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Phase 3A > Women's health > Flashcards

Women's health Flashcards

1
Q

What is the APGAR scoring system?

A

Assessment performed at 1 minute (determine how well baby tolerated birthing process + need for resuscitation) + 5 minutes (how well baby doing outside womb)

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2
Q

What does APGAR stand for?

A 
A: appearance
P: pulse
G: grimace (reflex irritability)
A: activity (muscle tone)
R: respiration
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3
Q

What Apgar Score would indicate a need for immediate resuscitation?

A

3 or less

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4
Q

A female PT presents with an abdominal mass, what are the differential diagnosis?

A 
Uterine fibroids 
Gynaecological malignancy
Ovarian cyst
Tubo-ovarian abscess
Pregnancy
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5
Q

What are uterine fibroids?

A

Benign, hormone-sensitive smooth muscle tumour of uterus.

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6
Q

State 2 RFs for fibroids

A

Early menarche/late menopause
Nulliparity
Age (25-45yo)

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7
Q

Give 3 clinical features of a woman presenting with fibroids

A

Abdominal mass (if big)
Pelvic pain
Menorrhagia
Infertility

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8
Q

What are the different types of fibroids?

A
  1. Submucosal
  2. Subserosal
  3. Intramural
  4. Diffuse
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9
Q

What is the gold-standard investigation for fibroids?

A

TVUS

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10
Q

How do you treat asymptomatic fibroids?

A

Do not treat, will shrink after menopause as hormone dependent

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11
Q

State 3 pharmacological interventions for fibroids

A

COCP/LNG-IUS
Trans-examic acid
GnRH agonist (Goserelin)
Ulipristal acetate

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12
Q

State 3 surgical interventions for fibroids

A

Myomectomy: excision of fibroids from uterus
Total hysterectomy: if family complete
UAE

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13
Q

What is pelvic inflammatory disease?

A

Infection + inflammation of upper female genital tract

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14
Q

Give 3 risk factors for PID

A 
New/multiple sexual partners
Women < 25yo
Previous STIs 
Abortion
Lower socioeconomic group
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15
Q

What is the main cause of PID?

A

Ascending bacterial infection from cervix e.g. STI, instrumentation or postpartum

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16
Q

How do PID PTs often present?

A

Often asymptomatic, have high index of clinical suspicion as other symptoms non-specific

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17
Q

When should you suspect PID?

A

Young, sexually active women with lower abdominal pain and cervical excitation

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18
Q

What is the main clinical sign of PID?

A

Cervical excitation/adnexal tenderness

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19
Q

What investigations might you perform in PT with pelvic pain and suspected PID?

A

B-HCG pregnancy test
TVUS: rule out ovarian cyst
FBC/CRP: show inflammation
ENDOCERVICAL SWABS: show STI, support diagnosis

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20
Q

What is basis of management go PID?

A

Suspect PID–> Do not delay ANTIBIOTIC treatment

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21
Q

What should you do it suspected PID PT does not respond to treatment?

A

Explorative laparoscopy

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22
Q

How should you treat a mild-moderate case of suspected PID?

A

Outpatient: IM STAT Ceftriaxone, followed by PO DOXYCYCLINE + METRONIDAZOLE

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23
Q

Give 4 possible complications of PID

A

INFERTILITY
CHRONIC PELVIC PAIN
ECTOPIC PREGNANCY
TUBO-OVARAIN ABSCESS

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24
Q

How should you treat severe case of PID?

A

ADMIT PT
IV Ceftriaxone + Doxycycline
PO Doxycycline + Metronidazole

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25
Q

How might a symptomatic PID PT present?

A

Abdominal pain (typically bilateral)
Deep dyspareunia
Abnormal vaginal bleeding
Vaginal discharge

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26
Q

What is endometriosis?

A

Presence of endometrial tissue outside the uterus

Inc. ovaries, utero-sacral ligaments, pouch of Douglas, rectum, bladder

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27
Q

Give 3 risk factors for endometriosis

A

Nulliparity
Early menarche/late menopause
FH
Obstruction to urethral outflow (FGM)

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28
Q

Who does endometriosis tend to affect?

A

Women of reproductive age (20-40yo)

Symptoms tend to settle after menopause as oestrogen levels drop (oestrogen drives endometrial cell production)

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29
Q

Give a brief overview of the pathology behind endometriosis

A

Endometrial cells have oestrogen receptors
Receptors respond to oestrogen to undergo proliferation and secretion during menstrual cycle
Endometrial cells produce pro-inflammatory factors increasing inflammation and scarring–> Adhesions

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30
Q

How does endometriosis often present?

