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3a > Women's health > Flashcards

Women's health Flashcards

1
Q

what would mammography of a ductal carcinoma in situ show?

A
  1. clustered calcification

2. soft tissue abnormality

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2
Q

what would mammography of a lobular carcinoma in situ show?

A

no classical mammographical findings

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3
Q

what would the histological findings in the biopsy of a DCIS show?

A

necrosis + high nuclear grade

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4
Q

what is tumour receptor status

A

whether it stains by immunohistochemistry for the:

  • oestrogen receptor
  • progesterone receptor
  • human epidermal growth factor receptor type 2 (HER-2)
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5
Q

breast: what are triple negative carriers

A
  • don’t express any of the hormone receptors
  • very aggressive
  • BRCA-1
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6
Q

breast: what is Ki67

A

a stain which shows up the % of cells active in the cell cycle

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7
Q

breast: what score on Ki67 is a poor prognostic marker (and so higher likelihood chemo will be effective)

A

14 and above

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8
Q

treatment for DCIS?

A
  • lumpectomy –> radiotherapy
  • Tamoxifen (if ER/pR +ve)
  • Trastuzumab (Herceptin) (if HER +ve)
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9
Q

side effects of tamoxifen

A
  • menopause symptoms: hot flushes, N, headache
  • indigestion
  • cataracts
  • DVT
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10
Q

severe side effects of Trastuzumab (herceptin)

A

heart and lung problems e.g. congestive heart failure

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11
Q

histological features of invasive ductal carcinoma

A
  • cords of tumour cells
  • among associated glandular formation
  • varying degrees of fibrotic response
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12
Q

histological features of invasive lobular carcinoma

A
  • small tumour cells invade BM of lobules
  • and form an ‘Indian file’ between collagen bundles
  • severe: well differentiated tumour cells that exhibit tubule formation
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13
Q

treatment for invasive ductal carcinoma

A
  • lumpectomy –> radiotherapy
  • mastectomy
  • chemotherapy
  • Trastuzumab or Tamoxifen
  • Biphosphonates
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14
Q

suspicious symptoms for breast cancer

A
  1. Painless lump,
  2. Skin distortion,
  3. Bloody nipple discharge,
  4. Recent onset nipple inversion
  5. Axillary lymphadenopathy
  6. Ulceration
  7. Paget’s disease of the nipple
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15
Q

indications for mammography

A
  1. Clinically suspicious lump in patients > 40 years
  2. Breast cancer where mammography not previously performed [any age]
  3. Residual lump after cyst aspiration
  4. Single duct blood stained nipple discharge
  5. Nipple skin change
  6. Triennial mammograms between 47-73 as part of screening
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16
Q 
patient presents with palpable mass
what are the minimum inx for patients:
<25
25-40
>40
A

< 25 yrs:

  • Histology or cytology only.
  • No imaging if clinically feels benign.
  • US if clinically indeterminate or suspicious.

25-40 yrs:
- Breast US + histology/cytology: Triple assessment

> 40 yrs:
- Mammography + US + hystology/cytology: Triple assessment.

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17
Q

breast screening programme

A
  • 47-73 yrs invited every 3 yrs

- mammogram

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18
Q

standard chemotherapy for breast cancer

A 
- epirubicin, 5 fluourouracil and
cyclophosphamide
- 6-8 courses over 12 weeks
- often with addition of a taxane
(so called FEC)
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19
Q

method of action for :

combined oral contraceptive pill

A

inhibits ovulation

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20
Q

COCP increases risk of (3)

A
  1. VTE
  2. breast cancer
  3. cervical cancer
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21
Q

method of action for progesteogen-only pill

A

thickens cervical mucus

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22
Q

common SE of progestogen-only pill

A

irregular bleeding

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23
Q

method of action for injectable contraceptive (medroxyprogesterone acetate)

A
  1. mainly inhibits ovulation

2. also thickens cervical mucus

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24
Q

how long does an injectable contraceptive (medroxyprogesterone acetate) last?

A

12 weeks

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25
Q

method of action for an implantable contraceptive (etonogestrel)

A
  1. mainly inhibits ovulation

2. also thickens cervical mucus

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26
Q

how long does the implant last?

A

3 years

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27
Q

common SE of the implant

A

irregular bleeding

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28
Q

mode of action for IUD

A

decreases sperm motility + survival

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29
Q

mode of action for IUS (levonorgestrel)

A
  1. mainly prevents endometrial proliferation

2. also thickens cervical mucus

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30
Q

what is a common SE of the IUS

A

irregular bleeding

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31
Q

what is desogestrel

A
  • a type of progestogen only pill
  • doesn’t thicken cervical mucus
  • but inhibits ovulation
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32
Q

name 3 methods of emergency contraception

A
  1. Levonorgestrel
  2. Ulipristal
  3. IUD
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33
Q

How does Levonorgestrel work?

