickly reversible
  • Decrease bone mineral density
  • irregular periods
  • weight gain (up to 3kg)
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31
Q

Describe Implanon/implants

A

Etonogestrel subdermal slow release in upper arm
Failure rate < 1 in 1000

Inhibits ovulation , thickens mucus, thins endometrium

Inserted with local anaesthetic
Can be given 21 days post partum
Can be given straight after termination

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32
Q

Advantages and disadvantages of Implants

A

A

  • No large initial dose or fluctuations
  • Low failure rate
  • Reversible after 4 days
  • Decreased menstrual problems
  • Safe

D

  • irregular bleeding
  • weight, mood and libido changes
  • Changes with bleeding DO NOT SETTLE WITH TIME
  • Increases risk of congenital malformation
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33
Q

Describe IUD

A

Copper containing
Long acting
Reversible
T shape, sits in fundus of uterus

Cytotoxic - inflammatory reaction and is spermicidal

Very low failure rate
5-10 years lifespan

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34
Q

Advantages and disadvantages of IUD

A

A

  • Effective, reversible
  • Long acting (up to 10 years)
  • Can be used as emergency contraception
  • No hormones

D

  • Spotting
  • Increased bleeding and pain in first few cycles
  • Perforation 0.2%
  • Increased ectopic pregnancy
  • Uncomfortable insertion
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35
Q

Describe IUS

A

Progesterone releasing

Decreased endometrial growth, thickens mucus

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36
Q

Advantages and disadvantages of IUS

A

A

  • effective, convenient
  • reversible
  • decreased blood loss and dysmenorrhoea
  • decrease risk of PID
  • local action only

D

  • common - irregular periods
  • increase ovarian cysts
  • increased ectopic pregnancy
  • expulsion or perforation
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37
Q

Side effects of progesterone

A

acne
breast tenderness
headache
mood changes

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38
Q

Describe caps and diaphragms

A

Rarely used
High failure rate

Diaphragms - thin dome 55-100mm. Lie between posterior fornix and pubic bone

Caps are smaller and fit over cervix, held by suction
Only used if problem with diaphragm

Often used with spermicide

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39
Q

Effectiveness of female barrier contraception

A

Percentage to conceive

16% - diaphragm
32% parous with cap
16% cap in nulliparous
21% female condom

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40
Q

Describe natural planning and A&D

A

Calendar methods/temperature/mucus thickness/palpating cervix

A - no side effects. complies with religious beliefs
D - commitment. unreliable. not effective

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41
Q

Steps in fertilisation

A

12-24 hours after ovulation

Sperm enter vagina and swim to uterus
Prostaglandin in semen stimulate uterine contractility
CAPACITATION (increase speed of sperm tail wiggle, removal of proteins/coatings)
Acrosomal enzymes aid penetration of corona radiata and zona pellucida
ZP3 in zona pellucida acts as sperm receptor and depolarises cell once in contact to prevent polyspermy

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42
Q

Procedure of termination

A

Offer antibiotic prophylaxis as 10% get genital tract infection (metronidazole +/- doxycycline or arythromycin)

Surgical

  • Less than 14 weeks, vacuum aspiration + vaginal misoprostol 3 hours prior
  • 14-24 weeks, dilation and evacuation
  • Under sedation, local or general

Medical

  • 200mg oral mifepristone followed by misoprostol
  • NSAID for pain relief
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43
Q

Complications of termination

A 
Infection (10%)
Cervical trauma - surgical only
Failed termination <1%
Haemorrhage 
Perforation - surgical
Long term psychological consequences
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44
Q

What is cryopreservation?

A

Freezing of gametes to preserve fertility
Availability if undergoing treatment that may affect fertility like chemotherapy
If
- will not worsen their condition
- enough time is available before the start of treatment

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45
Q

what is PCOS

A

polcystic ovarian syndrome

syndrome of polcystic ovaries AND systemic symptoms causing reproductive, metabolic and psychological disturbance

infertility, amenorrhoea, acne and hirsuitism

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46
Q

epidemiology of PCOS

A

33% of women have polcystic ovaries but not the syndrome

affects 5-10% of reproductive age women

pre menopausal women
onset at age of menarche

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47
Q

pathophysiology of PCOS

A

unknown but is multifactorial

excess androgen so by theca cells of ovary

insulin resistance

raised LH due to increased production

raised oestrogen

genetic link but no gene found

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48
Q

symptoms of PCOS

A 
oligomenorrhoea
infertility or subjectivity
acne
hirsuitism
alopecia
obesity 
psychological- mood swings, depression, anxiety 
sleep apnoea
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49
Q

signs of PCOS

A

hirsuitism
alopecia
central obesity
acanthosis nigricans (hyperpigmented skin in folds)

rarely - increased muscle mass, deep voice

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50
Q

what are the diagnostic criteria for PCOS

A

2 out of 3

  • polcystic ovaries on US. 12+ peripheral follicles or increased ovarian volume >10cm3
  • oligo ovulation or anovulation
  • clinical and/or biochemical signs of hyperandrogenism
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51
Q

investigations for PCOS

A

total testosterone - normal or slightly raised
free testosterone- may be raised
Sex hormone binding globulin - normal or low
free androgen index- normal or raised

LH - typically raised
LH: FSH >2 with normal FSH

ultrasound. cysts. raised volume

also consider: TFTs, prolactin, cortisol
fasting glucose and lipids

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52
Q

management of PCOS

A

advice on weight control

if not planning pregnancy

  • co-cyprinolol for hirsuitism and acne. induces regular bleeds to decrease endometrial cancer
  • COCP: for menstrual irregularity
  • metformin
  • eflornithine for hirsuitism
  • orlistat for weight loss
if planning pregnancy
- clomifene 
- metformin 
one of both
- laparoscopic ovarian drilling or gonadotrophins (if clomifene resistant)
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53
Q

complications of PCOS

A 
infertility
amenorrhoea
increased CV risk
sleep apnoea
increased type 2 or gestational diabetes
increased pre term birth or pre eclampsia
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54
Q

In Down’s screening what is tested in a quadruple test?

A

Beta-hcg
AFP (alpha fetoprotein)
Inhibin A
UE3 (unconjugated estriol)

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55
Q

What are the results of serum markers if a baby has Down’s?

A 
PAPP-A - lower in Down's
beta-hcg - raised in Down's
AFP - lower in Down's
UE3 - lower in Down's
Inhibin A - raised in Down's
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56
Q

What factors can affect Down’s screening?

A 
Weight
Race
IVF
Diabetes
Smokers
Twins
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57
Q

Describe nuchal scanning in Downs

A
  • Performed between 11 and 14 weeks
  • Measure nuchal pad at nape of neck
  • Increased nuchal translucency = higher change of chromosomal abnormality
  • 20% false positive rate
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58
Q

Describe amniocentesis

A
  • Sample of amniotic fluid to examine foetal cells
  • Done between 12-18 weeks
  • Chromosomal, genetic and biochemical analysis
  • Management of rhesus disease
  • Estimation of maturity

Indicated if:

  • Mother over 35
  • Previous child with chromosomal abnormality
    • antenatal screening

Procedure
- give rhesus prophylaxis where needed
- US guided, 22 gauge spinal needle through abdo wall into uterus
10-20ml aspirated

7% loss of pregnancy is done 12-14 weeks

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59
Q

Describe chorionic villus sampling

A

Sampling of developing plancenta late in the first trimester to allow examination of foetal karyotype/genotype
- Done transabdominally

Indicated if:

  • advanced maternal age
  • PHx of chromosomal/genetic abnormality

Procedure

  • between 11 and 13 weeks
  • US guided needle aspiration

First trimester, 2% miscarry, 2nd trimester 3%

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60
Q

What information should be provided during antenatal care?

A

FIRST CONTACT

  • folic acid supplementation
  • lifestyle advice - smoking, drugs, alcohol
  • food hygiene
  • information on all antenatal screening

AT BOOKING

  • nutrition and diet
  • place of birth
  • exercises
  • pregnancy care pathway
  • discuss mental health issues

BEFORE or AT 36 weeks

  • breastfeeding information
  • preparation for labour and birth
  • recognising active labour
  • care of the new baby
  • vitamin K prophylaxis
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61
Q

Lifestyle advice to be given in pregnancy

A

Folic acid 400 micrograms/day ideally before conception
Avoid vitamin A (teratogenic)
Vitamin D supplementation if darker skin or low
Avoid unpasteurised milk, soft cheese, pate (listeriosis)
Avoid salmonella risk - no raw or partially cooked eggs
Seatbelt placed above and below bump

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62
Q

What screening is done Antenatally?

A

Anaemia - booking, 28 weeks
Blood grouping - blood group and rhesus D status
Haemoglobinopathies
Foetal anomalies - 18-20 weeks US scan
Infection - MSU early pregnancy, BV, chlamydia, hep B, HIV, syphilis, rubella
Placenta praevia

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63
Q

How is foetal growth monitored?

A

Symphysis-fundal height from 24 weeks

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64
Q

Management of breech baby at 36 weeks?

A

external cephalic version

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65
Q

Management of pregnancy over 41 weeks

A
  • Vaginal exam plus membrane sweeping
  • Induction offered after 41 weeks
  • if declined, twice weekly cardiotocography
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66
Q

At what weeks are antenatal appointments offered?

A 
10 weeks
16 weeks
18-20 weeks - US scan
NP - 25 weeks (start symphysis-fundal height)
28 weeks - antiD
NP - 31 weeks
34 weeks - 2nd dose antiD 
36 weeks
38 weeks
NP - 40 weeks
41 weeks - for induction

All appointments - BP and proteinuria

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67
Q

Definition of miscarriage

A

Loss of pregnancy before 24 weeks of gestation.

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68
Q

Types of miscarriage

A

Threatened - mild bleeding, little or no pain. Cervical os closed. Ongoing pregnancy

Inevitable - heavy bleeding + clots and pain. Cervical os is open. Pregnancy will not continue

Incomplete - products of conception partially expelled

Missed/silent - foetus is dead but retained. uterus small for dates.

Habitual/recurrent - 3+ consecutive miscarriages

Septic - complication of incomplete or therapeutic abortion when intrauterine infection occurs

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69
Q

Epidemiology and risk factors for miscarriage

A

Increases with age
10-15% of pregnancies
85% in the first trimester

RFs

  • increased number of births (parity)
  • Smoking
  • Excess alcohol
  • Illicit drug use
  • Uterine surgery or abnormalities e.g. incomplete cervix
  • Connective tissue disorders (SLE, APLS)
  • uncontrolled diabetes
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70
Q

Aetiology of miscarriage

A

Often no cause found

  • Abnormal foetal development - abnormal chromosomes
  • Genetically balanced parental translocation
  • Placenta failure
  • uterine abnormality - bicornuate, fibroids
  • Incompetent cervix (2nd trimester)
  • Multiple pregnancy
  • Autoimmune - SLE, APLS
  • PCOS

50% unexplained

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71
Q

Presentation of miscarriage

A

Vaginal bleeding (heavier bleeding = increased risk)
Abdominal pain
Passed products of conception/clots
50% with threatened miscarriage will later miscarry

  • Open cervical os
  • Uterine size not appropriate for dates
  • Products of conception in cervical canal
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72
Q

Investigations for miscarriage

A

US - TV, if there is no visible heart beat, a 2nd scan should be done in 7-14 days depending on size of sac

Serum hcg - levels below 1000 in pregnancy of unknown location or complete miscarriage

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73
Q

Management of miscarriage

A

Support, follow up and counselling
Anti-D to all rhesus negative

CONSERVATIVE

  • Expectant, should resolve naturally 7-14 days
  • Consider other management if: risk of haemorrhage, late in first trimester, previous adverse miscarriage outcome, infection, coagulopathies
  • Pregnancy test 3 weeks after - if still positive, medical or surgical management

MEDICAL

  • Vaginal misoprostol, analgesia and anti-emetics
  • Causes more pain and bleeding than surgical
  • Pregnancy test 3 weeks after

SURGICAL

  • If persistent bleeding, haemodynamic instability, retained tissue, gestationaltrophoblastic disease
  • Manual vacuum aspiration under local or surgical under GA
  • Complications: perforation, cervical tears, adhesions, haemorrhages
  • Screen for chlamydia
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74
Q

Types of gestational trophoblastic disease

A

Can be pre-malignant or malignant - due to abnormal proliferation of trophoblastic tissue.

