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)
2
Q
What does APGAR stand for?
A
A: appearance P: pulse G: grimace (reflex irritability) A: activity (muscle tone) R: respiration
3
Q
What Apgar Score would indicate a need for immediate resuscitation?
A
3 or less
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
5
Q
What are uterine fibroids?
A
Benign, hormone-sensitive smooth muscle tumour of uterus.
6
Q
State 2 RFs for fibroids
A
Early menarche/late menopause
Nulliparity
Age (25-45yo)
7
Q
Give 3 clinical features of a woman presenting with fibroids
A
Abdominal mass (if big)
Pelvic pain
Menorrhagia
Infertility
8
Q
What are the different types of fibroids?
A
- Submucosal
- Subserosal
- Intramural
- Diffuse
9
Q
What is the gold-standard investigation for fibroids?
A
TVUS
10
Q
How do you treat asymptomatic fibroids?
A
Do not treat, will shrink after menopause as hormone dependent
11
Q
State 3 pharmacological interventions for fibroids
A
COCP/LNG-IUS
Trans-examic acid
GnRH agonist (Goserelin)
Ulipristal acetate
12
Q
State 3 surgical interventions for fibroids
A
Myomectomy: excision of fibroids from uterus
Total hysterectomy: if family complete
UAE
13
Q
What is pelvic inflammatory disease?
A
Infection + inflammation of upper female genital tract
14
Q
Give 3 risk factors for PID
A
New/multiple sexual partners Women < 25yo Previous STIs Abortion Lower socioeconomic group
15
Q
What is the main cause of PID?
A
Ascending bacterial infection from cervix e.g. STI, instrumentation or postpartum
16
Q
How do PID PTs often present?
A
Often asymptomatic, have high index of clinical suspicion as other symptoms non-specific
17
Q
When should you suspect PID?
A
Young, sexually active women with lower abdominal pain and cervical excitation
18
Q
What is the main clinical sign of PID?
A
Cervical excitation/adnexal tenderness
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
20
Q
What is basis of management go PID?
A
Suspect PID–> Do not delay ANTIBIOTIC treatment
21
Q
What should you do it suspected PID PT does not respond to treatment?
A
Explorative laparoscopy
22
Q
How should you treat a mild-moderate case of suspected PID?
A
Outpatient: IM STAT Ceftriaxone, followed by PO DOXYCYCLINE + METRONIDAZOLE
23
Q
Give 4 possible complications of PID
A
INFERTILITY
CHRONIC PELVIC PAIN
ECTOPIC PREGNANCY
TUBO-OVARAIN ABSCESS
24
Q
How should you treat severe case of PID?
A
ADMIT PT
IV Ceftriaxone + Doxycycline
PO Doxycycline + Metronidazole
25
How might a symptomatic PID PT present?
Abdominal pain (typically bilateral)
Deep dyspareunia
Abnormal vaginal bleeding
Vaginal discharge
26
What is endometriosis?
Presence of endometrial tissue outside the uterus
| Inc. ovaries, utero-sacral ligaments, pouch of Douglas, rectum, bladder
27
Give 3 risk factors for endometriosis
Nulliparity
Early menarche/late menopause
FH
Obstruction to urethral outflow (FGM)
28
Who does endometriosis tend to affect?
Women of reproductive age (20-40yo)
| Symptoms tend to settle after menopause as oestrogen levels drop (oestrogen drives endometrial cell production)
29
Give a brief overview of the pathology behind endometriosis
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
30
How does endometriosis often present?
Asymptomatic (incidental finding)
31
Give 3 symptoms of endometriosis
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
32
What is the classic examination sign of endometriosis?
Fixed, retro-verted uterus +/-adnexal tenderness
| If not present, do not exclude endometriosis
33
What is the gold-standard investigation for endometriosis?
Laparoscopy + biopsy
34
What other investigations may be useful in a PT with suspected endometriosis?
TVUS: rule out ovarian accident, may also indicate endometriotic cyst
MRI: differentiate adenomyosis, inform bowel involvement
35
If a PT has suspected endometriosis but is asymptomatic, how should you manage them?
No treatment
36
If a PT is experiencing pain from endometriosis, how should you manage them?
Pain relief: NSAIDs +/- paracetamol
Hormonal management: COCP/progestogen only/LNG-IUS (these mimic pregnancy + suppress ovarian function), not suitable in woman trying to conceive
37
What are the surgical options in a woman with endometriosis?