A
  • progesterone receptor modulator

- stops ovulation + inhibit implantation

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34
Q

when should Levonorgestrel be taken?

A

within 3 days (72 hours) of unprotected sex

hormonal contraception can be started immediately after

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35
Q

how does Ulipristal (EllaOne) work?

A
  • selective progesterone receptor modulator

- inhibition of ovulation

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36
Q

when should Ulipristal (EllaOne) be taken?

A

within 5 days (120hrs) after sex

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37
Q

when can contraception with the pill, patch or ring be started after having Ulipristal?

A

5 days

use barrier methods during the period

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38
Q

when using Ulipristal, caution should be exercised in patients with ____

A

severe asthma

breastfeeding should be delayed for 1 week after taking Ulipristal

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39
Q

when should an IUD be inserted after unprotected sex?

A

within 5 days

or up to 5 days after the ovulation date

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40
Q

how is non hormonals (IUD, condoms, natural family planning) stopped in women <50 and >50?

A

<50 yrs
strop contraception after 2 yrs of amenorrhoea

> =50 yrs
stop contraception after 1 yr of amenorrhoea

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41
Q

what age can COCP be continued to?

A

50 yrs. After this, switch to non-hormonal or progestogen only method

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42
Q

what age can Depo-Provera be continued to?

A

50 yrs

switch to non-hormonal method + stop after 2 yrs of amenorrhoea

or switch to a progestogen-only method

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43
Q

what age can the implant, POP, IUS be continued to?

A

beyond 50 yrs!

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44
Q

if amenorrhoeic and on the implant, POP or IUS, what should you do?

A
  • check FSH
    stop after 1 yr if FSH >= 30u/l

if not amenorrhoeic beyond 50, consider inx for abnormal bleeding pattern

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45
Q

what types of IUD are there

A
  1. the copper IUD aka as the coil

2. progestogen (levonorgestrel) IUD

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46
Q

how does the copper IUD work?

A

it slowly release copper into womb which:

  • kills sperm
  • stops fertilised egg from implanting the womb
  • thickens cervical mucus
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47
Q

how long can the copper IUD stay in place?

A

5-12 yrs

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48
Q

how long can the progestogen IUD stay in place?

A

3-5 yrs

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49
Q

how does the implant work

A
  • small device inserted into upper arm

- gradually released progestogen

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50
Q

what are the different types of implant?

A

2 small rods

  • contain progestogen
  • lasts 4-5 yrs
  • not used in UK

1 rod

  • contains progestogen
  • lasts 3 yrs
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51
Q

how does the contraceptive injection work?

A
  • injects progestogen in arm every 3 months
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52
Q

disadvantage of the contraception injection

A
  • can weaken bones

- can take up to a year to become fertile after stopping

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53
Q

how does the skin patch work?

A
  • contains oestrogen + progestogen
  • 1 patch lasts 1 week.
  • Have week 4 without a patch
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54
Q

how does the vaginal ring work?

A
  • slowly releases oestrogen + progestogen
    into vagina over several weeks
  • leave ring for 3 weeks them remove it for the last 7 days of cycle
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55
Q

what is sterilisation? (female)

A

operation to cut or block fallopian tubes so a man’s sperm cannot travel along them to fertilise an egg

reversible in theory but not routinely available

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56
Q

what is sterilisation? (man)

A

Vasectomy - Vas deferens (tubes that carry sperm from testes to penis) is cut and sealed off

reversible in theory but not routinely available

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57
Q

you should not take the COCP if you (7):

A
  1. smoke
  2. migraines w/ aura
  3. hx of heart disease
  4. had a stroke
  5. have severe liver disease
  6. have a v. high BP
  7. ever had DVT
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58
Q

Common causes of abnormal semen analysis (5)

A
  1. idiopathic
  2. smoking/alcohol/drugs/chemicals
  3. inadequate local cooling
  4. genetic factors - Kallman’s, CF, Klinefelter’s
  5. antisperm antibodies - common after vasectomy reversal
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59
Q

if semen analysis is oligospermic (<15mill/mL), how would you manage?

A

intrauterine insemination

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60
Q

If semen analysis is moderate-severe (<5 mill) oligospermic, how would you manage?

A

IVF +/-

intracytoplasmic sperm injection

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61
Q

if azoospermic (no sperm present) then…

A
  • examine presence of vas deferens
  • bloods: karyotype, CF, hormone profile
  • surgical sperm retrieval (sperm extracted direct from testis) , then IVF + ICSI/donor insemination
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62
Q

what are the risk factors for GBS (4)

A
  1. prematurity
  2. prolonged rupture of the membrane
  3. previous sibling GBS infection
  4. maternal pyrexia e.g. secondary to chorioamnionitis
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63
Q

Management for women who have had GBS detected in a preiovus pregnancy

A
  • inform them that their risk of maternal GBS carriage in this pregnancy is 50%
  • offer maternal IV abx prophylaxis
  • or testing in late pregancy + then abx if +ve
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64
Q

if women are to have swabs for GBS, when should this be offered?