Pre-malignant

  • Complete hydratiform mole
  • Partial hydratiform mole

Malignant

  • Invasive mole
  • Choriocarcinoma
  • Placental site trophoblastic disease
  • Epitheliod trophoblastic disease
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75
Q

Describe complete molar pregnancies

A

All genetic material comes from the father when an empty oocyte is fertilised

  • No foetal tissue
  • 46 XX karyotype
  • Placental tissue has marked hyperplasia and gross swelling of villi
  • “bunch of grapes” appearance
  • 10-15% become malignant, very sensitive to chemo
  • No embryo
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76
Q

Describe partial molar pregnancy

A
  • 3 sets of chromosomes
  • 2 sperm fertilise at the same time
  • 69 chromosomes, 46 paternal, 23 maternal
  • embryo visible on early US
  • usually diagnosed on histology after miscarriage
  • <1% malignancy
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77
Q

Describe complete mole

A
  • Develops form a complete molar pregnancy
  • Invades into myometrium
  • Uterine mass with elevated hCG
  • Responds well to chemo
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78
Q

Describe choriocarcinoma

A

Synctiotrophoblasts

  • Often follows a molar pregnancy but can be post normal pregnancy, ectopic or abortion
  • continued vaginal bleeding post-pregnancy
  • Often metastasises - lung, brain, GI, liver, kidney
  • Can occur up to 20 years post pregnancy
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79
Q

Epidemiology and risk factors for gestational trophoblastic disease

A

GTD - 1 in 714 births
Complete molar pregnancy - 1-3 per 1000 pregnancies
Partial - 1 per 1000
GTN - 1 in 50,000 live births

RFs

  • over 45 or under 16
  • previous molar pregnancy
  • multiple pregnancy
  • menarche over 12, light menstruation
  • COCP of history of use
  • Asian
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80
Q

Presentation of GTD

A

Vaginal bleeding in first trimester
Hyperemesis

Rare

  • abnormal uterine enlargement
  • hyperthyroidism
  • anaemia
  • respiratory distress
  • pre-eclampsia
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81
Q

Investigations for GTD

A
  • hCG (best for follow up)
  • Histology for definitive diagnosis (should be done for all products of conception
  • US: snowstorm appearance in 2nd trimester, heterogenous mass, no foetal development
  • CT if staging for metastatic disease
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82
Q

Management of GTD

A

Refer for follow up at a trophoblastic screening centre

  • Suction curettage
  • Uterine pregnancy test at 3 weeks
  • Anti D prophylaxis
  • SENIOR SURGEON

Follow up

  • 2 weekly until hCG normal
  • monthly for 6 months after

Chemotherapy

  • if choriocarcinoma, mets, heavy bleeding, plateaued or rising hCG
  • LOW risk: methotrexate & calcium folinate
  • HIGH risk: EMA/CO chemotherapy combination
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83
Q

Epidemiology and RF for ectopic pregnancy

A

1.1 per 1000 pregnancies
97% in fallopian tubes
2-3% interstitial (not extrauterine part of the tube)

RF

  • IVF
  • Hx of pelvic infection
  • Adhesions from inflammation, infection or endometriosis
  • tubal surgery
  • IUD/IUD
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84
Q

Symptoms of ectopic pregnancy

A 
Abdominal or pelvic pain
Amenorrhoea or missed period
Vaginal bleeding (with or without clots)
Dizziness, fainting or syncope
Breast tenderness
Shoulder tip pain
Urinary symptoms
Passage of tissue
Rectal pain or tenesmus
Diarrhoea and vomiting
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85
Q

Signs of ectopic pregnancy

A 
Pelvic or abdominal tenderness
Adnexal tenderness
Rebound tenderness
Cervical tenderness
Pallor
Abdominal distension
Enlarged uterus
Tachycardia and/or hypotension
Shock or collapse
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86
Q

Investigations of ectopic pregnancy

A

Pregnancy test in all women of child bearing age and lower abdominal pain

  • Transvaginal US most accurate
  • Need to identify: location of pregnancy, foetal pole, heartbeat
  • Serial hCG, 48 hours apart
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87
Q

Management of ectopic pregnancy

A
  • Admit as emergency
  • Anti-D prophylaxis in all rhesus negative women
  • Conservative if hCG declining and patient clinically well

MEDICAL

  • single dose methotrexate
  • First line if can return for follow up with no significant pain, unruptured, no intrauterine pregnancy on US and hCG <1500
  • Contraception for 3-6 months due to methotrexate teratogenicitiy

SURGICAL

  • If can’t come for follow up OR
  • significant pain
  • adnexal mass >35mm
  • Foetal heartbeat visible
  • Serum hCG>5000
  • Laparoscopic approach preferable
  • Salpingectomy
  • Complications: bleeding, infection, damage to surrounding organs
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88
Q

Describe BP in pregnancy

A

Falls slightly in 1st trimester due to decreased vascular resistance

  • Falls in 2nd to lowest point at 22-24 weeks
  • Increases in 3rd trimester to pre-pregnancy levels
  • Falls immediately after birth
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89
Q

Risks of hypertension in pregnancy

A

Abruptio placentae
Cerebrovascular accident
Disseminated Intravascular Coagulopathy

Intrauterine growth restriction
Prematurity
Intrauterine death

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90
Q

Management of hypertension of pregnancy

A

Education on symptoms of pre-eclampsia

  • US at 34 weeks for foetal growth and amniotic fluid volume
  • High risk of pre-eclampsia then 75mg aspirin daily

PRE-EXISTING

  • Review medication
  • Stop ACEi and ARBs
  • Keep BP <150/110
  • Test for proteinuria regularly
  • US for foetal growth restriction, amniotic fluid volume

MILD - 140/90
- Measure BP twice weekly and urine for protein at each visit

MODERATE - 150-159/100-110

  • Measure BP twice weekly
  • Start labetalol (alternatives: methyldopa, nifedipine)
  • Bloods

SEVERE >160/110

  • Admit, discharge when <150
  • Measure BP at least 4 times per day
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91
Q

When should aspirin be given in pregnancy?

A
  • Hypertension or pre-eclampsia in past pregnancy
  • CKD
  • Autoimmune disease
  • Diabetes mellitus
  • Chronic hypertension

OR 2 of the following

  • first pregnancy
  • aged over 40
  • previous pregnancy over 10 years ago
  • BMI > 35
  • FHx of pre-eclampsia
  • multiple pregnancy
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92
Q

Definition of antepartum haemorrhage

A

Vaginal bleeding after week 24 of gestation and before 2nd stage of labour

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93
Q

Epidemiology and risk factors for antepartum haemorrhage

A

3-5% of pregnancies
20% of very preterm babies are associated with APH

RFs depends on causes

  • Smoking
  • Cocaine use
  • Increasing maternal age
  • Increased parity
  • Pre-eclampsia
  • polyhydramnios
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94
Q

Aetiology of APH

A

No definitive cause found in 50%

  • Placenta praevia (insertion of placenta, partially or fully, in lower segment of the uterus)
  • Placental abruption (premature separation of normally placed placenta)
  • Local causes (vulval, cervical infection, trauma or tumours)
  • Domestic violence
  • Vasa praevia (bleeding from foetal vessels in foetal membranes, high risk of foetal haemorrhage)
  • Uterine rupture
  • Inherited bleeding problems
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95
Q

Presentation of APH

A 
Bleeding
With pain - abruption
Without pain - praevia
Uterine contractions 
Malpresentation or failure of head to engage
Signs of foetal distress
If severe - hypovolaemic shock
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96
Q

Investigations of APH

A

FBC
Group and save
Clotting studies

ADMIT

Urgent US for placenta praevia
Foetal monitoring
Rhesus negative women should have Kleihauer test - give anti-D after each bleed

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97
Q

Management of APH

A

Admit, even if only small amount of bleeding
Estimate blood loss - Minor <50ml, Major 50-1000ml, massive>1000ml

If foetal distress - urgent delivery regardless of gestation
If severe bleeding - mother’s life takes priority

Give corticosteroids if gestation between 24 and 36 weeks

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98
Q

Definition of placenta praevia

A

Placenta inserted wholly or partially into the lower segment of the uterus

MAJOR - placenta covers internal os of cervix
MINOR - leading edge is in lower segment but not covering the os

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99
Q

Epidemiology and risk factors for placenta praevia

A

1/200 births
1/1000 are major
Incidence is increasing

RFs

  • Previous history of placenta praevia
  • Previous C-section
  • Increased maternal age
  • Increased parity
  • Smoking
  • Cocaine use during pregnancy
  • Previous spontaneous or induced abortion
  • Deficient endometrium due to past history of endometritis, manual removal of placenta, curettage
  • Assisted conception
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100
Q

Presentation of placenta praevia

A

Painless bleeding after 28th week - sudden, profuse, does not last long

  • 25% have spontaneous labour in the next few days
  • Can just have bleeding in labour or membrane rupture
  • High presenting part or abnormal lie
  • No foetal distress unless complications
  • Bleeding provoked by sexual intercourse
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101
Q

Diagnosis/ investigations of placenta praevia

A

Should have high index of suspicion in bleeding after 20 weeks.
Diagnosis relies on US

  • Leading edge may be low on a 20 week scan
  • Apparent migration occurs during 2nd and 3rd trimester with development of lower uterine segment
  • Cannot exclude placental abruption (this is a clinical diagnosis)
  • TV US for all women whose placenta reaches or overlaps cervical os at anomaly scan
  • Minor - scan again at 36 weeks
  • major - scan again at 32 weeks
    Assists in planning and delivery
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102
Q

Management of placenta praevia

A

MINOR - may be able to deliver vaginally.
Placental edge <2cm from the os = caesarean section
If anterior, reaching os with history of C-section then treat as placenta accrete

MAJOR

  • Deliver by C-section
  • No penetrative intercourse
  • Should admit to hospital from 34 weeks
  • Defer C-section to 38 weeks if possible
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103
Q

Placenta accrete and management

A

Morbidly adherent placenta

  • high risk if placenta praevia with history of C-section
  • Requires consultant obstetrician and anaesthetist
  • Blood products on site
  • MDT pre-op planning
  • Deliver baby without disturbing placenta
  • DO NOT PERFORM VAGINAL EXAM
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104
Q

Describe implantation bleeding

A

Light spotting or bleeding
Occurs 10-14 days after conception
NORMAL
Occurs when fertilised egg attaches to lining of uterus

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105
Q

Describe normal placenta at term

A

Blue-red colour, discoid shape
450g in weight
Maternal surface - divided into lobules or cotyledons with irregular grooves or clefts
Foetal surface - smooth, shiny and translucent, choronic plane covered in amniotic membrane

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106
Q

Describe normal umbilical cord

A

50-60cm long
Abundant Wharton’s jelly, no true knots
2 umbilical arteries, 1 umbilical vein

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107
Q

Abnormalities of placental shape, size or surfaces

A

Circumvallate - foetal membranes double back on foetal side around edge of placenta, small central chorioic area inside a paler ring of membranes on foetal side

Succenturiate lobe - accessory lobes, associated with retained placenta and increased infection

Bipartate placenta - bilobed (uncommon)

Placenta membranacea - failure of chorion to atrophy during development, placental cotyledons form envelope around greater part of uterine wall

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108
Q

Describe placenta accreta and levels

A

PLACENTA ACCRETA
Placenta morbidly attached to uterine wall - chorionic villi penetrate the decidua basalis to attach to myometrium

PLACENTA INCRETA
villi penetrate deeply into myometrium

PLACENTA PERCRETA
villi breech myometrium into perioteum

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109
Q

Epidemiology of placenta accreta

A

1/2500 deliveries
40% deliver before 38 weeks
C-section planned at 36-37 weeks

RFs

  • Previous C-section
  • Placenta praevia
  • Increased age
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110
Q

Management of placenta accreta

A

Placenta is left in place with therapeutic uterine artery embolization, surgical internal iliac artery ligation or methotrexate therapy

Elective hysterectomy later has less blood

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111
Q

Describe placental abruption

A

Premature separation of a normally placed placenta before delivery of the foetus with blood collecting between placenta and uterus

  • 30% of all APH
  • 6 per 1000 births

Concealed (20%) - haemorrhage confined within uterine cavity, more severe as blood loss usually underestimated

Revealed (80%) - blood drains through cervix

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112
Q

Risk factors for placental abruption

A 
Previous abruption
Pre-eclampsia
Multiple pregnancy
Threatened miscarriage
Hypertension
Multiparity
Past C-section
Smoking
Non-vertex presentation
Cocaine/amphetamines
Thrombophilia
Intrauterine infections
Polyhydramnios
Trauma - RTA, domestic violence, iatrogenic
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113
Q

Presentation of placental abruption

A 
Vaginal bleeding
Continuous abdominal pain
Uterine contractions
Shock
Foetal distress

CLINICAL DIAGNOSIS

  • Tense, tender uterus with woody feel
  • Foetal hypoxia with HR abnormality on CTG
  • Low platelet count
  • Large level of compensation
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114
Q

Management of placental abruption

A 
Mothers life takes priority
ABCD
Crossmatch 4 units
Kleihauer test for anti-D
Left lateral position

Delivery -
If foetus alive, C-section or artificial rupture of amniotic membranes
If foetus dead - vaginal delivery

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115
Q

Determining gestational age

A

Physical exam/US
History - LMP

Naegele’s rule - EDD = -3months + 7 days from LMP

Uterine size - 6-8weeks = small pear, 8-10 weeks = orange, 10-12weeks = grapefruit
16 weeks = midway pubic symphysis and umbilicus
20 weeks = umbilicus

US

  • gestational sac diameter (until embryo visible)
  • Crown rump length
  • After 10 weeks - biparietal diameter and head circumference

Foetal biometry

  • Biparietal diameter
  • Head circumference
  • Femur length
  • Abdominal circumference
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116
Q

Symptoms of pregnancy

A 
Amenorrhoea
Nausea and vomiting
Breast enlargement and tenderness
Increased urinary frequency
Fatigue
Uterine cramping
Abdominal bloating
Constipation
heartburn
SOB
Mood changes
Food cravings/aversions
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117
Q

Diagnosis of pregnancy

A

hCG

  • first secreted 6-8 days post ovulation
  • doubles every 30-50 hours during the first 30 days
  • slower rise in abnormal pregnancy
  • urine requires high levels to detect