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
38
What is an ectopic pregnancy?
Pregnancy whereby embryo implants outside uterus
39
State the most common site of ectopic pregnancy
Fallopian tubes (ampulla> isthmus>timbre)- 95% ectopic pregnancies occur here
40
Give 4 risk factors for ectopic pregnancy
Anatomical alterations of Fallopian tube
41
State 3 common symptoms of ectopic pregnancy
1. Pelvic/abdominal pain: non-specific, unilateral
2. Amenorrhoea
3. Vaginal bleeding
42
Give 3 indications that an ectopic pregnancy has ruptured
1. Severe, sudden abdominal pain
2. Profuse bleeding (into pelvis)
3. Hypovolaemic shock: tachycardia, hypotension, syncope
43
Give more non-specific symptoms of ectopic pregnancy
Dizziness/syncope
Shoulder tip pain (haematoperitoneum)
Breast tenderness/ frequent urination (signs of pregnancy)
Diarrhoea & vomiting
44
What investigation should you do in all women of reproductive age with pain, bleeding or collapse?
Urine Beta- HCG pregnancy test
45
What other investigations would you do if there was a suspected ectopic pregnancy?
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
46
How should you manage a pregnancy of unknown location?
Laparoscopy
47
How should you initially manage suspected ectopic pregnancy?
Emergency admission
ABCD
IV access, cross-match and anti-D for rhesus -ve mum
48
What are the different management options for ectopic pregnancy?
Expectant: allow to resolve naturally
Medical
Surgical
49
What is the criteria for expectant/medical management?
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
50
Describe the medical management of ectopic pregnancy
Methotrexate (single dose)
| Monitor hCG levels, if fallen by <15% by day 7 repeat methotrexate dose
51
What are the surgical options for ectopic pregnancy?
Salpingotomy: removal of part of tube containing EP
Salpingectomy: removal of entire Fallopian tube containing EP
52
What surgical procedure would you perform in ectopic pregnancy in woman with contralateral healthy tube?
Salpingectomy
53
What surgical procedure would you perform in ectopic pregnancy in woman with unhealthy contralateral tube?
Salpingotomy, to preserve possibility of IU pregnancy
54
What is cervical cancer?
Malignancy of the cervix
| Most commonly a squamous cell carcinoma
55
What area of the cervix is susceptible to malignant change?
Squamo-columnar junction: transitional zone between endometriosis + ectopic-cervix
56
What are the 2 peaks of incidence of cervical cancer?
1. 30-39yo
| 2. >70yo
57
What does CIN stand for? What is it?
Cervical intraepithelial Neoplasm
| Pre-invasive phase to cervical cancer
58
State 3 risk factors for CIN/cervical cancer
```
HPV infection (16 + 18 )- multiple sexual partners/not using barrier contraception
Non-attendance to screening
Immunosuppression
Smoking
COCP (reduced barrier methods)
```
59
What is the most common symptom of cervical cancer?
Abnormal vaginal bleeding
60
State some other symptoms of cervical cancer
Abnormal vaginal bleeding
Vaginal discharge: mucoid/blood-tinged, malodorous
Vaginal discomfort
61
What are some of the late clinical features of cervical cancer?
```
Pelvic pain
Ureteric obstruction
Fistulas
Leg oedema
Bowel disturbance
Haematuria/ rectal bleeding
```
62
What features of an examination may indicate cervical cancer?
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
What is the purpose of cervical screening?
Detect pre-invasive phase (CIN) of cervical cancer
64
What is the likely plan for a PT with mild changes to their cervical cells?
HPV status tested
- HPV +ve--> Colposcopy
- HPV -ve--> No colposcopy, 3 yearly screening
65
What is the likely plan for a PT with mod-severe changes to cervical cells?
Colposcopy regardless of HPV status
66
What other investigations might you perform in suspected cervical cancer?
```
FBC/U&Es/LFTs
CT/MRI pelvis + abdomen (staging)
Punch biopsy (histology)
```
67
What must you consider in management of cervical cancer?
Cervical cancer often affects women of child-bearing age- must consider fertility sparing in treatment
68
If a cervical cancer is micro- invasive, what treatment would you perform?