A
  • at 35-37w

- or 3-5 week prior to anticipated delivery date

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65
Q

who should maternal IV abx prophylaxis be offered to for GBS?

A
  • women with a previous baby with early or late onset GBS disease
  • women in preterm labour regardless of their GBS status
  • women >38 degrees during labour
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66
Q

what is the abx of choice for GBS prophylaxis

A

benzylpenicillin

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67
Q

RFs for cervical cancer

A
  1. HPV INFECTION
  2. 45-49 yrs
  3. multiple sexual partners
  4. early 1st intercourse
  5. immunosuppression
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68
Q

clinical features of cervical cancer

A
  1. none
  2. abnormal vaginal bleeding
  3. postcoital bleeding
  4. offensive vaginal discharge
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69
Q

histopathological subtypes of cervical cancer

A
  1. squamous (80%)
  2. adenocarcinoma (15%)
  3. Adenosquamous (5%)
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70
Q

inx for cervical cancer

A
  1. vaginal/speculum exam
    - cervical mass
    - bleeding
  2. colposcopy
    - abnormal vascularity
    - white change with acetic acid
    - exophytic lesions
  3. biopsy
    - CONFIRMS DIAGNOSIS histologically
    - identifies subtype
  4. HPV testing
    - atypical Pap smear (atypical squamous cells of undertermined significance )
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71
Q

describe CIN I (cervical intra-epithelial neoplasia)

A
  • low grade lesion
  • with mildly atypical cellular change
  • in lower 1/3 of epithelium
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72
Q

describe CIN II (cervical intra-epithelial neoplasia)

A
  • high grade lesion
  • w/ moderately atypical cellular changes
  • confined to basal 2/3 of epithelium
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73
Q

describe CIN III (cervical intra-epithelial neoplasia)

A
  • severely atypical cellular changes
  • encompassing >2/3 of epithelium thickness
    • includes full-thickness lesions (severe dysplasia, carcinoma in situ)
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74
Q

FIGO staging of cervical cancer

Stage 1

A

lesions confined to cervix

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75
Q

FIGO staging of cervical cancer

Stage 2

A

invasion into vagina but not the pelvic sidewall

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76
Q

FIGO staging of cervical cancer

Stage 3

A
  • invasion of lower vagina or pelvic wall

- or causing ureteric obstruction

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77
Q

FIGO staging of cervical cancer

Stage 4

A

invasion of bladder or rectal mucosa or beyond true pelvis

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78
Q

normal Pap/HPV/smear with no evidence of high risk HPV

management

A

rescreen every 3 yrs if 25-49 yrs

every 5 yrs if >50yrs

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79
Q

if evidence of high-risk HPV in smear, what do you do next

A

check cytology (study cells)

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80
Q

high risk HPV smear + normal cells

management

A

repeat screen in 1 yr

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81
Q

high risk HPV smear + abnormal cells

next inx

A

refer for colposcopy

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82
Q

high risk HPV smear + normal cells 2 yrs in a row

next inx

A

colposcopy

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83
Q

management for cervical cancer

microinvasive disease 1a(i)

A
  • cone biopsy

If pathology reveals persistent positive margins after cone biopsy

  • hysterectomy
  • chemoradiation (cisplatin + radiotherapy)
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84
Q

management for cervical cancer

early stage disease
all other stage 1 + 2a

A
  • radical hysterectomy + lymphadenectomy
  • chemoradiation
  • Radical trachelectomy with lymphadenectomy if wanting to get pregnant
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85
Q

management for cervical cancer

locally advanced stage 2b - 4a

A

chemoradiation

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86
Q

management for cervical cancer

metastatic disease stage 4b

A

combo chemo (cisplatin + paclitaxel)

+ bevacizumab

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87
Q

what is placental abruption

A

when part (or all) of the placenta separates before delivery of fetus

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88
Q

features of a major placental abruption

A
  • maternal collapse
  • coagulopathy
  • fetal distress or death
  • ‘woody’ hard uterus
  • poor urine output or renal failure
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89
Q

what are the types of placental abruption

A

concealed - abdo pain. Blood collects behind placenta with no vaginal bleeding

revealed - painful bleeding. Blood tracks between the membranes

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90
Q

clinical features of a placental abruption

A
  • vaginal bleeding
  • abdominal pain
  • uterine contractions
  • uterine tenderness
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91
Q