US

  • gestational sac at 4-5 weeks
  • yolk sac from 5 weeks to 10 weeks
  • foetal pole and cardiac activity 5-6 weeks
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118
Q

Reasons for pregnancy false positives

A

operator error (home kits)
pregnancy loss soon after implantation
interference from hCG from infertility treatment
hCG from tumour
Pituitary hCG secretion in perimenopausal women

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119
Q

Describe pre-eclampsia

A

Pregnancy induced hypertension in association with proteinuria +/- oedema

Characterised by

  • Maternal hypertension
  • Proteinuria
  • Oedema
  • Foetal IUGR
  • premature birth

Severe SBP > 160, diastolic >110
Foetus may have neurological damage post-hypoxia

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120
Q

Epidemiology and RF for pre-eclampsia

A

2nd leading cause of direct maternal death

  • 5 per 1000
  • Death rate 0.4 per 100,000
  • 20% stillbirths without congenital abnormality is caused by pre-eclampsia
  • 50% with severe will deliver by 36 weeks
RFs
HIGH
- past pre-eclampsia, eclampsia, hypertension in a previous pregnancy
- pre-existing hypertension
- Pre-existing CKD
- Pre-existing diabetes
- SLE or APLS

MODERATE

  • 10+ years since last pregnancy
  • first pregnancy
  • aged over 40
  • BMI>35
  • FHx of pre-eclampsia
  • multiple pregnancy
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121
Q

Pathophysiology of pre-eclampsia

A

Suboptimal uteroplacental perfusion associated with maternal inflammatory response and maternal vascular endothelial dysfunction

Phase 1 - Abnormal placentation
NORMAL
- During 6-18 weeks placentation occurs
- Alterations in spiral arteries occur to increase blood supply
- Trophoblasts invade spiral arteries to 5x diameter
- Coverts low flow, high pressure to low resistance, high flow
PRE-ECLAMPSIA
- inadequate trophoblast invasion, inadequate placental perfusion
- Causes IUGR and pre-eclampsia

Phase 2 - endothelial dysfunction

  • Platelet adhesion and thrombosis
  • Exaggerated maternal systemic inflammatory response
  • Decreased organ perfusion - HELLP
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122
Q

Presentation of pre-eclampsia

A

Systolic BP>140, diastolic >90 in 2nd half of pregnancy with >1+ of proteinuria

  • New hypertension
  • New proteinuria

SEVERE

  • Severe frontal headache
  • Sudden swelling (oedema)
  • Liver tenderness
  • Visual disturbance
  • Epigastric pain
  • Vomiting
  • Low platelet count
  • Raised ALT and AST
  • Clonus
  • HELLP syndrome
  • Papilloedema
  • Foetal distress
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123
Q

Monitoring of pre-eclampsia

A

If patient has any risk factors - increasing frequency of BP and urine measurements

Admit if they have:

  • BP>140/90, >1+ proteinuria
  • Systolic BP >160
  • Diastolic >100
  • Any symptoms or signs
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124
Q

Investigations of pre-eclampsia

A
  • Urinanalysis - microscopy, culture
  • Frequent monitoring of FBC, LFTs, renal function, electrolytes & urate
  • Look for HELLP syndrome
  • Clotting if severe or thrombocytopaenia
  • 24 hour urine for protein and creatinine
  • Assessment of foetus - US and amniotic fluid
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125
Q

HELLP

A

Haemolysis
Elevated Liver enzymes
Low Platelets

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126
Q

Management of pre-eclampsia

A

Conservatively until at least 34 weeks where possible (no HELLP)

Delivery of the placenta is the ONLY cure

SEVERE
- Antihypertensives (labetolol) if BP>160/110
Can also use nifedipine or hydralazine
- Magnesium sulphate to prevent seizures
- Fluid restruction - to minimise fluid overload which can result in pulmonary oedema
- Delivery
- If under 34 weeks, give corticosteroids
- Method of delivery depends on presentation of foetus, foetal condition and chance of success
- IM syntocinon to prevent haemorrhage
- Prophylaxis against VTE

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127
Q

Management of eclampsia

A 
Resuscitation
Magnesium sulphate as anticonvulsant
Intubation may be required if repeated seizures
IV labetalol or hydralazine
Continuous foetal monitoring
Monitor fluid intake, and urine output
Attempts to prolong pregnancy not of use
  • it is unsafe to deliver a baby from an unstable mother
  • Control seizures, reduce HTN and correct hypoxia
  • c-section
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128
Q

Complications of pre-eclampsia

A 
Haemolysis
HELLP
AKI
DIC
Adult respiratory distress syndrome
Cerebrovascular haemorrhage
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129
Q

Prevention of pre-eclampsia

A

75mg aspirin from 12 weeks if high risk

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130
Q

Maternal issues associated with substance misuse in pregnancy

A 
Low nutrition
Risk of anaemia
Oral hygiene issues
Infection from needles
Increased risk of mental health problems
Increased obstetric complications
Increased premature delivery
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131
Q

Foetal issues associated with substance misuse in pregnancy

A 
IUGR
Pre-term delivery
Increase perinatal mortality
Increased miscarriage
Increased placental abruption
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132
Q

Management of opioid addiction in pregnancy

A

Maintenance with methadone to stop/minimise illicit use
Detox in first trimester has high miscarriage risk
Can detox in 2nd or 3rd trimester, small frequent reductions
Withdrawal will increase foetal distress and still birth

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133
Q

Management of a cocaine use in pregnancy

A

STOP - no safe prescribed alternative

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134
Q

Risks of cocaine in pregnancy

A

Increased miscarriage, still birth
PROM
Placental abruption
Preterm labour

For baby

  • stroke
  • poor growth
  • deformed limbs
  • feedbing problems
  • brain damage
  • SIDS

NO BREAST FEEDING

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135
Q

Risks of opiates in pregnancy

A

Increased pre term delivery
Still born
IUGR
Increased neonatal death

Neonatal withdrawal syndrome - high pitch cry, poor feeding, tremors, irritability, D&V, sweating, seizures

Heroin = NO BREAST FEEDING
Opiates = OK to breastfeed
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136
Q

Induction of labour

A

60-80% success rate

Starting labour by uterine stimulation. Approximately 20% of births.

Offer to women in healthy pregnancy over 41 weeks to decrease risk of still birth
Offer to diabetic women before term
Offer if PROM after 37 weeks

  • Membrane sweep
  • Prostaglandin gel or pessary (PV)
  • Oxytocin +/- artificial rupture of membranes

Monitor with CTG for myometrial over-reaction

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137
Q

Contraindications for induction of labour

A 
Severe placenta praevia
Transverse foetal lie
Severe cephalopelvic disproportion
Cervix <4 on Bishop's score
Active primary genital herpes infection
High and floating foetal head (risk of prolapsed cord)
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138
Q

Complications of induction of labour

A

Uterine Hyperstimulation - foetal distress, hypoxic damage
Uterine rupture
Intrauterine infection with prolonged membrane rupture
Prolapsed cord if presenting part not engaged
Amniotic fluid embolization
Atonic PPH

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139
Q

Prevention for instrumental delivery

A

Presence of supporting person with the woman at all times
Mother labouring in upright or left lateral position
Avoidance of epidurals

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140
Q

What is Bishop’s system?

A

Score for ripeness of cervix

>8 = successful delivery

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141
Q

Classification of forceps deliveries

A

OUTLET - foetal scalp visible, labia separated
Foetal skull has reached pelvic floor
Rotation required > 45 degrees

LOW - leading point (not caput) is at +2, rotation required

MIDCAVITY - head 1/5 palpable per abdomen, leading point >2+ but not above ischial spines

HIGH = not recommeded

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142
Q

Indications for instrumental delivery

A

Presumed or diagnosed foetal compromise
Protect head during breech delivery

MATERNAL
Avoid Valsalva manourvre
Hypertensive crisis
CV disease
Myasthenia gravis
Spinal cord injury

Inadequate progress

  • Active stage > 2 hours in nulliparous, >1 hour in multiparous
  • Maternal fatigue
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143
Q

Contraindications for instrumental delivery

A

Predisposition to fractures in foetus
Bleeding tendency or active bleeding in foetus
Face presentation
Vacuum extractor should not be used under 34 weeks

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144
Q

Requirements for an instrumental delivery

A 
Fully dilated cervix
Occipital-anterior position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief adequate
Sphincter (bladder) empty

Mediolateral episiotomy before instrumental delivery to reduce tears

If unsuccessful with 3 pulls - c-section

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145
Q

Indications for episiotomy

A 
Rigid perineum preventing delivery
Large tear imminent
Instrumetnal delivery
Shoulder dystocia
Vaginal breech delivery
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146
Q

What is an episiotomy

A

Right mediolateral incision with local anaesthetic

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147
Q

Degrees of tears

A

1st - injury to vaginal epithelium and vulval skin only

2nd - injury to perineal muscles but not anal sphincter

3rd - injury to perineum, involving anal sphincter

4th - injury to perineum, anal sphincter complex and anal or rectal mucosa

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148
Q

Indications for induction of labour

A 
uteroplacental insufficiency
prolonged pregnancy > 41 weeks
IUGR
Oligo or anhydramnios
Abnormal uterine or umbilical artery Doppler
Non-reassuring CTG
PROM
Severe pre-eclampsia, eclampsia
Intrauterine death of foetus
APH
Chorioamnitis

Severe hypertension
Uncontrolled diabetes
Deteriorating renal function
Malignancy

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149
Q

Methods for induction of labour

A

Cervical ripening
- Separation of membranes from the cervix - stretch and sweep

Amniotomy
- Artificial rupture of membranes

Prostaglandins - DINOPROSTONE

  • Intravaginally as tablets or gel
  • VE after 6 hours
  • CTG before and after
  • Only 2 doses as risk of Hyperstimulation

Oxytocin infusion

  • best after rupture of membranes
  • wait 6 hours after prostaglandins
  • continuous CTG and want 3-4 contractions in 10 minutes
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150
Q

First stage of labour

A

Begins with regular contractions when the foetal presenting part has reached true pelvis
End when the cervix is fully dilated (10 cm)

Latent phase

  • 2-24 hours
  • Cotnractions not painful, 5-10 minute intervals
  • Cervix dilating slowily

ACTIVE PHASE

  • Primi - 12-14 hours, multi 6-10 hours
  • Start when cervix 3-4 cm dilated
  • Rapid dilation 0.5-1cm per hour
  • Foetal head descends into maternal pelvis and foetal neck flexes
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151
Q

Management of first stage of labour

A

Hourly temp and HR
4 hourly BP
30 minute monitoring frequency of contractions

Foetal HR auscultated for 1 minute immediately after a contraction every 15 minutes
Should be 100-160

VE every 4 hours
Discuss need for pain relief

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152
Q

Second stage of labour

A

Starts when cervix is fully dilated
Ends with birth of baby

Contractions are stronger, 2-5 minute intervals lasting 60-90 seconds

Primigravida 60 minutes, multi 30 minutes

Feotal head descends and rotates anteriorly
Wants to push
After head through, shoulders rotate to allow shoulders through

Midwife/doctor present throughout
Monitor contractions, and foetal HR ever 5 minutes
Push during contractions, relax between
If >2 hours nulliparous or > 1 hour multiparous then consider instrumental delivery or c-section

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153
Q

Third stage of labour

A

Starts with birth of baby
Ends with delivery of placenta and membranes

Separation of placenta occurs immediately after birth

20-30 minutes or 5-15 with active management
Haemorrhaging prevented by contraction of uterine muscle fibres

Separation noted by gush of blood, prominence of fundus in abdomen and lengthening of umbilical cord

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154
Q

Management of 3rd stage of labour

A

Expectant - uterus rubbed up to produce contraction, uterus pushed to vagina to aid expulsion

Active - IM oxytocin after birth
Controlled traction of umbilical cord to aid expulsion

Examine placenta and membranes for completeness

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155
Q

Braxton Hicks contraction

A

Mild
Irregular
Non-progressive

can occur from 30 weeks, more common after 36 weeks

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156
Q

Poor progress in 1st stage of labour

  • Criteria
  • Causes
A

Criteria
<2cm progression in 4 hours
- Slowing in progress in parous woman

Insufficient uterine activity (power)
Malpositions, malpresentation, large baby (passenger)
Inadequate pelvis (passage)
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157
Q

Management of poor progress in 1st stage of labour

A

Amniotomy and reassess in 2 hours
Amniotomy + oxytocin infusion
C-section if foetal distress

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158
Q

Benefits of active management of 3rd stage of labour

A 
Decreased PPH
Decreased length of time in 3rd stage
Decrease blood loss
Decreased post-natal anaemia
Decreased transfusions
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159
Q

Definition of premature labour

A

Contractions of sufficient strength and frequency to effect progressive effacement and dilation of cervix before 37 weeks

Very premature is before 32 weeks

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160
Q

Risk factors for premature labour

A 
Multiple pregnancy
Genital tract infection 
P-PROM
Antepartum haemorrhage
Cervical incompetence
Congenital uterine abnormality 
APLS
Diabetes
Past pre-term delivery

30% are unexplained and spontaneous

161
Q

Investigations for pre-term labour

A

If under 30 weeks with in tact membranes, no investigations

If over 30 weeks

  • TV US to estimate cervical length
  • Foetal fibronectin: if less than 50 then unlikely to be pre-term labour