```
Cone biopsy (fertility sparing)
Hysterectomy (older man)
```
69
In early stage disease (stage 1 + 2), what surgical procedure would be recommended in those women trying to maintain fertility?
Radical trachelectomy: removal of cervix/upper vagina
70
If cervical cancer is locally advanced (stage 2 + 3), how would you manage this PT?
Chemoradiation
71
Cervical cancer has metastasised to distant organs, how would you manage the PT?
Palliative care including chemotherapy e.g. to control bleeding
72
What investigations must you always do in a woman who presents with menorrhagia?
FBC to check Hb level, risk of Fe2+ deficient anaemia
73
Give some differential diagnosis of uterine fibroids
Ovarian cyst/tumour
Adenomyosis
Pregnancy
Ectopic pregnancy
74
What is menorrhagia?
Heavy menstrual bleeding
Affects physical, emotional + social QofL
>80ml +/or >7 days bleeding
75
What are the two most common causes of menorrhagia?
```
Uterine fibroids (30%)
Endometrial polyps (10%)
```
76
State some causes, other than fibroids + polyps, that can cause menorrhagia?
Chronic pelvic infection e.g. chlamydia
Ovarian, cervical + endometrial Ca.
Miscarriage
Systemic: hypothyroidism, coagulation disorders
Iatrogenic: anti-coagulation, chemotherapy
77
What investigations would you consider performing in menorrhagia?
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
What are the indications for an endometrial biopsy?
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
What treatment can pre-dispose women to endometrial polyps?
Tamoxifen treatment for breast Ca.
80
State 3 risk factors for endometrial polyps
```
Increasing age
HRT
Tamoxifen treatment
Obesity
Hypertension
```
81
Give some symptoms a PT with endometrial polyps might present with
```
Asymptomatic
Menorrhagia
PMB
IMB
Infertility
```
82
State 2 differential diagnosis of endometrial polyps
Endometrial cancer
| Uterine fibroid
83
What investigations would you do in a PT with a suspected endometrial polyp?
TVUS: visualise polyp
| + Biopsy/hysteroscopy to rule out malignancy
84
How should you manage an asymptomatic polyp?
Watchful waiting/observation, alter modifiable RFs including HRT/obesity
85
What is the recommended management of an endometrial polyp, particularly if it is causing symptoms?
Hysteroscopy + resection of polyp with cutting diathermy
86
What is a miscarriage?
Loss of a pregnancy before 24wks gestation
87
When do majority of miscarriages occur?
1st trimester
88
Give some causes of miscarriage
Feto-placental: chromosomal abnormalities [50%], abnormal foetal development
Maternal: uterine fibroids/adhesions, PCOS, septate uterus, systemic disease
Other: trauma, iatrogenic, drugs/smoking
89
State 3 risk factors for miscarriage
```
Advanced maternal age (>35yo)
Advanced paternal age (>45yo)
Smoking/alcohol abuse
Uterine abnormalities
Connective tissue disorders
```
90
What is the definition of a recurrent miscarriage?
3 or more miscarriages in succession
91
What is the most common cause of recurrent miscarriage?
Anti-phospholipid syndrome
92
What is a threatened miscarriage? State some of the presenting features
```
Mild vaginal bleeding but foetus still alive
Little/no pain
Uterus is size from expected dates
Cervical os closed
75% settle, 25% miscarry
```
93
What is an inevitable miscarriage?
Miscarriage is about to occur
Heavier vaginal bleeding + visible clots
Foetal activity may or may not be present
Cervical os open
94
What is an incomplete miscarriage?
Vaginal bleeding with products of conception partially expelled, not all foetal products have been passed
95
What is an incomplete miscarriage?
Vaginal bleeding with products of conception partially expelled, not all foetal products have been passed
Cervical os usually open
96
What is complete miscarriage?
All foetal tissue has been passed
Bleeding stopped + foetus no longer enlarged
Cervical os closed
97
What is a missed miscarriage?
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
What are the main clinical symptoms for miscarriage?
```
Vaginal bleeding (passing products of conception)
Abdominal pain: lower, cramping, intermittent, period like pain
```
99
In a suspected miscarriage, state some important parts of the examination
Uterine size
Cervical os open vs closed
Tenderness [unusual]
100
What investigations would you carry out in a suspected miscarriage PT?