RFs for a placental abruption

A
  • chronic hypertension
  • pre-eclampsia
  • smoking
  • cocaine use
  • trauma
  • chorioamnionitis
  • uterine malformations
  • prior placental abruption
  • oligohydramnios
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92
Q

inx for a placental abruption

A
  • fetal monitoring
  • Hb and Hct
  • coagulation studies
  • Kleihauer-Betke (K-B) test
  • ultrasound: exclude placenta praevia
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93
Q

management for a placental abruption

A
  1. stabilisation of mother
  2. monitoring of mother + fetus

> 34 weeks

  • stable fetus: vaginal delivery
  • unstable mum/foetus: urgent caesarean

<34 weeks

  • stable: IM corticosteroid (betamethasone sodium phosphate)
  • unstable: urgent caesarean
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94
Q

what is a threatened miscarriage

A
  • vaginal bleed +/- pain
  • at 20-24 weeks
  • pregnancy MAY continue
  • bleeding is often less than menstruation
  • cervical os is closed
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95
Q

what is a missed (delayed) miscarriage

A
  • A miscarriage with US features consistent with a non-viable or non-continuing pregnancy, even in the absence of clinical features.
  • usually an incidental finding
  • a gestational sac which contains a dead fetus without the symptoms of expulsion
  • before 20 weeks
  • mother may have light vaginal bleeding/discharge + symptoms of pregnancy which disappear
  • pain is not usually a features
  • ‘blighted ovum/anembryonic pregnancy’ : gestational sac <25mm + no embryonic/fetal part seen
  • cervical os is closed
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96
Q

what is an inevitable miscarriage

A
  • pregnancy will not continue + will proceed to incomplete or complete miscarriage
  • heavy bleeding with clots + pain
  • cervical os is open
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97
Q

what is an incomplete miscarriage

A
  • not all products of conception have bene expelled
  • pain + vaginal bleeding
  • cervical os is open
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98
Q

what is recurrent miscarriage

A

3 or more consecutive spontaneous abortions

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99
Q

what are the causes of recurrent miscarriages

A
  • antiphospholipid syndrome
  • endocrine disorders: poorly controlled DM/thyroid disorders. - PCOS
  • uterine abnormality: e.g. uterine septum
  • parental chromosomal abnormalities
  • smoking
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100
Q

3 types of management for a miscarriage

A

1st line: expectant
wait 1-2 weeks for miscarriage to completed spontaneously

medical:
vaginal misoprostol to expedite the miscarriage

surgical:
vacuum aspiration/ suction evac

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101
Q

what is primary amenorrhoea

A

menstruation has not started by age 16

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102
Q

what is secondary amenorrhoea

A

previously normal menstruation ceased for >= 6 months

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103
Q

what is delayed puberty

A

lack of secondary sex characteristics by age 14

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104
Q

Amenorrhoea

Causes of hypothalamic hypogonadism (4)

A
  1. Kallman’s (anosmia)
  2. Idiopathic
  3. Low weight
  4. XS exercise
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105
Q

Amenorrhoea

Hypothalamic hypogonadism levels of:

GnRH
FSH/LH

A

↓ GnRH

↓ FSH/LH

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106
Q

Amenorrhoea

Pituitary hyperplasia/adenoma

GnRH
FSH/LH
Prolactin

A

↓ GnRH
↓ FSH/LH
↑ Prolactin

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107
Q

Amenorrhoea

Sheehan’s syndrome
what is it?

A

childbirth –> blood loss –> low oxygen levels –> damage to pituitary gland –> hypopituitarism

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108
Q

Amenorrhoea

Sheehan’s syndrome

GnRH
FSH/LH
Prolactin
TSH

A

⟷GnRH
↓ FSH/LH
↓ Prolactin
↓ TSH

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109
Q

Amenorrhoea

Hypothyroidism

GnRH
FSH/LH
Prolactin
TSH

A

↓ GnRH
↓ FSH/LH
↑ Prolactin
↑ TSH

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110
Q

Causes of amenorrhoea (7)

A
  1. hypothalamic hypogonadism: Kallman’s, low weight
  2. Pituitary hyperplasia/adenoma, Sheehan’s syndrome
  3. Hypothyroidism
  4. Menopause/premature ovarian failure
  5. PCOS
  6. Turner’s
  7. CAH
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111
Q

Amenorrhoea

Menopause

GnRH
FSH/LH

A

↑ GnRH

↑ FSH/LH

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112
Q

Amenorrhoea

PCOS

GnRH
FSH/LH
Testosterone
SHBG
Prolactin
A 
↑GnRH
⟷↓FSH/LH
↑Testosterone
↓SHBG
↑Prolactin
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113
Q

define polycystic ovary

A

a characteristic transvaginal US appearance

  • of >= 12
  • small 2-8mm follicles
  • in an enlarged (>10ml) ovary
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114
Q

define polycystic ovary syndrome

A

2/3 of:

1) PCO on US
2) Oligomenorrhoea (irregular) (>35 days apart)
3) Hirsutism: acne/XS body hair +/or ↑ testosterone

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115
Q

aetiology of PCOS

A

Disordered LH production + peripheral insulin resistance w/ compensatory raised insulin levels

↑ LH + insulin = ↑ androgen production
↑ insulin = ↑ adrenal androgens + ↓steroid hormone binding globulin –> ↑ free androgen levels