No VE if ruptured membranes unless confirmed labour
Vaginal swabs

162
Q

Management of pre-term labour

A

Tocolytic drugs - not if P-PROM

  • Nifedipine
  • Can delay delivery for up to 7 days

Corticosteroids if between 24 and 36 weeks

Magnesium sulphate to reduce risk of CP

Emergency cervical cerclage if between 16 and 34 weeks with dilated cervix and exposed unruptured membranes

Delivery vaginally if cephalic
Breech under 32 weeks = C-section

Most over 30 weeks survive without lasting abnormality

163
Q

Non-pharmacological methods of pain relief in labour

A

Maternal support

Environment - light diet, keep mobile, soothing music, comfortable position

Birthing pool - not within 2 hours of opioids due to drowsiness

164
Q

Drugs used as analgesia in labour

A

Entonox

  • Inhaled
  • Patient controlled, works in seconds, wears off quickly, minimal side effects

IM opiate

  • SE nausea, vomiting, drowsiness
  • Pethidine
  • Short term respiratory depression and drowsiness
  • Drowsy neonate

Epidural

  • Central nerve block with local anaesthetic
  • Most effective, avoids further analgesia for instrumental delivery.
  • Increases length of 2nd stage, rate of operative delivery
  • Can cause transient hypotension, dizziness
  • Severe headache if dural tap
  • need CTG

Local anaesthesia
- if tear, episiotomy or instrumental delivery

165
Q

Differences between epidural and spinal

A

Epidural

  • extradural catheter placement
  • cannula allows top up
  • patchy analgesia

Spinal

  • subarachnoid injection
  • 1 off injection, can last 2-4 hours
  • dense, reliable block
166
Q

Causes of cerebral palsy

A 
Unknown
Complication of prematurity
Peripartum asphyxia
Postnatal (encephalitis, accidents)
Perinatal infection (CMV, rubella)
Multiple pregnancy
Chromosomal abnormality
167
Q

Types of multiple pregnancy

A

Dizygotic - non identical twins
- Foetus has it’s own placenta, own amnion and chorion

Monozygotic
Depends on when the embryo splits
- 3 days: 2 chorion, 2 amnion
- 4-7 days, 1 placenta, 1 chorion, 2 amnion
- 8-12 days: 1 placenta, 1 chorion, 1 amnion
- 13 days - conjoined twins

168
Q

Risk factors for multiple pregnancy

A

RFs at only for dizygotic twins - monozygotic has no RFs

- Past multiple pregnancy
FHx on maternal side
Increased maternal age
West African
Assisted conception
169
Q

Antenatal care in multiple pregnancy

A

Refer to obstetrics
US as normal at 11-13 wees and 18-20 for abnormality
Monitor carefully for IUGR and feto-feto transfusion syndrome

Scan
Dichorionic - 20, 24, 28, 32 and 26 weeks
Monochorionic - 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks

Inform

  • increased risk of Down’s and increased risk of false positive on screening
  • Twins use combined test
  • Triplets use nuchal translucency

Take 75mg aspirin OD from 12 weeks if 1st pregnancy, over 40, pregnancy interval over 10 years, BMI > 35or FHx of pre-eclapmsia

170
Q

Delivery of multiple pregnancy

A

Offer elective birth at 36 weeks (mono-chorionic) after course of steroids
Dichorionic - 37 weeks
Triplets - 35 weeks

If 1st twin is cephalic presentation then trial vaginal delivery, if breech or transverse then C-section

  • May need IV oxytocin after first child as contractions can decrease
  • 2nd should be born within 45 minutes
171
Q

Maternal complications of multiple prengnacy

A 
Increased
miscarriage
anaemia
pre-eclampsia
APH
PPH
C-section
symptoms of pregnancy
Polyhydramnios
Hyperemesis gravidarum
Post natal illness
death
172
Q

Foetal complications of multiple prengancy

A 
Increased
Still birth
pre-term birth
neonatal mortality
morbidity
FFTS
Umbilical entanglement
IUGR
congenital abnormality
173
Q

Physiological changes in prengnacy

A 
Increased blood volume
Decreased Hct (due to dilution) - anaemia of pregnancy is physiological
Increased RBC
Increased stroke volume, cardiac output
Decreased peripheral vascular resistance
BP stable or decreased

Increased tidal volume
Decreased functional residual capacity from gravid uterus
Decreased total lung capacity

Increased clotting
Increased renal function

increased uterine blood flow
Increased uterine weight
No autoregularion of uterine blood flow - hypotension can cause foetal distress

174
Q

Why is left lateral an important position in pregnancy

A

Otherwise can have overt caval compression- IVC compression

  • Hypotension
  • Sweating
  • Bradycardia
  • Pallor
  • Nausea and vomiting
175
Q

Spinal anaesthesia

A

L3/L4
Pierce the ligamentum flavum before dura
Use heavy LA to prevent upwards movement
Uterus supply at T10 - block up to nipple line (T4)

Phenyepherine - alpha blocker to counteract hypotension
Inject bupropripcaine
- 20x safer than GA

176
Q

GA in prengancy

A 
Avoid at all costs
Need to neutralise stomach acid with ranitidine and metoclopramide
No strong opioids prior to delivery
Difficult airway
Give +++ oxygen before anaesthesia

Only if spinal or epidural contraindicated e.g. raised ICP, coagulopathy, patient refusal or infection

177
Q

Reasons for CTG

A 
MATERNAL
Past C-section
cardiac problems
pre-eclampsia
prolonged pregnancy >42 weeks
PROM
induction of labour
Diabetes
APH
FOETAL
IUGR
prematurity
oligohydramnios
abnormal Doppler
multiple pregnancy
meconium stained liquor
breech position
INTRAPARTUM
oxytocin augmentation
epidural anaesthesia
intrapartum PV bleed
pyrexia > 37.5
fresh meconium bleeding
abnormal foetal HR
prolonged labour
178
Q

Normal baseline foetal HR

A

110-160
Bradycardia <110
Tachycardia > 160

179
Q

Normal baseline variability on CTG

A

Normal 5-25bpm
Reduced 0-5
Saltatory >25

180
Q

Define acceleration and deceleration on CTG

A

Transient rise in FHR > 15 bpm for >15 seconds
Transient decrease as above

Early decelerations - peaks co-incides with contraction and is due to head compression - 2nd stage of labour

Late decelerations - acidosis, if shallow with decrease baseline variability very concerning

181
Q

Maternal factors that can cause abnormal CTG

A 
Position - not left lateral
Hypotension
VE
Emptying bladder or bowels
Vomiting
Vasovagal episodes
Topping up anaesthesia
182
Q

Foetal blood sampling

A

Taken from scalp via needle and speculum
Obtain if pathological CTG
Woman in L lateral

Normal ph>7.25 then repeat in 1 hour if CTG still abnormal
Borderline 7.21-7.24, repeat in 30 mins
Abnormal <7.20 IMMEDIATE DELIVERY

183
Q

RF for pre term premature rupture of membranes P-PROM

A

Smoking
Previous pre-term delivery
Vaginal bleeding
Lower genital tract infection

184
Q

Investigations for PROM

A 
No VE
Visualise amniotic fluid draining through cervix
Sterile speculum exam
US to determine liquor volume
12 hourly temperatures
Foetal monitoring
185
Q

Management of PROM

A

Refer to hospital, admit for first 48 hours
Prophylactic antibiotics
Antenatal steroids if between 24 and 35 weeks
Consider delivery post-34 weeks

186
Q

Complications of PROM

A 
prematurity
Sepsis
Pulmonary hypoplasia
Umbilical cord prolapse
Placental abruption
Oligohydramnios
Increased retained placenta and PPH
187
Q

Epidemiology and RF for post-natal depression

A

As common as depression
Most common in first few weeks post-natally
10-15%

MAJOR RF
Previous history of MH problems
Psychological disturbance in pregnancy
Poor social support
Poor relationship with partner
Baby blues
Recent major life events 
Other RF
Unplanned pregnancy
Not breast feeding
Unemployment
Antenatal parental stress
Depression in father
2+ children
Neonatal illness/death/SIDS
Substance misuse
Low family outcome
History of abuse
188
Q

Presentation of post-natal depression

A 
Low mood
Anhedonia
Anxiety
Disturbed sleep
Decreased appetite
Poor concentration
Decreased self-esteem
Decreased energy
Decreased libido
Suicidal thoughts
189
Q

Assessment of post-natal depression

Questions to be asked in history

A 
Hx or FHx or MH problem
Physical wellbeing
Alcohol and drug misuse
Mother-baby relationship
Relationships, social networks, isolation
Domestic violence, abuse, sexual abuse, trauma
Housing
Employment
Economic and migration status
190
Q

Management of post-natal depression

A

Mild-moderate = consider self-help strategies

Mild + history of severe depression = consider antidepressant

Moderate-severe = CBT, antidepressants or combination

Psychological therapies are first line
Women can breastfeed unless taking = lithium, sodium valproate, carbamazepine, clozapine

Higher threshold for pharmacological therapy due to risk

191
Q

Complications in post natal depression

A

Adverse effects in the children
Poorer cognitive, emotional, social and behavioural development

Post-partum psychosis 1/1000

  • first few weeks
  • psychiatric emergency
  • paranoia, delusions, hallucinations, loss of inhibition

Most resolves in 3-6 months
Course of illness widely variable

192
Q

Incidence and factors that increase breast feeding

A

81% of mothers, increasing
1/3 are still breast feeding at 6 months
Only 1% are exclusive breast feeding at 6 months

More likely to breast feed if…

  • From ethnic minority group (Chinese, black)
  • managerial and professional occupation
  • aged over 30
  • Live in England (vs. rest of GB)
  • First time mother
  • Left full time education over 18
193
Q

Advantages of breast feeding

A 
Free
No preparation
Immunity
Infection protection (decreased LRTI, otitis media, gastroenteritis)
May protect against asthma and eczema
Decrease SIDS
Protection from future Type 2 diabetes (in mother and child)
Decrease breast and ovarian cancer
Contraception - lactational amenorrhoea
194
Q

Disadvantages of breast feeding

A

issues with feeding in public
low in vitamin D (may need supplements)
transmission of HIV and hep C
Can transmit maternal infection - N. gonorrhoea, H. influenza, group B strep, staph

cracked/sore nipples
blocked ducts and breast engorgement
mastitis
thrush

195
Q

Causes of cracked and sore nipples (breast feeding)

A

Nipple soreness is very common in the first few weeks

Caused by

  • improper positioning of baby - alter
  • improper feeding technique - incomplete suction release
  • improper nipple care - excessively dry or moist
196
Q

Blocked ducts and breast engorgement (breast feeding)

A

caused by poor drainage of the breast
swollen, hard, painful, redness
nipples can protrude to allow baby to latch
causes by pressure on breast and prolonged gaps between feeds
nurse 8+ times in 24 hours for 15+ minutes
can develop in mastitis if persists

197
Q

Mastitis (breast feeding)

A

occurs in 20%
Increased if: nipple damage, over supply of milk, S.aureus
Engorgement can lead to mastitis which can lead to abscess

Treat with flucloxacillin

198
Q

Advice for breast feeding mothers

A

Should begin within an hour of birth
It should be on demand - when baby wants it
Avoid pacifiers or bottles
Baby head and body in line
Hold baby close
Place baby nipple to nose - baby will tip head back
Milk released by oxytocin

199
Q

Define neonatal abstinence syndrome

A

Infant born to mother addicted to opioids at the risk of withdrawal.