A

Asymptomatic (incidental finding)

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31
Q

Give 3 symptoms of endometriosis

A

Chronic pelvic pain (worsens before menses)
Deep dyspareunia
Dysmenorrhagia
Sub-fertility (adhesions make implantation hard)
Dyschezia: pain on passing stool during menses
Urgency/frequency/dysuria: bladder affected

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32
Q

What is the classic examination sign of endometriosis?

A

Fixed, retro-verted uterus +/-adnexal tenderness

If not present, do not exclude endometriosis

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33
Q

What is the gold-standard investigation for endometriosis?

A

Laparoscopy + biopsy

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34
Q

What other investigations may be useful in a PT with suspected endometriosis?

A

TVUS: rule out ovarian accident, may also indicate endometriotic cyst
MRI: differentiate adenomyosis, inform bowel involvement

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35
Q

If a PT has suspected endometriosis but is asymptomatic, how should you manage them?

A

No treatment

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36
Q

If a PT is experiencing pain from endometriosis, how should you manage them?

A

Pain relief: NSAIDs +/- paracetamol
Hormonal management: COCP/progestogen only/LNG-IUS (these mimic pregnancy + suppress ovarian function), not suitable in woman trying to conceive

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37
Q

What are the surgical options in a woman with endometriosis?

A
  1. Laser ablation/ laparoscopic excision of endometrial tissue- improves conception, preferable if sub fertility is issue
  2. Hysterectomy + oophorectomy: last resort if other treatment fails + family complete
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38
Q

What is an ectopic pregnancy?

A

Pregnancy whereby embryo implants outside uterus

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39
Q

State the most common site of ectopic pregnancy

A

Fallopian tubes (ampulla> isthmus>timbre)- 95% ectopic pregnancies occur here

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40
Q

Give 4 risk factors for ectopic pregnancy

A

Anatomical alterations of Fallopian tube

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41
Q

State 3 common symptoms of ectopic pregnancy

A
  1. Pelvic/abdominal pain: non-specific, unilateral
  2. Amenorrhoea
  3. Vaginal bleeding
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42
Q

Give 3 indications that an ectopic pregnancy has ruptured

A
  1. Severe, sudden abdominal pain
  2. Profuse bleeding (into pelvis)
  3. Hypovolaemic shock: tachycardia, hypotension, syncope
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43
Q

Give more non-specific symptoms of ectopic pregnancy

A

Dizziness/syncope
Shoulder tip pain (haematoperitoneum)
Breast tenderness/ frequent urination (signs of pregnancy)
Diarrhoea & vomiting

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44
Q

What investigation should you do in all women of reproductive age with pain, bleeding or collapse?

A

Urine Beta- HCG pregnancy test

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45
Q

What other investigations would you do if there was a suspected ectopic pregnancy?

A

TVUS: will show intrauterine pregnancy, empty uterine cavity + thickened endometrial lining may indicate EP
Serum hCG: if declining suggests ectopic or non-viable IU pregnancy
Serum progesterone: decrease indicates failing pregnancy

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46
Q

How should you manage a pregnancy of unknown location?

A

Laparoscopy

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47
Q

How should you initially manage suspected ectopic pregnancy?

A

Emergency admission
ABCD
IV access, cross-match and anti-D for rhesus -ve mum

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48
Q

What are the different management options for ectopic pregnancy?

A

Expectant: allow to resolve naturally
Medical
Surgical

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49
Q

What is the criteria for expectant/medical management?

A

Asymptomatic/mild symps
Serum hCG <3000
Ectopic pregnancy <3cm on scan (no foetal heart activity)
No haemoperitoneum on TVUS
Understand diagnosis/risks of EP
Continue to monitor hCG if take expectant approach

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50
Q

Describe the medical management of ectopic pregnancy

A

Methotrexate (single dose)

Monitor hCG levels, if fallen by <15% by day 7 repeat methotrexate dose

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51
Q

What are the surgical options for ectopic pregnancy?

A

Salpingotomy: removal of part of tube containing EP
Salpingectomy: removal of entire Fallopian tube containing EP

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52
Q

What surgical procedure would you perform in ectopic pregnancy in woman with contralateral healthy tube?

A

Salpingectomy

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53
Q

What surgical procedure would you perform in ectopic pregnancy in woman with unhealthy contralateral tube?

A

Salpingotomy, to preserve possibility of IU pregnancy

54
Q

What is cervical cancer?