↑ intraovarian androgens disrupt folliculogenesis –> irregular or absent ovulation

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116
Q

inx of PCOS (5)

A
  • serum 17-hydroxyprogesterone - rule out CAH
  • serum prolactin - rule out hyperprolactinaemia
  • serum thyroid-stimulating hormone
  • oral glucose tolerance test - diabetes is prevalent
  • fasting lipid panel
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117
Q

Management for PCOS desiring fertility

A
  1. weight loss

2. letrozole/clomifene (inhibits oestrogen -ve feedback –> ↑FSH –> ovulation )

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118
Q

Management for PCOS not desiring fertility

A

1st line: oral contraceptive pill

2nd line: anti-androgens: spironolactone, finasteride

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119
Q

definition of SFD (small for dates)

A

fetus weight <10th centile for its gestation on a customised growth chart

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120
Q

definition of IUGR (intrauterine growth restriction)

A

pathological restriction of genetic growth potential → can manifest with foetal compromise

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121
Q

How do we assess foetal growth / monitor for foetal compromise ? (6)

A

1) Abdominal circumference
2) Head circumference
3) Femur length
4) Umbilical artery dopplers (EDF)
5) Foetal dopplers (MCA & DV)
6) Liquor volume

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122
Q

Causes of IUGR (7)

A

1) infections: CMV, HIV
2) pre-eclampsia
3) CKD
4) drug/smoking/malnutrition
5) congenital abnormalities
6) maternal obesity + diabetes
7) multiple pregnancy

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123
Q

transmission of CMV

A

vertical
delivery
breastfeeding

124
Q

diagnostic inx of CMV

A

IgG (avidity index)

amniocentesis >20 weeks

125
Q

feotal USS of CMV

A
  • hepatosplenomegaly
  • SGA
  • ventriculomegaly
  • foetal hydrops
  • cerebral calcifications
  • microcephaly
126
Q

babies with CMV have ___

A

sensorineural hearing loss

127
Q

management for CMV infection

A

Ganciclovir

128
Q

HIV is a risk factor for _____ (5)

A
  1. stillbirth
  2. pre-eclampsia
  3. gestational DM
  4. IUGR
  5. prematurity
129
Q

mode of delivery if HIV viral load <50

A

normal vaginal delivery

130
Q

mode of delivery if HIV viral load 50 - 399

A

consider c-section (38-40w)

131
Q

mode of delivery if HIV viral load >400

A

recommend c-secrion

132
Q

mode of delivery if HIV viral load >1000

A

intrapartum Zidovudine

133
Q

HIV

what makes a neonate at very low risk

A
  • cART >10w
  • viral load <50 greater than 4 weeks apart
  • viral load <50 on or after 36 weeks
134
Q

HIV

what makes a neonate at low risk

A
  • viral load <50 on or after 36 weeks

- infant born at <34 weeks + maternal viral load <50

135
Q

HIV

what do you treat a very low risk neonate with?

A

2 weeks zidovudine

136
Q

HIV

what do you treat a low risk neonate with?

A

4 weeks zidovudine

137
Q

HIV

what makes a neonate at high risk

A
  • viral load >50 or not known

- poor compliance w/ cART

138
Q

HIV

what do you treat a neonate at high risk with?

A

combination PEP (zidovudine, lamivudine + nevirapine)

139
Q

clinical features of pre-eclampsia

A
  • headache
  • upper abdo pain
  • reduced fetal movement
  • fetal growth restriction
  • oedema
  • visual disturbances
  • seizures
  • breathlessness
  • oliguria
  • hyper-reflexia and/or clonus
140
Q

pre-eclampsia triad

A

1) BP >= 140/90
2) Proteinuria >0.3g/24hr
3) Gestation >20/40

141
Q

definition of gestational hypertension

A

new HTN presenting after 20 weeks without proteinuria

142
Q

risk factors for pre-eclampsia

A
  • primiparity
  • pre-eclampsia in previous pregnancy
  • family history of pre-eclampsia
  • BMI >30
  • maternal age >40 years
  • multiple (twin) pregnancy
  • sub-fertility
  • gestational hypertension
  • pre-existing diabetes
  • PCOS
  • autoimmune disease
  • renal disease
  • pre-existing CVD and chronic HTN
143
Q

inx for pre-eclampsia (7)

A
  1. urinalysis:
    ≥0.3 g protein/24 hours
    or protein:creatinine ratio ≥30 mg/mmol; albumin:creatinine ratio of ≥8 mg/mmol;
  2. fetal USS
    fetal movement reduced
    fetal growth restriction
  3. umbilical artery Doppler - ‘the main assessment tool’
    absence of end diastolic flow- delivery will be necessary soon
  4. amniotic fluid assessment
  5. fetal cardiotocography
  6. FBC, LFTs, creatinine
  7. low placental growth factor
144
Q

management of pre-eclampsia before delivery

A
  1. hospital admission + monitoring
  2. decision regarding delivery
  3. Anti-hypertensives: Labetalol + hydralazine
  4. Magnesium sulfate
  5. Betamethasone if BP >= 160 +/or >=110
145
Q

screening test for pre-eclampsia

A
  • uterine artery Doppler at 23 weeks
146
Q

prevention for pre-eclampsia

A

low-dose aspirin (75mg) before 16 weeks in high risk women

147
Q

What factors should be considered during labour and how are these managed in someone with pre-eclampsia