  • Heroin
  • Methadone
200
Q

Presentation of neonatal abstinence syndrome

A

CNS

  • tremors
  • irritability
  • increased wakefulness
  • high pitched cry
  • hypertonicity
  • hyperactive reflexes
  • seziurs
  • yawning, sneezing

GI TRACT

  • poor feeding
  • uncoordinated, constant sucking
  • vomiting
  • regurgitation
  • loose, watery stools
  • dehydration

AUTONOMIC

  • increased sweating
  • nasal stuffiness
  • fever
  • temperature instability
  • tachypnoea
  • mottling of skin

Starts within 24 hours if heroin or 24-72 days if methadone

201
Q

Management of neonatal abstinence syndrome

A

Decrease sensory stimulation
Small frequent feeding
Increased calorie dense formula
MONITOR

Pharmacology if seizures, poor feeding, fever, significant D&V

Opioid therapy - morphine/methadone/buprenorphine

Adjunct therapy if multiple drug exposure = phenobarbital

202
Q

Information required for post-partum contraception advice

A

Normally discussed at 6 week GP check

Contraceptive needs
Future child plans
Any periods
Breastfeeding
Any medical conditions
203
Q

Contraception for non-breast feeding mother under 21 days post partum

A

Barrier methods
POP
Progesterone only injectable and implants

204
Q

Contraception for non-breast feeding mother over 21 days post partum

A

COCP
Barrier methods
POP
Progesterone only injectable and implant

IUS over 6 weeks

205
Q

Contraception for breast feeding mother under 6 weeks post partum

A

Lactational amenorrhoea methods
POP
Progesterone only implants
Barrier methods

206
Q

Contraception for breast feeding mother over 6 weeks post partum

A 
LAM
POP
Progesterone injectable and implant
IUS  - from 6 weeks
IUD
Barrier methods
Sterilisation

No COCP until after 6 months

207
Q

Criteria for lactational amenorrhoea methods

A

Under 6 months post partum
Amennorhoeic
Full daily breast feeding

208
Q

Define 3rd stage of labour

A

From the time of birth to expulsion of placenta

209
Q

Define prolonged 3rd stage of labour

A

Prolonged if not completed in:
30 minutes - active
60 minutes - physiological

210
Q

Describe management of 3rd stage of labour

A

Active management

  • routine use of uterogenic drugs - oxytocin IM with birth of anterior shoulder
  • deferred clamping and cutting of cord (between 1 minutes to 5 minutes)
  • controlled cord traction

Physiological
- delivery of placenta by maternal effort

211
Q

Care of newborn immediately post-partum

A

Apgar score at 1 minute and 5 minutes
Record time from birth to regular respirations
Skin to skin contact
Avoid separation of mother and baby for 1 hours
Encourage breast feeding within 1st hour
Record head circumference, body temp and weight

212
Q

Care of mother immediately post-partum

A 
Assess uterine contraction and lochia
Examine placenta and membranes
Assess emotional and physical condition
Successful voiding of bladder
Assess for genital trauma
If genital trauma then rectal exam 
If required perineal repair
213
Q

Define post-partum haemorrhage

A

Excessive bleeding post-delivery

Primary - loss of blood >500ml within 24 hours of delivery
MINOR - 500-1000ml
MAJOR - over 1000ml

Secondary - abnormal bleeding between 24 hours and 6 weeks

214
Q

Aetiology of PPH

A

Tone - uterine atony (most common), distended bladder

Trauma - lacerations of uterus, cervix or vagina

Tissue - retained placenta, clots

Thrombin - pre-existing or acquired coagulopathy

215
Q

Epidemiology and RF for PPH

A

5-10%
Severe less than 1%
Increased in Asians
Increased in over 40s

Antenatal RF

  • APH
  • Placenta praevia (x12)
  • Placental abruption
  • Multiple pregnancy (x5)
  • Uterine over-distension (polyhydramnios, macrosomia)
  • pre-eclampsia
  • multi parity > 4
  • previous PPH or retained placenta
  • increased if BMI > 35

Delivery RFs

  • emergency section (x4)
  • elective seciont (x2)
  • Retained placenta (x5)
  • episiotomy (x5)
  • induction of labour
  • instrumented delivery
  • labour > 12 hours
  • Baby > 4kg
  • Maternal pyrexia in labour

Clotting disorders

216
Q

Management of PPH

A

Resusciattion

  • Minor = 14G cannula and crystalloid infusion
  • Major = ABCs, high flow O2, 2x14G cannula, transfuse bloods ASAP and Hartmanns until blood available

Monitor and investigate

  • Minor = blood group, coag screen
  • Major = FBC, coag, U&E, LFTs, crossmatch 4 units. Consider arterial line and ITU transfer, MEOWS charts

Stop bleeding

  • If uterine atony:
  • bimanual uterine compression
  • empty bladder
  • oxytocin infusion
  • ergometrine
  • carboprost or misoprostol
  • balloon tamponade
  • haemostatic brace suturing
  • bilateral ligation of uterine or internal iliac arteries
  • selective arterial embolization

Hysterectomy - should be a 2 consultant decision

217
Q

Complications from primary PPH

A 
Hypovolaemic shock
DIC
AKI
Liver failure
Acute respiratory distress syndrome
Death in 1 in 100,000 deliveries
218
Q

Aetiology of secondary PPH

A

Infection - endometritis

Retained products of conception

219
Q

RF for secondary PPH

A

1-3% of vaginal deliveries

C-section
prolonged rupture of membranes
severe meconium staining in liquor
long labour with multiple examinations
manual removal of placenta
extremes of maternal age
decreased socio economic status
maternal anaemia
prolonged surgery
220
Q

symptoms of secondary PPH

A 
fever
abdominal pain
offensive smelling lochia
abnormal vaginal bleeding
abnormal vaginal discharge
dyspareunia
dysuria
malaise
221
Q

signs of secondary PPH

A 
fever
rigors
tachycardia
tenderness of suprapubic area and adnexa
elevated boggy uterus if retained products of conception
222
Q

Investigations for secondary PPH

A 
FBC
Blood cultures
MSU
High vaginal swab - gonorrhoea, chlamydia
US if ?RPOC
223
Q

Management of secondary PPH

A

Urgent referral if any red flags (sepsis)

  • pyrexia >38
  • sustained tachycardia&raquo_space;90
  • RR >20
  • abdominal and chest pain
  • D+V
  • uterine or renal angle pain
  • IV antibiotics (for endometriits) - piperacilin/taxobactam (tazocin)
224
Q

Epidemiology of cervical cancer

A 
Increased in developing countries
30% detected through screening
13th most common cancer in females
1 per 10,000
Peak age 25-29

RF

  • HPV 16 and 18
  • Heterosexual
  • multiple sexual partner
  • Smoking
  • Lower social class
  • Immunosuppression
  • COCP
225
Q

Pathogenesis of cervical cancer

A

70% squamous carcinoma
15% adenocarcinoma
15% mixed

CIN

  • CIN1 - disease confined to lower 1/3 epithelium
  • CIN2 - confined to lower and middle 1/3 of epithelium
  • CIN3 - full thickness of epithelium
226
Q

Symptoms of cervical cancer

A 
Abnormal vaginal bleeding
vaginal discharge
bleeding - post coital, on micturition or defaecation
Vaginal discomfort
Urinary symptoms

Late symptoms

  • painless haematuria
  • chronic urinary frequency
  • painless fresh rectal bleeding
  • altered bowel habit
  • leg oedema, pain, hydronephrosis

If any suspicion refer on 2 week wait, do not do a smear

227
Q

Signs of cervical cancer

A 
White patches on cervix
Abnormal cervical appearance - erosion, ulcer, tumour
Mass on rectal exam
Pelvic bulkiness or mass
peripheral oedema
Hepatic/pulmonary mets
228
Q

Investigations for cervical cancer

A

Pre-menopausal - STI screen
Post-menopausal - urgent gynae referral

Colposcopy
- cleaned with acetic acid
- Insepction +/- biopsy +/- treatment
Cone biopsy
FBC, U&amp;Es, LFTs
229
Q

Staging of cervical cancer

A 
FIGO staging
Based on tumour size
Vaginal or parametrial involvement
Bladder or rectum involvement
Mets

Most are diagnosed in early stages

230
Q

Management of cervical cancer

A

Surgery, radiotherapy, chemotherapy or combination
Fertility sparing treatment may be important
If pregnant may delay for a few weeks or abort

Surgery

  • If fertility sparing, removal with margins
  • Or hysterectomy
  • Radical: Wertheim’s hysterectomy: tumour + main lymph nodes + upper 1/3 vagina

Radiotherapy
- external beam or internal brachytherapy

Chemo - cisplatin

231
Q

Prognosis of cervical cancer

A 
1 = 90% survival at 5 years
2 = 60-90%
3 = 30-50%
4 = <20%
232
Q

Prevention of cervical cancer

A

HPV vaccine 16 and 18
or 16, 8, 6 and 11 (includes for warts)
- Given in females aged 11 to 13
2 doses

233
Q

Screening for cervical cancer

A

From 25
Every 3 years until 50
After 50 every 5 years until 65

234
Q

Pathophysiology of endometrial cancer

A

Mainly adenocarcinoma from lining of uterus

OESTROGEN DEPENDENT

235
Q

Epidemiology of endometrial cancer

A

90% are over 50
Increased with age
Most common in Western societies
3% of total cancer cases

RF

  • prolonged periods of unopposed oestrogen
  • Nulliparous
  • Post menopausal
  • Obesity
  • Endometrial hyperplasia
  • PCOS
  • HNPCC
  • Diabetes
  • Tamoxifen
236
Q

Presentation of endometrial cancer

A

POST MENOPAUSAL BLEEDING IS endometrial cancer unless proven otherwise

237
Q

Investigations for endometrial cancer

A

TV US
- 3mm cut off for endometrial cancer

Endometrial biopsy

  • pipelle
  • done as outpatient and offers definitive diagnosis
  • hysteroscopy and biopsy
238
Q

Management of endometrial cancer

A

TAH and BSO for all

If stage 2 - TAHBSO and systematic pelvic node clearance
If stage 3/4 - debulking surgery
- surgery/radio/chemotherapy

239
Q

Types of ovarian cancer

A

Epithelial (85-90%)

  • In over 50s
  • Serous is most common subtype (40-60 years)
  • Endometroid
  • Clear cell tumour
  • Mucinous tumour

Germ cell (2-10%)

  • derived from germ cells of embryonic gonad
  • <35
  • Curable
  • Rapid enlarging, bloating, pain, rupture, torsion
  • Dysgerminoma, endodermal sinus tumours, teratoma, embryonal carcinoma, choriocarcinoma

Sex cord stromal tumour (<5%)
- derived from connective tissue cells

Borderline (10-15%)

  • Not benign or malignant
  • Do not respond well to chemotherapy
240
Q

Epidemiology of ovarian cancer

A

2% lifetime risk
17 per 100,000
Peaks in 70-80s

RF

  • Increasing age
  • Smoking
  • Obesity
  • Decreased exercise
  • Talcum powder use pre 1975 (asbestos)
  • Hx of infertility or treatment
  • Nulliparous
  • FHx
  • BRCA1 or 2
  • Endometriosis
  • HRT

Protective factors - COCP, child bearing, breastfeeding, early menopause

241
Q

Presentation of ovarian cancer

A 
58% present with stage 3 or 4
Insidious onset
- Abdominal discomfort
Distension
Bloating
Urinary frequency
Dyspepsia
Pelvic or abdominal mass associated with pain
Abnormal uterine bleeding
Ascites
Pleural effusion
242
Q

Investigations for ovarian cancer

A

Refer with any mass or ascites
Test over 50s if symptomatic with multiple attendances
Test over 50s with new IBS

CA125
If raised then US and refer

CT pelvis and abdo for staging
If aged under 40, alpha fetoprotein (endodermal sinus tumours)
- beta hCG for dysgerminomas, embryonal carcinoma, choriocarcinoma

Biopsy prior to chemotherapy

243
Q

Staging of ovarian cancer

A

1 limited to ovaries
2 one or both ovaries with pelvic extension
3 microscopically confirmed peritoneal deposits outside pelvic
4 distant mets

244
Q

Management of ovarian cancer

A

Explorative laparotomy for staging and tumour debulking
TAH and BSO
Conservative if fertility sparing

Chemo post surgery
- Paclitaxel and carboplatin

Relapses are treated with chemotherapy
CA125 useful for monitoring

245
Q

Complications of ovarian cancer

A 
Torsion
Rupture
Infection
Malnutrition
Electrolyte imbalance
Bowel obstruction 
Ascites
Pleural effusion

10 year survival 35%
Better outcome if under 40

246
Q

Define metorrhagia

A

Irregular and frequent periods

247
Q

Aetiology of post-coital bleeding

A 
Infection
Cervical ectropion
Cervical or endometrial polyps
Vaginal cancer
Cervical cancer
Trauma

No specific cause is found in 50%

248
Q

Aetiology of intermenstrual bleeding

A 
Pregnancy related - ectopic, GTD
Physiological - 1-2% spot around ovulation
Vaginal - adenosis, vaginitis, tumour
STI
Cervical cancer
Cervical/endometrial polyps
Ectropion
Fibroids
Endometrial cancer
Adenomyosis
Enodmetritis
Oestrogen secreting ovarian cancers

Tamoxifen
Missed oral contraceptive
Drugs altering clotting - anticoagulants, SSRIs, steroids

Dysfunctional uterine bleeding

249
Q

History features for vaginal bleeding

A 
LMP
Usual cycle length and regularity
Duration of abnormal bleeding
Menorrhagia?
Associated symptoms - abdo pain, fever, vaginal discharge, dyspareunia, aggravating factors

Previous pregnancies and deliveries
Risk of current pregnancy
RF for ectopic - PID, IVF, IUCD, POCP

Current contraception
Smear history
Past gynae investigations or surgery

Sexual history - STIs
Medical history - diabetes, bleeding disorders

Current medications

250
Q

Cervical ectropion

A

red ring around external os due to extension of endocervical columnar epithelium over ectocervix
More common in young people on COCP

251
Q

Cervicitis

A

red, congested oedematous cervix
May have purulent discharge with tender cervix on palpation

Chlamydia or gonorrhoea

252
Q

Strawberry cervix

A

Trichomonas vaginalis infection
Cervix is friable
Prominent papillae
Punctate haemorrhages

253
Q

When to refer a woman with PV bleeding

A

Women with abnormal looking cervix
Suspicious looking cervical polyp
Pelvic mass
High risk of endometrial cancer (Fhx, prolonged or irregular cycles, on tamoxifen
Over 45 + IMB
Under 45 with persistent symptoms or RFs for endometrial cancer

254
Q

Investigations for PV bleeding

A 
Always exclude pregnancy
Exclude STI
Smears only if due 
FBC, clotting, TFT, FSH/LH
TV US is investigation of choice (best to do immediately post-menstrually as thinnest and cysts and polyps most obvious)
Endometrial biopsy using Pipelle
Colposcopy
255
Q

Define polymenorrhoea

A

Bleeding at intervals <21 days

256
Q

Dysfunctional uterine bleeding

A

Abnormal uterine bleeding without any structural or systemic pathology
Usually menorrhagia
Diagnosis of exclusion