A

Malignancy of the cervix

Most commonly a squamous cell carcinoma

55
Q

What area of the cervix is susceptible to malignant change?

A

Squamo-columnar junction: transitional zone between endometriosis + ectopic-cervix

56
Q

What are the 2 peaks of incidence of cervical cancer?

A
  1. 30-39yo

2. >70yo

57
Q

What does CIN stand for? What is it?

A

Cervical intraepithelial Neoplasm

Pre-invasive phase to cervical cancer

58
Q

State 3 risk factors for CIN/cervical cancer

A 
HPV infection (16 + 18 )- multiple sexual partners/not using barrier contraception
Non-attendance to screening
Immunosuppression
Smoking
COCP (reduced barrier methods)
59
Q

What is the most common symptom of cervical cancer?

A

Abnormal vaginal bleeding

60
Q

State some other symptoms of cervical cancer

A

Abnormal vaginal bleeding
Vaginal discharge: mucoid/blood-tinged, malodorous
Vaginal discomfort

61
Q

What are some of the late clinical features of cervical cancer?

A 
Pelvic pain
Ureteric obstruction
Fistulas
Leg oedema
Bowel disturbance
Haematuria/ rectal bleeding
62
Q

What features of an examination may indicate cervical cancer?

A

BVE: cervix rough/hard, advanced disease there may be loss of fornices
Speculum: cervix appears inflamed, mass, bleed on contact
Visible ulcerating lesion or foul-smelling discharge

63
Q

What is the purpose of cervical screening?

A

Detect pre-invasive phase (CIN) of cervical cancer

64
Q

What is the likely plan for a PT with mild changes to their cervical cells?

A

HPV status tested

  • HPV +ve–> Colposcopy
  • HPV -ve–> No colposcopy, 3 yearly screening
65
Q

What is the likely plan for a PT with mod-severe changes to cervical cells?

A

Colposcopy regardless of HPV status

66
Q

What other investigations might you perform in suspected cervical cancer?

A 
FBC/U&amp;Es/LFTs
CT/MRI pelvis + abdomen (staging)
Punch biopsy (histology)
67
Q

What must you consider in management of cervical cancer?

A

Cervical cancer often affects women of child-bearing age- must consider fertility sparing in treatment

68
Q

If a cervical cancer is micro- invasive, what treatment would you perform?

A 
Cone biopsy (fertility sparing)
Hysterectomy (older man)
69
Q

In early stage disease (stage 1 + 2), what surgical procedure would be recommended in those women trying to maintain fertility?

A

Radical trachelectomy: removal of cervix/upper vagina

70
Q

If cervical cancer is locally advanced (stage 2 + 3), how would you manage this PT?

A

Chemoradiation

71
Q

Cervical cancer has metastasised to distant organs, how would you manage the PT?

A

Palliative care including chemotherapy e.g. to control bleeding

72
Q

What investigations must you always do in a woman who presents with menorrhagia?

A

FBC to check Hb level, risk of Fe2+ deficient anaemia

73
Q

Give some differential diagnosis of uterine fibroids

A

Ovarian cyst/tumour
Adenomyosis
Pregnancy
Ectopic pregnancy

74
Q

What is menorrhagia?

A

Heavy menstrual bleeding
Affects physical, emotional + social QofL
>80ml +/or >7 days bleeding

75
Q

What are the two most common causes of menorrhagia?

A 
Uterine fibroids (30%)
Endometrial polyps (10%)
76
Q

State some causes, other than fibroids + polyps, that can cause menorrhagia?

A

Chronic pelvic infection e.g. chlamydia
Ovarian, cervical + endometrial Ca.
Miscarriage
Systemic: hypothyroidism, coagulation disorders
Iatrogenic: anti-coagulation, chemotherapy

77
Q

What investigations would you consider performing in menorrhagia?

A

FBC: always in HMB, risk of Fe2+ deficient anaemia
Triple swab: if suspect pelvic infection e.g. chlamydia
TVUS: rule out masses e.g. cancer, fibroids, polyps
Endometrial biopsy + hysteroscopy

78
Q

What are the indications for an endometrial biopsy?

A

Endometrial thickness >10mm in pre-menopausal, >4mm in post-menopausal
>40yo + menorrhagia or IMB
No response to treatment
High risk endometrial Ca. e.g. Tamoxifen treatment

79
Q

What treatment can pre-dispose women to endometrial polyps?

A

Tamoxifen treatment for breast Ca.