A
  • Epidural to reduce BP
  • CTG monitoring
  • avoid pushing
  • Oxytocin to manage 3rd stage as ergometrine can increase BP
148
Q

you have an increased risk of pre-eclampsia if you have CKD. What drugs do you continue if you have CKD and are pregnant

A

prednisolone, azathioprine, ciclosporin and tacrolimus

149
Q

what inx do you do if you have CKD and are pregnant

A

screen for UTI

and treat asymptomatic bacteriuria

150
Q

management for opiate drug user and pregnant

A

methadone maintenance

151
Q

definition of antepartum haemorrhage

A

bleeding from genital tract after 24 weeks gestation

152
Q

common causes of antepartum haemorrhage

A
  • unknown
  • placental abruption
  • placental praevia
153
Q

rarer causes of antepartum haemorrhage

A
  • incidental genital tract pathology
  • uterine rupture
  • vasa praevia
154
Q

what is vasa praevia

A

when a fetal blood vessel runs in the membranes in front of the presenting part

155
Q

what is placenta praevia

A

placenta overlying the cervical os

156
Q

classification types of placenta praevia

A
  • complete
  • partial
  • marginal
  • low lying
157
Q

what is a complete placenta praevia

A

placenta covers entire internal cervical os

158
Q

what is a partial placenta praevia

A

placenta covers portion of internal cervical os

159
Q

what is a marginal placenta praevia

A

edge of placenta lies within 2cm of internal cervical os

160
Q

what is a low lying placenta

A

edge of placenta lies within 2- 3.5cm of internal cervical os

161
Q

Key diagnostic factors of placenta praevia

A
  1. scarred uterus
  2. painless vaginal bleeding
  3. speculum: absence of cervical/vaginal causes of bleeding
  4. US anomaly in 1st trimester
  5. no uterine tenderness
  6. low BP + tachycardic
162
Q

what should you never perform with someone who has placenta praevia

A

digital vaginal exam

163
Q

risk factors for placenta praevia

A
  • uterine scarring (previous c section)
  • infertility treatments
  • prior placenta praevia
164
Q

1st investigations to order for placenta praevia

A
  • uterine US w/ colour flow Doppler analysis
  • FBC: low Hb in acute bleeding
  • type + cross-match
165
Q

Management of bleeding w/ unknown placental position

A
  1. resus + stabilisation, urgent US

2. emergency C-section

166
Q

management of bleeding w/ known placenta praevia

not in labour

A
  1. resus + stabilisation
  2. emergency c-section
  3. urgent consultation + transfer
  4. corticosteroid if <34w
167
Q

management of bleeding w/ known placenta praevia (preterm labour)

A
  1. resus + stabilisation
  2. emergency c section
  3. urgent consultation + transfer
  4. corticosteroid if <34w
  5. tocolytics: terbutaline
168
Q

management of placenta praevia with no bleeding (preterm not in labour)

A
  1. monitoring + pelvic rest

2. corticosteroids if <34 w

169
Q

management of placenta praevia with no bleeding (preterm in labour)

A
  1. tocolytics: terbutaline

2. corticosteroids if <34 w

170
Q

management of placenta praevia with no bleeding (full term complete or partial PP)

A
  1. c section
171
Q

management of placenta praevia with no bleeding (marginal or low lying placenta praevia full term)

A
  1. await spontaneous labour

2. c section if not

172
Q

what is a primary postpartum haemorrhage

A
  • loss of >=500ml blood from genital tract

- within 24hrs of birth of baby

173
Q

what is secondary postpartum haemorrhage

A
  • excessive vaginal bleeding
  • from 24hrs after delivery
  • to 12 weeks postpartum
174
Q

what are the primary postpartum haemorrhage causes

A
  1. Tone
  2. Tissue
  3. Trauma
  4. Thrombin
175
Q

PPH

what is tone

A

abnormalities of uterine contraction

  • polyhydramnios
  • multiple gestation
  • macrosomia
  • precipitous labour (rapid)
  • prolonged labour
  • fibroids
  • uterine anomalies
  • placenta praevia
  • chorioamnionitis from prolonged rupture of membranes
  • Nifedipide, Mg, Terbutaline, anaesthetics, GTN
  • bladder distention
176
Q

PPH

What is tissue

A

retained products of conception

  • placental tissue
  • blood clots
177
Q

PPH

what is trauma

A

genital tract injury

  • precipitous labour
  • operative delivery
  • uterine rupture
  • uterine inversion: xs cord traction, high parity
178
Q