257
Q

Aetiology of menorrhagia

A 
40-60% have no pathology 
20% anovulatory cycles
Fibroids
Endometrial polyps
Endometriosis
Adenomyosis
PID
Endometritis
Endometrial hyperplasia/carcinoma
Systemic disease - hypothyroid, liver or kidney disease, obesity, bleeding disorder
IUCD
Anticoagulants
258
Q

Investigations for menorrhagia

A 
FBC
Haemotinics (iron deficiency)
TFTs
Assessment of bleeding disorders
US to assess underlying pathology
259
Q

Management of menorrhagia

A

Pharmacological

  1. Mirena IUS
  2. Tranexamic acid, NSAIDs (mefamic acid), COCP
  3. Progestogens - POP or depot
  4. 3-4 months of gonadotrophin releasing hormone (GnRH)
  5. Hysterectomy/myomectomy

Surgical

  • Endometrial ablation if not enlarged utuerus (not if large fibroids)
  • Radiofrequency/microwave etc.
  • Uterine artery embolization (if wish to keep uterus)
  • Hysteroscopic myomectomy
  • Hysterectomy
260
Q

Complications of endometrial ablation

A 
Vaginal discharge
Increased period pain
Need for additional surgery
Infection
Perforation
261
Q

Fibroid

A

Bengin monoclonal tumours of smooth muscle cells of uterine myometrium with disordered collagen
Growth is stimulated by oestrogens and progesterone

262
Q

Classification of fibroids

A

Intramural (most )
Submucosal (growing into uterine cavity)
Subserosal - growing outwards from uterus

263
Q

Epidemiology of fibroids

A

77% of women
Increased in Africans
30-40 years old
FHx (x2.5 if first degree relative)

RF

  • Obesity
  • Early menarche

Protective factors: increased parity, smoking and exercise

264
Q

Presentation of fibroids

A

50% are asymptomatic
30-50 years old
Excessive or prolonged heavy periods
IMB
Pelvic pain (especially in pregnancy due to pressure and resultant fibroid degeneration)
Constipation/ urinary symptoms from pressure
Recurrent miscarriage or infertility (only if submucosal)
Palpable mass
Enlarged irregular firm non-tender uterus
Iron deficiency anaemia

265
Q

Investigations for fibroids

A 
Pregnancy test
FBC and haematinics
TV US
MRI if US not definitive
Endometrial sampling with pipelle for other causes
Hysteroscopy and biopsy
266
Q

Management of fibroids

A
  • NSAIDs to reduce blood loss
  • Transexamic acid
  • COCP
  • Mirena coil
  • GnRH agonists decrease size but will regrow when stopped
  • Surgery: if pressure symptoms, increased uterine size, medical treatment insufficient or fertility affected
  • Myomectomy (recurrence rate 3%)
  • Hysteroscopic endometrial ablation
  • Laparoscopic hysterectomy
267
Q

Complications of fibroids

A 
Iron deficiency anaemia
Bladder frequency
Constipation
Infertility
Problems in pregnancy - miscarriage, premature labour and PPH, IUGR.
268
Q

Define endometriosis

A

Chronic oestrogen dependent condition characterised by growth of endometrial tissues in sites other than the uterine cavity

269
Q

Most common sites for endometriosis

A 
Pelvic cavity including ovaries
Uterosacral ligaments
Pouch of Douglas
Rectosigmoid colon
Bladder and distal ureter
Rare sites - umbilicus, scar sites, pleura, pericardium, CNS
270
Q

Define adenomyosis

A

Invasion of myometrium by endometrial tissue

271
Q

Epidemiology of endometriosis

A

10-15% of women of reproductive age
Exclusive to reproductive age
Diagnosed in 30s

RFs
- Infertile
- Early menarche
- Delayed child bearing
- Long duration of menstrual flow
- Obstruction to vaginal flow (hydrocolpos)
- FHx (6x with first degree relative)
Chromosomes 7 and 10

Protective; multiparity and use of oral contraceptives

272
Q

Symptoms of endometriosis

A 
Dysmenorrhoea (painful periods)
Dyspareunia
Cyclical or chronic pelvic pain
Subfertility
Bloating
Lethargy
Constipation
Lower back pain
Less common:
cyclical rectal bleeding
menorrhagia
diarrhoea
haematuria

Severity of symptoms increase with age

Worsening of symptoms at the time of menstruation or just prior to it

273
Q

Signs of endometriosis

A 
Examination often normal
Posterior fornix or adenexal tenderness
Palpable nodules
Bluish haemorrhagic nodules in posterior fornix
Chocolate cysts on ovaries
274
Q

Investigations for endometriosis

A

Lapararoscopy is gold standard
Symptoms and laparoscopic findings do not always correlate

TV US to exclude ovarian pathology

FBC,
Urinalysis
Cervical swabs
beta hCG
MRI may be useful
275
Q

Management of endometriosis

A

Medical treatment may decrease symptoms in 80-90%

  • Try suppressing ovarian function for 6 months
  • COCP, danazol, oral or depot progesterone, IUS
  • NSAIDs for pain
  • or GnRH analogues with add back therapy

Surgery

  • Laparoscopic excision or ablalation
  • Endomeriomata (large cysts from endometriosis) need stripping out
  • Hysterectomy as last resort
276
Q

Complications of endometriosis

A

Increased breast and ovarian cancers
Infertility due to tubal damage
Adhesions post-op
Increased IBD

277
Q

Pathophysiology of atrophic vaginitis

A

Decreased oestrogen
Vaginal mucosa thins, drier, decreased elasticity
Can become inflamed and lead to urinary symptoms
Changes in vaginal pH and flora can predispose to UTIs

278
Q

Aetiology of atrophic vaginitis

A 
Natural menopause or oophorectomy
Anti-oestrogen treatments: tamoxifen. aromatase inhibitors
Radiotherapy
Chemotherapy
Post partum
Breastfeeding
279
Q

Presentation of atrophic vaginitis

A 
Vaginal dryness
Burning/itching of vagina or vulva
Dyspareuunia
Vaginal discharge (white/yellow)
Vaginal bleeding
Post coital bleeding
Urinary symptoms: frequency, nocturia, dysuria, recurrent UTI, stress incontinence
Decreased pubic hair
Narrow introitus
Thin mucosa
Diffuse erythema
Dryness
Lack of vaginal folds
280
Q

Investigations for atrophic vaginitis

A

Exclude other causes of PCB/infection/UTI
Vaginal pH testing - alkaline
Vaginal cytology - lack of maturation of vaginal epithelium
Often a clinical diagnosis

281
Q

Management of atrophic vaginitis

A

Lubricants - short term relief
Water or silicone based

Moisturisers - regular use

Hormonal treatments:
- HRT topical
Restores pH, thickens epithelium, improves lubrication
Very effective in long term, minimal side effects

282
Q

Define menopause

A

12 months of spontaneous amenorrhoea

Early menopause is between 40-45

283
Q

Symptoms of menopause

A 
Menstrual irregularity 
Hot flushes - head, face, neck, chest
Sweats
Urogenital symptoms
- dyspareunia, vaginal discomfort, dryness, recurrent UTI, incontinence
Sleep disturbance
Mood changes - anxiety, nervousness, irritability
Loss of libido
Brittle nails, thinning skin, hair loss
284
Q

Investigations for menopause

A

Generally clinical
Lab requirements only if under 45
Raised FSH

Check
TFTs
Blood glucose
cholesterol

Check up to date with cervical and breast screening

285
Q

Define premature ovarian failure

A

Amennorhoea
Raised gonadatrophins
Oestrogen deficienct

Women under 40

286
Q

Aetiology for ovarian failure

A

Decreased ovarian follicles at birth, accelerated follicle atresia or follicular dysfunction
Mutations in FSH receptor
Iatrogenic - surgery, radio or chemotherapy
X linked chromosomal abnormality - Turners
Autoimmune lymphocytic oophritis
Infections - mumps, TB, malaria, chicken pox, CMV

287
Q

Investigations for premature ovarian failure

A

Raised FSH - on 2 occasions, 4 weeks apart
Decreased oestrodiol
TFTs and prolactin
DEXA scan
Anti-Mullerian hormone as a measure of decreased ovarian reserve

Test - adrenal antibodies, autoimmune, hypothyroid, diabetes, addison’s

288
Q

Management of premature ovarian failure

A

Manage depression and anxiety
Lifestyle advice to decrease CV risk
Adequate vitamin D and calcium
HRT until 51 (no risks of HRT as under 50s)

289
Q

Benefits of HRT

A 
Decreased vasomotor symptoms in 4 weeks
Increased quality of life
Increased sleep
Increased mood
Decreased vaginal atrophy
Decreased osteoporosis risk
Decreased CV disease (doesn't increase if started under 60)
Decreased colorectal risk
Decreased aging
290
Q

Risks of HRT

A 
VTE
PE
Stroke
Breast and endometrial cancer (If BMI normal)
Gallbladder disease
291
Q

Side effects of HRT

A 
Breast tenderness
Leg cramps
Bloating
Nausea
Headache
PMS 
Backache
Depression
Pelvic pain
292
Q

Prescribing HRT

A 
Check personal and FHx of VTE
Confirm no sinister pathology
No maximal duration
Transdermal has fewer risks
Continuous combined
Erratic bleeding common for first 3-6 months
293
Q

Ovarian cycles of menstruation

A

Follicular phase - follicles are stimulated due to rise of FSH

Ovulation - ovarian follicles mature, egg released, rise in oestrogen causes rise of LH. LH surge causes release of egg

Luteal phase - corpus luteum forms and produces progesterone which causes decrease in FSH and LH. When corpus luteum dies, decrease in progesterone which causes menstruation

294
Q

Describe changes of LH and FSH in menstruation

A

LH remains at baseline until day 12-14 where there is very large LH surge
There is a corresponding increase in FSH during this period but much lower than LH

295
Q

Describe levels of oestrogen and progesterone in menstruation

A

oestrogen peaks just before ovulation

progesterone is low until after ovulation at which is steadily rises before dropping just before mensturation

296
Q

Pathogenesis of dysmenorrhoea

A

Thought to be due to excess or imbalance of prostaglandins and leukotrienes in the menstrual fluid
Causes vasoconstriction in uterine vessels
Causes uterine contractions and pain

297
Q

Define dysmenorrhoea

A

Low anterior pelvic pain which occurs in association with menstruation

298
Q

Types of dysmenorrhoea

A

Primary

  • Occurs in young females with no pelvic pathology
  • Often begins 6-12 months after menarche
  • Pain begins with onset of period and lasts for 24-72 hours

Secondary

  • Occurs in association of pelvic pathology
  • Can precede period by several days and last for the whole period
  • May be associated with dyspareunia
299
Q

Aetiology of dysmenorrhoea

A 
Endometriosis
Adenomyosis
PID
Fibroids
Adhesions
Developmental abnormalities
IUD
300
Q

Adenomyosis

A

Invasion of myometrium with endometrial tissue
Causes inflammation, pain and adhesions
Chronic pelvic pain, dyspareunia and infertility

301
Q

Epidemiology of dysmenorrhoea

A

Very common, incidence unknown

RFs

  • Longer duration of periods
  • Early menarche
  • Smoking
  • Alcohol
  • Obesity
  • Depression

Severity decreases with age
Incidence decreases with childbirth

302
Q

Presentation of dysmenorrhoea

A

Pain is usually suprapubic, but may be felt in the lower back/ back of legs
May have pathological features: discharge, IMB or PCB, dyspareunia
Dyschezia/rectal pain - endometriosis

Hx features - age at menarche, cycle length, regularity, duration of period, timing of pain, smoking, sexual activity, obstetric and contraceptive history

303
Q

Investigations for dysmenorrhoea

A 
Speculum
High vaginal swab/chlamydia screen
Smear (if due)
Pelvic US/TV US
MRI
Laparoscopy
304
Q

Management of dysmenorrhoea

A 
Lifestyle - smoking cessation
TENS and locally applied heat
NSAIDs - all are equally effective
COCP
POP
Depo-medroxyprogesterone 
The above only if not trying to conceive

If trying to conceive then Danazol (only under specialist)
Surgery - laparoscopic uterine nerve ablation or hysterectomy (only in refractory)

305
Q

Aetiology of acute pelvic pain

A 
UTI
Miscarriage
Ectopic pregnancy
Torsion or rupture of ovarian cysts
PID
In late pregnancy - premature labour, placental abruption, uterine rupture 
Ovulation
Dysmenorrhoea
Degeneration of fibroid
Pelvic tumour
Pelvic vein thrombosis

Appendicitis, IBS, adhesions, prostatitis, strangulated hernia

306
Q

Pelvic vein thrombosis

A

Associated post partum or in malignancy
Pelvic pain
Fever
Abdominal mass

307
Q

Investigations in acute pelvic pain

A 
Urinalysis
MSU
High vaginal swab and endocervical swab
Pregnancy test
FBC
Urgent US - if ?ectopic or miscarriage
Laparoscopy (if severe)
308
Q

Define chronic pelvic pain

A

Intermittent or constant pain in lower abdomen for >6 months.
Does not occur exclusively with menstruation or sex
Not associated with pregnancy