```
FBC: check for Fe2+ deficient anaemia from bleeding
Rhesus group
Urine B-hCG pregnancy test
Serum hCG
TVUS + doppler
```
101
What is the main tool used to assess foetal wellbeing?
USS + doppler
102
What are the potential outcomes if the gestational sac diameter is <25mm on TVUS?
Miscarriage or early intrauterine pregnancy
| Rescan in 1wk
103
What are the potential outcomes if gestational sac diameter is >25mm, without a foetal pole?
Miscarriage, by this size there should be a foetal pole
| Rescan in 1wk
104
What are the possible outcomes if a foetal pole is seen and the crown rump length is >7mm, with no heartbeat?
Miscarriage, heartbeat should be visible at this size
105
What are the possible outcomes if a foetal pole is seen but the crown rump length is <7mm, with no heartbeat?
Miscarriage or early intrauterine pregnancy
| Rescan 1wk
106
What should you do if you cannot see an intrauterine pregnancy?
Treat as pregnancy of unknown location (PUL)
| Perform serum b-hCG
107
State 3 differential diagnosis of a miscarriage
```
RULE OUT ECTOPIC PREGNANCY
Implantation bleeding
Cervical ectropion
Polyps
Malignancy
```
108
How might you manage a case whereby there is incomplete evacuation of products of conception?
Speculum examination + sponge forces removal of contents
109
What medication might you give to a mother who is experiencing severe bleeding (suspect miscarriage)?
IM ERGOMETRINE
110
What is the conservative/expectant approach to miscarriage? When would this be appropriate?
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
In what circumstances might you consider medical or surgical management of miscarriage?
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
Was is the medical management of miscarriage?
Misoprostol +/- Mifepristine
113
How does Misoprostol work in the management of miscarriage?
Misoprostol = prostaglandin that increases cervical ripening and stimulates uterine expulsion of products of conception
114
What is the surgical management of miscarriage?
Vacuum aspiration [LA]
| Laparoscopy [GA]
115
State 3 possible complications of miscarriage
Surgery--> Asherman's syndrome
Septic miscarriage
Systemic infection
116
What is androgen-insensitivity syndrome?
Disorder of sexual development whereby X-linked mutation in androgen receptors--> End-organ insensitivity to androgens
117
What is the karyotype for androgen insensitivity syndrome?
46XY- PT genetically male
118
What is Turner's syndrome?
Disorder of sexual development whereby there is loss of one X chromosome resulting in gonadel dysgenesis
119
What is the karyotype for Turner's syndrome?
45XO- PT genetically and phenotypically female
120
What is the result of gonadel dysgenesis seen in Turner's syndrome?
Decreased production of oestrogen + progesterone--> Primary amenorrhoea, delayed puberty + infertility
121
Give 4 clinical features of a PT with Turner's syndrome
```
Primary amenorrhoea
Delayed puberty
Infertility
Short stature
Broad-chest + wide-spaced nipples
Short fingers
High-arched palate
```
122
Give 3 other clinical associations with Turner's syndrome
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
What is the best way to diagnose Turner's syndrome?
Karyotyping
| Bloods would also show decreased oestrogens/androgens
124
What other investigations might you perform on a PT with Turner's syndrome
Cardio monitoring: ECG, ECHO + MRI
| Renal USS
125
How would you manage a PT with suspected Turner's syndrome?
```
No cure, genetic problem
Growth hormone- short stature
Oestrogen/progesterone- regular periods
IVF- infertility
Psychological support: appearance, infertility
```
126
What is the pathophysiology behind androgen-insensitivity syndrome?
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
What is the risk with cryptorchidism?
Risk of testicular cancer
| Problem in AIS
128
State the two types of androgen insensitivity
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
What is the classic presentation of androgen insensitivity syndrome?
Adolescence/young woman with PRIMARY AMENORRHOEA, FERTILITY PROBLEMS OR DIFFICULTY HAVING SEX
130
If you performed an USS scan of an individual with complete androgen insensitivity syndrome, what would you expect to see?
1. Absent uterus/ovaries: blind-ended vaginal pouch
| 2. Undescended testes
131
How might you investigate a PT with suspected androgen-insensitivity syndrome?
Karyotyping (46XY)
Genetic testing
Bloods: raised testosterone level
USS: absent uterus/ovaries, undescended testes
132
How would you manage a PT with androgen-insensitivity syndrome?
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