80
Q

State 3 risk factors for endometrial polyps

A 
Increasing age
HRT
Tamoxifen treatment
Obesity 
Hypertension
81
Q

Give some symptoms a PT with endometrial polyps might present with

A 
Asymptomatic 
Menorrhagia
PMB
IMB
Infertility
82
Q

State 2 differential diagnosis of endometrial polyps

A

Endometrial cancer

Uterine fibroid

83
Q

What investigations would you do in a PT with a suspected endometrial polyp?

A

TVUS: visualise polyp

+ Biopsy/hysteroscopy to rule out malignancy

84
Q

How should you manage an asymptomatic polyp?

A

Watchful waiting/observation, alter modifiable RFs including HRT/obesity

85
Q

What is the recommended management of an endometrial polyp, particularly if it is causing symptoms?

A

Hysteroscopy + resection of polyp with cutting diathermy

86
Q

What is a miscarriage?

A

Loss of a pregnancy before 24wks gestation

87
Q

When do majority of miscarriages occur?

A

1st trimester

88
Q

Give some causes of miscarriage

A

Feto-placental: chromosomal abnormalities [50%], abnormal foetal development
Maternal: uterine fibroids/adhesions, PCOS, septate uterus, systemic disease
Other: trauma, iatrogenic, drugs/smoking

89
Q

State 3 risk factors for miscarriage

A 
Advanced maternal age (>35yo)
Advanced paternal age (>45yo)
Smoking/alcohol abuse 
Uterine abnormalities 
Connective tissue disorders
90
Q

What is the definition of a recurrent miscarriage?

A

3 or more miscarriages in succession

91
Q

What is the most common cause of recurrent miscarriage?

A

Anti-phospholipid syndrome

92
Q

What is a threatened miscarriage? State some of the presenting features

A 
Mild vaginal bleeding but foetus still alive
Little/no pain
Uterus is size from expected dates
Cervical os closed
75% settle, 25% miscarry
93
Q

What is an inevitable miscarriage?

A

Miscarriage is about to occur
Heavier vaginal bleeding + visible clots
Foetal activity may or may not be present
Cervical os open

94
Q

What is an incomplete miscarriage?

A

Vaginal bleeding with products of conception partially expelled, not all foetal products have been passed

95
Q

What is an incomplete miscarriage?

A

Vaginal bleeding with products of conception partially expelled, not all foetal products have been passed
Cervical os usually open

96
Q

What is complete miscarriage?

A

All foetal tissue has been passed
Bleeding stopped + foetus no longer enlarged
Cervical os closed

97
Q

What is a missed miscarriage?

A

Foetus has not developed or has died in utero
Not recognised until bleeding occurs or incidental USS
Uterus smaller than expected for dates
Cervical os closed

98
Q

What are the main clinical symptoms for miscarriage?

A 
Vaginal bleeding (passing products of conception)
Abdominal pain: lower, cramping, intermittent, period like pain
99
Q

In a suspected miscarriage, state some important parts of the examination

A

Uterine size
Cervical os open vs closed
Tenderness [unusual]

100
Q

What investigations would you carry out in a suspected miscarriage PT?

A 
FBC: check for Fe2+ deficient anaemia from bleeding
Rhesus group
Urine B-hCG pregnancy test
Serum hCG
TVUS + doppler
101
Q

What is the main tool used to assess foetal wellbeing?

A

USS + doppler

102
Q

What are the potential outcomes if the gestational sac diameter is <25mm on TVUS?

A

Miscarriage or early intrauterine pregnancy

Rescan in 1wk

103
Q

What are the potential outcomes if gestational sac diameter is >25mm, without a foetal pole?

A

Miscarriage, by this size there should be a foetal pole

Rescan in 1wk

104
Q

What are the possible outcomes if a foetal pole is seen and the crown rump length is >7mm, with no heartbeat?

A

Miscarriage, heartbeat should be visible at this size

105
Q

What are the possible outcomes if a foetal pole is seen but the crown rump length is <7mm, with no heartbeat?

A

Miscarriage or early intrauterine pregnancy

Rescan 1wk

106
Q

What should you do if you cannot see an intrauterine pregnancy?

A

Treat as pregnancy of unknown location (PUL)

Perform serum b-hCG

107
Q

State 3 differential diagnosis of a miscarriage

A 
RULE OUT ECTOPIC PREGNANCY
Implantation bleeding
Cervical ectropion 
Polyps
Malignancy
108
Q

How might you manage a case whereby there is incomplete evacuation of products of conception?