309
Q

Aetiology of chronic pelvic pain

A 
Endometriosis
Adhesions
IBS
Interstitial cystitis
MSK
Pelvic organ prolapse
Nerve entrapment
Psychological and social issues  - depression, physical or sexual abuse as children
310
Q

Red flags for chronic pelvic pain

A 
Rectal bleeding 
New bowel symptoms in over 50s
New pain after menopause
Pelvic mass
Suicidal ideation
Excessive weight loss
Irregular vaginal bleeding in over 40s
PCB
311
Q

Investigations for chronic pelvic pain

A 
STI screen]
FBC, CRP
CA125 if ?ovarian Ca (new IBS >50 is suspicious)
Urinalysis and MSU
TV US
MRI if ?adenomyosis
Diagnostic laparoscopy is gold standard
312
Q

Management of chronic pelvic pain

A

Treat cause and psychological causes
Challenging as pain often continues after treatment without diagnosis
Treat underlying disorder
Most managed in primary care

If cyclical pain can use COCP or GnRH agonists or mirena

313
Q

Types of benign ovarian tumours

A

Functional (24%)
Benign (70%)
Malignant (6%)

Benign epithelial neoplastic cysts (60%)

  • Serous cystadenoma (40-50 years, papillary growths can appear solid, 20% malignant)
  • Mucinous cystadenoma (20-40 years - filled with mucinous material, become enormous, 5% malignant)

Benign neoplastic cystic tumours of germ cell origin
- Benign cystic teratoma (rarely malignancy, may contain well differentiated tissue, common in young women)

Benign neoplastic solid tumours

  • Fibroma (<1% malignant, small solid, benign fibrous tumours - associated with Meig’s syndrome and ascitets)
  • Thecoma
  • Adenofibroma
  • Brenner’s tumour
314
Q

Epidemiology of benign ovarian tumours

A

30% of females with regular periods
50% of females with irregular periods
Occur in premenopausal women
Uncommon pre-menarche and post-menopausal

RF

  • Obesity
  • Tamoxifen
  • Early menarche
  • Infertility
  • Dermoid can run in families
315
Q

Presentation of benign ovarian tumours

A

Asymptomatic

Dull ache or pain in lower abdomen/back
If rupture/torsion - severe abdominal pain and fever
Dyspareunia
Swollen abdomen, palpable mass
Pressure effects - urinary frequent, peripheral oedema

Torsion - severe pain, can be intermittent

Rupture - peritonitis, shock, mucinous cystadeomas can continue to secrete mucin causing build up and death (psudomyxoma peritonei)

Ascites

316
Q

Meig’s syndrome

A

Ascites
Pleural effusion
Benign ovarian tumour
(fibroma, fibrothecoma, Brenner tumour)

317
Q

Investigations for benign ovarian tumour

A 
Pregnancy test
FBC - infection, haemorrhage
Urinalysis
TV US
CT or MIR if US inconclusive
Diagnostic laparoscopy
CA125 (do not do if premenopausal with cyst on US) - it is not reliable in distinguishing malignant/benign in fertile women
LDH, AFP, beta - HCG for germ cell tumours
318
Q

Risk of malignancy index

A

For suspected ovarian cancer
Not to be used pre-menopausally
Uses CA125, menopausal status and US score

RMI = U x M x Ca125

US - 1 point each for: multilocular cysts, solid area, mets, ascites, bilateral lesions

RMI > 200 = CT abdo pelvis

319
Q

Management of benign ovarian tumours

A

<50mm, expectant management
50-70mm = yearly US follow up
>70mm = MRI/surgery

Do not use COCP
Laparoscopic removal
If torsion may need oophorectomy and uncoiling
Immediate surgery if haemorrhagic - more common in R ovary

320
Q

Epidemiology of dyspareunia

A

More common in women
9% of all women
Increase in 20s-30s and over 60s

RFs

  • Sexually inexperienced
  • peri or post-menopausal
321
Q

Presentation of dyspareunia

A

Superficial (felt at introits) OR deep (felt with thrusting and deep in pelvis)

tightening of vaginal muscles on penetration - vaginismus
When/where/duration
Is intercourse possible? Desired?
Any evidence of sexual abuse, rape or trauma
Any FGM
STI risk

322
Q

Aetiology of dyspareunia

A

Pain with arousal

  • Hymenal ring bands
  • Swelling of Bartholin’s gland cyst

Sensitive external genetalia

  • Vulvodynia
  • Chronic vulvitis - allergy, candida, herpes, trichomonas
  • Lichen planus/sclerosis

Pain at introitus on penetration

  • Painful episiotomy scar
  • rigidity of hymenal ring
  • Inadequate lubrication
  • atrophic vaginitis
  • vaginitis
  • vaginismus
  • insufficient foreplay
  • congenital abnormality

Mid vaginal pain

  • Acute/chronic cystitis
  • Urethritis
  • Shortened vagina

Deep pain

  • PID
  • Vaginiits
  • Cervicitis
  • Malposition of IUS/IUD
  • Endometrisosis/adenomysosis
  • Fibroids
  • Fixed retroverted uterus
  • IBS
  • IBD
  • Pelvic mass
  • Interstitial cystitis
323
Q

Investigations for dyspareunia

A

Swab for STIs
Urine dip &; MSU
US

324
Q

Types of incontinence

A 
Functional
Stress
Urge
Mixed
Overactive bladder syndrome
Overflow
True
325
Q

Functional incontinence

A

Patient is unable to reach the toilet in time e.g. poor mobility or unfamiliar surroundings

326
Q

Stress incontinence

A

Involuntary leakage of urine on effort or exertion e.g. sneezing or coughing.
Due to incompetent sphincter
May be associated with GU prolapse

327
Q

Urge incontinence

A

Involuntary urine leakage accompanied or preceded by urgency of micturition
Detrusor instability or hyper-reflexia leading to involuntary detrusor contraction
Idiopathic or neurological

328
Q

Mixed incontinence

A

Involuntary leakage associated with both urgency and exertion

329
Q

Overactive bladder syndrome

A

Urgency that occurs with or without urge incontinence and usually with frequency and nocturia

330
Q

Overflow incontinence

A

Usually due to chronic bladder outflow obstruction
e.g. prostatic disease
Can cause obstructive nephropathy

331
Q

True incontinence

A

Fistulous track between vagina and ureter or bladder and urethra.
Continuous urine leakage

332
Q

Epidemiology of incontinence

A 
Very common ~ 8%, up to 40%
Increase in females
Most common = stress incontinence
Increases with age
Increased if in institution

RFs

  • Pregnancy, vaginal delivery especially with forceps
  • Diabetes
  • Oral oestrogen therapy
  • Raised BMI
  • Hysterectomy (RF for stress)
  • Increased parity (RF for stress)
  • Frequent UTIs
  • Neurological disease - stroke, dementia, Parkinson’s
  • Cognitive impairment
333
Q

History features of incontinence

A

Leakage on sneezing, coughing, exercise, standing
Urgency
LUTS - dribbling, frequency, dysuria, incomplete emptying
Sexual dysfunction
Full obstetric history
Bladder chart

334
Q

Investigations for incontinence

A

Urine dipstick + MSU
Assessment of residual volume (bladder scan for post-void volume)
Urinary flow rates
Urodynamic studies

Refer

  • any haematuria
  • prolapse below introitus
  • neurological disease
  • persisting pain
  • faecal incontinence
335
Q

Management of incontinence

A

Temporary containment products only until specific diagnosis and management plan.

STRESS

  • Pelvic floor exercises for 3 months, 8 contractions TDA
  • Duloxetine
  • Retopubic mid-urethral tape
  • Colopsuspension
  • Autologous rectal fascial sling

MIXED

  • pelvic floor exercises and bladder taining
  • Oxybutinin (anitmuscarinic)
  • Annual review

OVERFLOW

  • relieve obstruction
  • intermittent self-catheterisation if persistent retention
  • botulinum toxin A
  • desmopressin if troublesome nocturia
336
Q

Define overactive bladder

A

Urgency
Often with frequency
Nocturia
Sometimes urge incontinence

Often associated with detrusor muscle over activity

337
Q

Epidemiology of overactive bladder

A

2nd most common cause of female urinary incontinence
Increases with age
Associated with Parkinson’s, spinal cord injury, diabetic neuropathy, MS, dementia, stroke

338
Q

Presentation of overactive bladder

A 
Sudden urge to urinate
Hard to delay
Frequency of micturition
Nocturia
Abdominal discomfort
Urge incontinence
339
Q

Management of overactive bladder

A

Lifestyle - decrease caffeine, increase fluid intake, lose weight if BMI > 30

Bladder tainting - 1st line, minimum of 6 weeks. Scheduled voiding, regular intervals, increasing time intervals

Drugs - anticholinergics (oxybutynin, propiverine)
Decreases involuntary contractions to increase bladder capacity
Intravaginal oestrogens in vaginal atrophy

Botulinum A toxin
Nerve stimulation - sacral nerve
Surgery - only for severe

340
Q

Epidemiology of faecal incontinence

A

Increased in women
3 per 100,000
Increases with age

RFs
diarrhoea
anal problems - obstetric injury, rectal or pelvic organ prolapse, pelvic radiotherapy
Urinary incontinence
Frail elderly patients 
Neuro problems/spinal disease
Vaginal delivery
Severe cognitive impairment
341
Q

Aetiology of faecal incontinence

A 
Child birth
Obstetric trauma
Anal surgery
Chronic anal fissure
Degeneration of smooth muscle in internal anal sphincter
Neurological disease
Dementia
Congenital disorders - Hirschprung's, spina bifida
Constipation
Rectal prolapse
IBD
342
Q

Management of faecal incontinence

A 
Treat underlying cause
Diet
Encourage bowel opening after a meal
Sitting or squatting to avoid straining
Antidiarrhoeal medications - loperamide or codeine

Continence produces
Skin care
Odour control

If faecal loading - clear bowel

Pelvic floor training
Bowel retraining
Electrical stimulation
Rectal irrigation

343
Q

Physiology of micturition

A

Pudendal nerve is under our control
- when activated causes contraction of external sphincter to contract

Hypogastric nerve (sympathetics)
- NA causes contraction of external sphincter

Sympathetics cause urinary retention
Parasympathetic causes voiding

Parasympathetic pelvic nerve causes detrusor contraction

Empty bladder

  • no stretching
  • slow impulse along sensory pelvic nerve
  • this activates hypogastric nerve
  • causes relaxation of detrusor

Full bladder

  • stretching
  • increasing fast signals to sacral region
  • bypass straight to pontine micturition centre
  • inhibits sympathetics (hypogastric nerve)
  • Relaxation of external sphincter - contracts detrusor
344
Q

Where in brainstem is micturition centre?

345
Q

Aetiology of vaginal discharge

A 
Physiological
- New born infants - from maternal oestrogens
- Reproductive age: normal
Low oestrogen = mucus thick and sticky
High oestrogen = mucus clearer, wetter
- Cervical ectopy and polyps
- Foreign bodies e.g. retained tampon
- Vulval dermatitis
- Erosive lichen planus
- Genital tract malignancy
- Fistulae

Infection

  • BV
  • Thrush. Candidiasis
  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Trichomonas vaginalis
346
Q

Presentation of vaginal discharge

A

BV - thin, profuse, fishy smelling. No soreness, no itch.
Candidiasis - thick, curd like, white, non-offensive. Vulval itch, soreness. Mild dyspareunia and dysuria.
Chlamydia - copious purulent discharge. Asymptomatic in 80%
Trichomonas - offensive, yellow discharge. profuse and frothy. Vulval itch, soreness, dysuria, abdo pain, superficial dyspareunia
Gonorrhoea - purulent vaginal discharge. asymptomatic in 50%

Retained foreign body - foul smelling seroanguinous discharge
Fistulae - foul or faeculent discharge

347
Q

Signs vaginal discharge is abnormal

A 
Discharge heavier than normal
Discharge thicker than normal
Pus like discharge
White and clumpy discharge
Grey/green/yellow/blood tinged
Foul smelling
Accompanied by itching, burning, rash or soreness
348
Q

Causes of vaginal discharge in pregnancy and consequences

A

BV - poor perinatal outcomes

Candida - No harm to foetus

Chlamydia - doesn’t affect pregnancy outcome but mother baby transmission can occur

  • opthlamia neonatorum 15-25%
  • pneumonitis 5-15%
349
Q

Investigations for vaginal discharge

A

If typical BV or candidia, can be treated without testing

STI screening and swabs

  • Vulvovaginal/ endocervical swabs
  • Urine chlamydia testing
  • Blood tests for HIV and syphilis

Vaginal pH testing
- BV pH>4.5

350
Q

Epidemiology of bacterial vaginosis

A

5-12% of normal population
30% undergoing termination of pregnancy
Increased in sexually active women

RFs

  • Sexual activity
  • New sexual partner
  • Other STIs
  • Increased in Afro-Caribbean
  • IUCD (copper)
  • Vaginal douching
  • Bubble baths
  • Receptive oral sex
  • Smoking

Protective

  • COCP
  • Condoms
  • Circumcised partner
351
Q

Aetiology of bacterial vaginosis

A

Overgrowth of anaerobic organisms

Most common - Gardnerella vaginalis, prevotella, mycoplasma hominis, mobiluncus

They replace the lactobacilli

Raised pH from 4.5 to 6 (becomes alkaline)