PPH

what is thrombin

A

abnormalities of coagulation

  • Haemophilia A, ITP, vWD
  • gestational thrombocytopenia
  • DIC
  • heparin, warfarin
179
Q

secondary PPH causes

A
  • endometritis

- retained placental tissue

180
Q

management of PPH

A
  • ABC
  • IV syntocinon or IV ergometrine
  • IM carboprost

Surgery
1st line if uterine atony cause: intrauterine balloon tamponade

other options: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

Severe: hysterectomy

181
Q

what are the 3 types of placenta accreta

A
  1. accreta
  2. increta
  3. percreta
182
Q

what is placenta accreta

A

chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis

183
Q

what is placenta increta

A

chorionic villi invade into the myometrium

184
Q

what is placenta percreta

A

chorionic villi invade through the perimetrium

185
Q

diagnosis of placenta accreta spectrum

A

high index of clinical suspicion

US and MRI

186
Q

presentation of placenta accreta spectrum

A
  • painless vaginal bleed in 1st/2nd trimester
  • sudden abdo pain
  • abdo distention
187
Q

management of placenta accreta spectrum

A

planned c section

188
Q

RF’s for uterine prolapse (6)

A
  • vaginal delivery
  • older age
  • high BMI
  • previous surgery for prolapse
  • genetic factors
  • white ancestry
189
Q

presentation of uterine prolapse

A
  • vaginal bulge/protrusion
  • dragging sensation
  • urinary incontinence
  • constipation
190
Q

investigation of uterine prolapse

A
  • post-void residual urine volume w/ transurethral catheter or bladder US: >100ml
  • urinalysis
  • urodynamic testing if urinary incontinence is principle complaint
191
Q

asymptomatic treatment for uterine prolapse

A
  • observation

- pelvic floor rehab

192
Q

symptomatic treatment for uterine prolapse

A

1st: pessary

2nd: reconstructive surgery or native tissue repair
- Sacrocolpopexy (mesh)
- uterosacral ligament suspension
- sacrospinous ligament suspension

3rd line: Colpocleisis - not sexually active

adjunct: Burch urethropexy or mid-urethral sling- to reduce post op stress incontinence

193
Q

what is endometriosis

A

the presence + growth of tissue similar to the endometrium outside the uterus

194
Q

RFs for endometriosis

A
  1. reproductive age group
  2. positive FH
  3. nulliparity
  4. mullerian anomalies
195
Q

clinical features of endometriosis (8)

A
  1. dysmenorrhoea - painful
  2. chronic or cyclic pelvic pain
  3. deep dyspareunia
  4. subfertility
  5. uterosacral ligament nodularity
  6. pelvic mass (ovaria endometriomas aka chocolate cysts
  7. fixed, retroverted uterus
  8. depression
196
Q

endometriosis inx

A

1st line: transvaginal US

diagnostic: Laparoscopy - visualisation + biopsy

197
Q

treatment for endometriosis

A
  1. COCP
    NSAIDs
    progestogen
  2. GnRH agonist e.g. leuprorelin/ nafarelin + norethisterone
  3. androgen e.g. danazol
  4. hysterectomy w/ bilateral salpingo-oopherectomy + excision of visible peritoneal disease
198
Q

what disease are breast disadvants associated with?

A

anaplastic large cell lymphoma

199
Q

what are fibrocystic breasts?

A

‘lumpy’ breasts, associated with pain and tenderness that fluctuate with the menstrual cycle.

200
Q

clinical features of fibrocystic breasts

A
  • mastalgia (breast pain)

- diffuse symmetrical lumpiness through both breasts

201
Q

management of fibrocystic breasts

A
  1. reassure
  2. tamoxifen if mastalgia severe
  3. cyst aspiration if palpable symptomatic cyst
202
Q

what is a cervical extropian

A

when the columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix

203
Q

young woman, on the pill, PCB, discharge. What is it?

A

cervical ectropion

204
Q

what is a cervical polyp?

A

benign tumour of the endocervical epithelium

205
Q

woman >40yrs
PCB/IMB
<1cm mass
what could it be

A

cervical polyps

206
Q

gram negative diploocci

A

Gonorrhoea

207
Q

what is adenomyosis

A

endometrial tissue in myometrium causing moderate enlargement

208
Q

symptoms of adenomyosis

A

may be identical to endometriosis

  1. dysmenorrhoea - painful
  2. chronic or cyclic pelvic pain
  3. deep dyspareunia
209
Q

inx of adenomyosis

A

MRI

  • diffuse or focal widening of the inner myometrium
  • islands of endometrial tissue or cystic dilation of glands or haemorrhage
  • linear striations radiating out from the endometrium into the myometrium
  • mass within the myometrium (adenomyoma).