A

Speculum examination + sponge forces removal of contents

109
Q

What medication might you give to a mother who is experiencing severe bleeding (suspect miscarriage)?

A

IM ERGOMETRINE

110
Q

What is the conservative/expectant approach to miscarriage? When would this be appropriate?

A

Waiting to see if miscarriage resolves naturally without intervention
1st line if incomplete or missed miscarriage
Do when PT happy to comply, no complications

111
Q

In what circumstances might you consider medical or surgical management of miscarriage?

A
  1. Increased risk of haemorrhage (late 1st trimester)
  2. Previous traumatic experience with pregnancy
  3. Increased risk of effects from haemorrhage (clotting disorder)
  4. Infection
112
Q

Was is the medical management of miscarriage?

A

Misoprostol +/- Mifepristine

113
Q

How does Misoprostol work in the management of miscarriage?

A

Misoprostol = prostaglandin that increases cervical ripening and stimulates uterine expulsion of products of conception

114
Q

What is the surgical management of miscarriage?

A

Vacuum aspiration [LA]

Laparoscopy [GA]

115
Q

State 3 possible complications of miscarriage

A

Surgery–> Asherman’s syndrome
Septic miscarriage
Systemic infection

116
Q

What is androgen-insensitivity syndrome?

A

Disorder of sexual development whereby X-linked mutation in androgen receptors–> End-organ insensitivity to androgens

117
Q

What is the karyotype for androgen insensitivity syndrome?

A

46XY- PT genetically male

118
Q

What is Turner’s syndrome?

A

Disorder of sexual development whereby there is loss of one X chromosome resulting in gonadel dysgenesis

119
Q

What is the karyotype for Turner’s syndrome?

A

45XO- PT genetically and phenotypically female

120
Q

What is the result of gonadel dysgenesis seen in Turner’s syndrome?

A

Decreased production of oestrogen + progesterone–> Primary amenorrhoea, delayed puberty + infertility

121
Q

Give 4 clinical features of a PT with Turner’s syndrome

A 
Primary amenorrhoea
Delayed puberty
Infertility
Short stature
Broad-chest + wide-spaced nipples
Short fingers
High-arched palate
122
Q

Give 3 other clinical associations with Turner’s syndrome

A

Cardio: aortic dissection, hypertension, BAV, Coarctation of aorta
Kidney malformations e.g. horseshoe kidney, more prone to infections
AI: increased susceptibility to Crohn’s, thyroiditis
Osteoporosis

123
Q

What is the best way to diagnose Turner’s syndrome?

A

Karyotyping

Bloods would also show decreased oestrogens/androgens

124
Q

What other investigations might you perform on a PT with Turner’s syndrome

A

Cardio monitoring: ECG, ECHO + MRI

Renal USS

125
Q

How would you manage a PT with suspected Turner’s syndrome?

A 
No cure, genetic problem
Growth hormone- short stature
Oestrogen/progesterone- regular periods
IVF- infertility
Psychological support: appearance, infertility
126
Q

What is the pathophysiology behind androgen-insensitivity syndrome?

A
  1. Testes (undescended) still produce testosterone
  2. Mutation in androgen hormone receptor
  3. End-organ insensitivity to testosterone
  4. External genitalia female/ambiguous + well-developed breasts
127
Q

What is the risk with cryptorchidism?

A

Risk of testicular cancer

Problem in AIS

128
Q

State the two types of androgen insensitivity

A
  1. Complete: testosterone no effect on sexual development. Genitals entirely female
  2. Partial: testosterone some effect on sexual development. Genitals mix of female + male
129
Q

What is the classic presentation of androgen insensitivity syndrome?

A

Adolescence/young woman with PRIMARY AMENORRHOEA, FERTILITY PROBLEMS OR DIFFICULTY HAVING SEX

130
Q

If you performed an USS scan of an individual with complete androgen insensitivity syndrome, what would you expect to see?

A
  1. Absent uterus/ovaries: blind-ended vaginal pouch

2. Undescended testes

131
Q

How might you investigate a PT with suspected androgen-insensitivity syndrome?

A

Karyotyping (46XY)
Genetic testing
Bloods: raised testosterone level
USS: absent uterus/ovaries, undescended testes

132
Q

How would you manage a PT with androgen-insensitivity syndrome?

A

Depends on phenotype + gender identity
Counselling + psychological therapy
Surgery: removal of undescended testes, make PT more male or female depending on preference
Hormone treatment: oestrogen or testosterone depending on preference

Phase 3A (3 decks)

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