352
Q

Presentation of bacterial vaginosis

A

Offensive, fishy smelly discharge
No soreness or irritation
50% are asymptomatic

Thin wall of white discharge on vaginal walls

353
Q

Investigations for bacterial vaginosis

A

Amsel’s criteria (3+ of)

  • Homogenous offensive discharge
  • Microscopy - large numbers of bacilli “clue cells” on vaginal epithelial cells
  • pH>4.5
  • Fishy odour on adding 10% potassium hydroxide
  • Cannot use isolation of G. vaginalis as it is normal flora in 40%
    Often treated empirically

Examine and swab
Vaginal pH

354
Q

management of bacterial vaginosis

A

Avoid vaginal douching
Avoid shower gel and bubble bath
Do not need treatment if asymptomatic

Oral metronidazole +/- clindamycin

355
Q

Complications of bacterial vaginosis

A

Endometritis and PID
Increased risk of acquiring HIV and STIs
Late miscarriage, pre-term delivery, PROM, decreased birth weight
70% relapse in 3 months

356
Q

Chlamydia

A

Small, obligate, intracellular
Gram negative
Infected columnar and transitional epithelium

Can cause

  • Ocular infections
  • GU infections
  • Proctitis
  • Sexually acquired reactive arthritis
  • Lymphgranuloma venerum - STI tropical infection, genital ulcer and inguinal lymphadenopathy
357
Q

Epidemiology of GU chlamydia

A

Most common STI in UK
Most common preventable cause of infertility worldwide
Prevalence dependent on age
Increased in under 25s
Decreasing numbers presenting to screening

RFs

  • Age < 25
  • Sexual partner chlamydia positive
  • 2+ sexual partners in 1 year
  • Recent change in sexual partner
  • Non barrier contraception
  • Infection with another STI
  • decreased socio-economic status
358
Q

Presentation of chlamydia infection

A

Most cases are asymptomatic

Female

  • Vaginal discharge
  • Dysuria (sterile pyuria)
  • Lower abdominal pain
  • Fever
  • IMB, PCB
  • Deep dyspareunia

Male

  • Urethritis
  • Dysuria
  • Urthethral discharge
  • Epididymo-orchiditis
  • Fever

Reiter’s syndrome - urethritis, arthritis, conjunctivitis. Associated with HLAB27

Proctitis with mucopurulent discharge if anal chlamydia

359
Q

Signs of chlamydia infection

A

Female

  • Friable, inflamed cervix
  • Mucopurulent discharge
  • abdominal tenderness
  • adnexal tenderness
  • cervical excitation

Males

  • epididymal tenderness
  • mucopurulent discharge
  • perineal fullness
360
Q

Investigations for chlamydia

A

Samples for nucleic acid amplification tests (NAATs)
Vulvovaginal swabs
Can do endocervical swab or first catch urine
Opportunistic screening at GP

Test when

  • Symptoms suggest infection
  • Sexual partners of chlamydia positive patients
  • All sexually active under 25 annually or with change of partner
  • Termination of pregnancy
  • At GUM clinic
361
Q

Management of chlamydia

A

Antibiotics - doxyxyxline 100mg BD 7/7 or azithromycin 1g stat

Screen for other STIs

Partner notification

  • If asymptomatic: back to 6m
  • If symptomatic 4/52 before symptoms

No need to retest after treatment unless pregnant, persistent symptoms, non-compliant or re-exposed

362
Q

Complications of chlamydia infection

A 
PID
Female infertility
Ectopic pregnancy
Perihepatitis (Fitz-Hugh and Curtis syndrome)
Reactive arthritis (Reiter's syndrome)
363
Q

Gonorrhoea

A

Gram negative diplococcus
Infects mucus membranes
Transmission via direct inoculation of infected secretions - sexually or perinatally

364
Q

Epidemiology of gonorrhoea

A

Increasing prevalence
Most causes in homosexual men
Most diagnosed in GUM clinics
Increased in younger ages

RFs

  • History of previous STI
  • Co-existent STIs
  • New or multiple sexual partners
  • Recent sexual activity abroad
  • Inconsistent condom use
  • Anal intercourse and frequent insertive oral sex
  • Drug use or commercial sex work
365
Q

Presentation of gonorrhoea

A

Symptomatic in most men (90-95%)
Asymptomatic in 50% of women

Male

  • urethral discharge
  • dysuria
  • rectal infection (anal discharge)
  • pruritus
  • urthethral discharge

Female

  • discharge
  • abdominal pain
  • dysuria
  • rare cause of IMB
  • pelvic tenderness
  • mucopurulent discharge
366
Q

Investigations for gonorrhoea

A

Culture - for resistant strains
NAAT - urine or urthethral swabs
Vulvovaginal swab is superior in women

367
Q

Management of gonorrhoea

A

Check for other STIs
Partner notification
Ceftriaxone 500mg IM stat + azithromycin 1g stat
Resistance is an ongoing issue

368
Q

Complications of gonorrhoea

A

male - urethral scarring and stricture (BOO), acute epididymitis, prostatitis, peri-urethral abscess

Female
PID
Infetrilty
Peri-hepatitis (Fitz-Hugh Curtis syndrome)
Bartholin's abscess 
Ectopic pregnancy
Premature labour
miscarriage

Can have haematogenous dissemination <1%
Skin lesions, Reiter’s syndrome, arthralgia, meningitis, endocarditis

369
Q

Trichomonas vaginalis

A 
Flagellated protozoan
Most curable STI worldwide
Urethral infection in 90% 
Most are women
Underdiagnosed and undertreated
370
Q

Presentation of trichomonas vaginalis

A

FEMALE

  • vaginal discharge, frothy and yellow
  • Vulval itching
  • dysuria
  • offensive odour
  • lower abdominal discomfort
  • cervicitis
  • 10-50% have no symptoms
  • 5-15% have normal exam

MALE

  • usually asymptomatic
  • dysuria
  • urethral discharge
  • most have no signs
371
Q

Investigations for trichomonas vaginalis

A 
High vaginal swab
Refer to GUM clinic
Wet microscopy
Test for other STIs
Urethral culture or urine culture 
NAATs are being gold standard
372
Q

Management of trichomonas vaginalis

A

Treat both partners at the same time
Avoid sex 7/7 post-treatment
Metronidazole 2g stat

373
Q

Complications of trichomonas vaginalis

A 
Pre term delivery
Low birth weight
Increased maternal post partum sepsis
Prostatis in men
Persistent and recurrent infections
374
Q

Epidemiology of HIV

A 
6000 new UK diagnoses per year
Increased in males
Increased in men who have sex with men (MSM)
Increased in Blacks
Increased if born abroad
375
Q

Stages of HIV infection

A 
Seroconversion illness
Asymptomatic infection
Persistent generalised lymphadenopathy
Symptomatic infection
AIDS
376
Q

Seroconversion illness in HIV

A 
1-6 weeks post infection
20-60% present at this time
Glandular fever like illness
Fever, malaise, myalgia, headaches, diarrhoea, lymphadenopathy, maculopapular rash
Viral p24 antigen positive
High HIV RNA levels
Antibody tests negative
377
Q

Persistent generalised lymphadenopathy in HIV

A

Nodes>1cm in diameter at 2 extra inguinal sites

Persists for longer than 3 months

378
Q

Symptomatic HIV infection

A

Non specific constitutional symptoms - fever, night sweats, diarrhoea, weight loss

Minor opportunistic infections: oral candida, herpes zoster, recurrent herpes simplex, seborrheic dermatitis
- Prodrome to AIDS

379
Q

Investigations for HIV

A

anti-HIV IgG antibody tests (not reliable in under 18m old)
HIV DNA PCR and virus culture

In acute infection will be p24 positive
IgG and IgM to HIV

4 weeks to get test results back
HIV counselling before and after testing

380
Q

Staging of HIV

A

CD4 grade

  1. CD4 > 500 cells/mm3 or 29%
  2. CD4 200-499 cells/mm3 or 14-28%
  3. CD4<200 cells/mm3 or <14%

Clinical grade
A. Documented HIV infection. Asymptomatic or persistent lymphadenopathy
B.. Symptomatic but no category C conditions
C. AIDs indicator condition. Cannot move out of category C

Receive both clinical and CD4 grading
Clinical Grade

381
Q

AIDS defining conditions

A 
Candidiasis - lung/trachea/oesophagus
Invasive cervical carcinoma
Coccidiodomycosis. Crytococcosis. 
CMV (not liver or spleen)
Encephalopathy
Herpes simplex
Histoplasmosis
Kaposi's sarcoma
Lymphoma - Burkitt's, primary brain or immunoblastic
TB
Pneumocystis jirovecci
Recurrent pneumonia
Progressive multifocal leukoencephalopathy
Toxoplasmosis of brain
Wasting syndrome due to HIV
382
Q

Management of HIV

A

Support
Anti retroviral therapy for all patients
HAART - combination of 3 drugs to decrease resistance
Efaurenz + tenofovir + lamivudine

Chemoprophylaxis to prevent infection

383
Q

Preventing spread of HIV

A 
Promote lifelong safer sex
Barrier contraception
Decrease number of partners
Condom program in brothels
Warn heterosexuals the dangers of sex tourism
Treat other STIs
Don't share needle - needle exchange programs
Decrease unnecessary blood transfusions
Encourage HIV tests in pregnancy
Pre-exposure prophylaxis in high risk
384
Q

Karposi’s sarcoma

A

Multiple echhymotic skin nodules, macules or papules.
Skin or mucosal surfaces
Can have visceral disease e.g. lungs and GIT

385
Q

HIV encephalopathy

A 
Brain involved in most late HIV
Decreased concentration and memory
Gradual decrease in intellect
Increased motor problems and weakness
Hyper-reflexia
Extensor plantars
386
Q

Aetiology of anogenital warts

A

HPV infection
Sexually transmitted
60% transmission rate between partners
95% caused by HPV 6 or 11

387
Q

Epidemiology of anogenital warts

A

Most common viral STI
Numbers should decrease with HPV vaccination
35% of those being screened for chlamydia

RF
Smoking
Multiple sexual partners
Early age of first intercourse
History of other STIs
Anoreceptive intercourse
Immunosuppression
388
Q

Symptoms of anogenital warts

A

Painless lesions
Can be disfiguring or embarrassing
Can cause itching, bleeding or dyspareunia
Urethral lesions may distort urinary stream
Pelvic or scrotal pain

389
Q

Signs of anogenital warts

A 
Often multiple lesions
Can become confluent (huge in immunocompromised)
Can be keratinsed or non-keratinised
May be broad based or pedunculated
may be pigmented

In women on: labia, clitoris, urethral meaturs, introitus, vagina or cervix
Men - frenulum, corona, glans penis, shaft, scrotum, urethral meatus
both - perineum, groin, pubic, perianal area, anal canal

390
Q

Investigations for anogenital warts

A

Biopsy and viral typing not usually required

Only biopsy if anything suspicious e.g. over 35 with minimal risk factors

391
Q

Diseases associated with anogenital warts

A

cervical cancer
Vaginal, penile and vulval cancer
Anal cancer
Oral and oropharyngeal cancer

392
Q

Management of anogenital wards

A

Explain long term latency - does not mean infidelity
Advise condom use until resolved
Advise HPV persists long after warts
20% have concurrent STIs = SCREEN

Assess current and past partners - last 6 months
Non-smokers have better response to treatment

No treatment, 1/3 regress spontaneously in 6 months
Podaphylotoxin cream or imiquimod 5%

Can use ablation. cryotherapy or excision if resistant
Treatments cause itching, burning, pain.
Recurrence occurs after all treatmetns.

393
Q

Herpes Simplex

A

HSV Type 1- usual cause of cold sores. Now most common cause of genital herpes

HSV type 2 - causes genital infection.

transmission:
Contact with infected secretion
Close contact
Vaginal, anal and oral sex

394
Q

Cause of genital herpes

A

Herpes simplex - type 1 and 2

395
Q

Epidemiology of herpes simplex

A 
7% of new STIs
Numbers are increasing
Highest in 15-24s
Lifelong disease
80% are not aware they have it
20% of population
Rf
Sexual promiscuity
Previous history of STIs
Early age of first intercourse
MSM
HIV infection
Females
396
Q

Presentation of herpes simplex

A 
Primary infection
Commonly asymptomatic
Febrile flu like prodrome 5-7 days
Myalgia. Fever
Tingling neuropathic pain in genital area
Extensive painful crops of blisters/ulcers in genital area
Usually bilateral
Tender inguinal lymph nodes
Dysuria/ Vaginal or urethral discharge
Secondary infection
After latency, reactivation
Episodes are shorter e.g. 10 days
Mild and self-limiting
Lesions unilateral

HSV type 1 less recurrence (1/year) 2 = 4 per year

397
Q

Investigations for herpes simplex

A

Viral culture
DNA detection using PCRR
Serology testing - takes 12 weeks

398
Q

Management of herpes simplex

A

Refer to GUM clinic
Swab
Supportive management
Saline bathing
Oral analgesia
Topical lidocaine
Micturation sitting in bath to prevent urinary retention
Increase fluid intake to dilute urine to decrease pain
Antivirals not recommended unless within 5 days, aciclovir

399
Q

Complications of herpes simplex infection

A 
Autonomic neuropathy e.g. urinary retention
aseptic meningitis
Spread to extra-genital areas
2y infection with candida or strep
Perinatal transmission
psychological or psychosexual problems

Year 4 (7 decks)

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