Laparoscopy

  • normal pelvis
  • or concurrent endometriosis.
210
Q

Management of adenomyosis

A
  • IUS (Mirena), OCP, NSAIDs may control menorrhagia + dysmenorrhoea
  • HYSTERECTOMY is often required
  • trial of GnRH analogue therapy to determine if hysterectomy will work
211
Q

risk factors for endometrial carcinoma

LEPTOON

A
  • Late menopause
  • Exogenous oestrogens
  • PCOS
  • Obesity
  • Ovarian granulosa (oestrogen secreting) tumoutrs
  • Nullparity
212
Q

clinical features of endometrial carcinoma

A
  • POSTMENOPAUSAL BLEEDING
  • IMB
  • recent-onset menorrhagia
213
Q

inx of endometrial carcinoma

A

Histological diagnosis:
USS- endometrial thickness >4mm

Diagnosis:
endometrial biopsy w/ pipelle or hysteroscopy

214
Q

management of endometrial carcinoma

A

hysterectomy
bilateral salpingoopherectomy
external beam radiotherapy

215
Q

classic triad of vasa praevia

A

rupture of membranes
followed by painless vaginal bleeding
and fetal bradycardia

216
Q

1st line inx for preterm prelabour rupture of the membranes

A

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

then US if no pooling

217
Q

Management of prelabour rupture of the membranes

A
  1. regular observations to ensure chorioamnionitis is not developing
  2. PO erythromycin for 10 days
  3. antenatal corticosteroids
  4. delivery considered at 34w - trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
218
Q

biggest RF for cord prolapse

A

artificial amniotomy (rupture of membranes)

219
Q

4-day history of vaginal bleeding along with lower abdominal discomfort and nausea. Last menstrual period was 6 weeks ago. What is it

A

ectopic pregnancy

220
Q

clinical features of ectopic pregnancy

A
  • abdominal pain
  • amenorrhoea (LMP typically 6-8w ago)
  • vaginal bleeding
  • abdominal tenderness
  • adnexal tenderness or mass
  • blood in vaginal vault
221
Q

what are the indications of a ruptured ectopic pregnancy?

A
  • pain w/ vomiting
  • involuntary guarding, rebound, or other acute abdo findings
  • hypotension
  • tachycardia
  • cervical motion tenderness
  • urge to poo (from pooling of blood in the cul-de-sac)
  • shoulder tip pain: bleeding from fallopian tube may irritate diaphragm
222
Q

investigations for ectopic pregnancy

A
  • urine or serum pregnancy test
  • high resolution transvaginal ultrasound (TVUS): diagnostic
  • transabdominal ultrasound
223
Q

management for a ruptured ectopic pregnancy

A
  • salpingostomy

- salpingectomy (no or less desire for fertility)

224
Q

management of unruptured ectopic pregnancy (medium risk)

A
  • methotrexate
    Measure hCG post-treatment day 4 and day 7
    if decrease is <15% re-administer methotrexate on day 7
    check hCG level on day 11.
    If decrease between day 7 and day 11 is <15% re-administer methotrexate on day 11 and check hCG level again on day 14.
  • surgical management if hCG is still not decreasing
225
Q

management of low risk tubal ectopic pregnancy

A

expectant management

226
Q

what are fibroids (aka leiomyomata)

A

benign tumours of the uterus

primarily comprised of smooth muscle + fibrous connective tissue

227
Q

clinical presentation of fibroids

A

most are asymptomatic

  • menorrhagia (heavy)
  • irregular. firm, central pelvic mass
  • pelvic pain
  • pelvic pressure
  • dysmenorrhoea
  • bloating
228
Q

RFs for fibroids

A
  • increased patient weight
  • age in the 40s
  • black ethnicity
229
Q

1st inx to order for fibroids

A
  • US

- endometrial biopsy: normal

230
Q

treatment for fibroids when fertility is desired

A

Medical therapy
- IM leuprolide
or PO mifepristone
or levonorgestrel IUD

Myomectomy

231
Q

treatment for fibroids when fertility is not desired and suitable for surgery

A

hysterectomy

232
Q

treatment for fibroids when fertility is not desired and not suitable for surgery or uterine preservation is desired

A
  1. uterine artery embolization

2. myomectomy

233
Q

what is the screening for ovarian cancer?

A
  • no national screening programme
  • family hx –> counselling + genetic mutation test
  • mutation found –> yearly TVUS + CA 125 screening or prophylactic salpingoophorectomy
234
Q

what is so dangerous about ovarian cancer?

A

silent nature so presents late

235
Q

types of ovarian cancer?

A
  • epithelial carcinoma (99%)
  • germ cell
  • sex cord stromal tumours
236
Q

RFs for ovarian cancer

A
  • BRACA1/2 mutation
  • hereditary non-polyposis colon cancer (HNPCC)
    Many ovulations:
  • nullparity
  • early menarche
  • late menopause
  • increasing age
  • never used OCP
237
Q

symptoms for ovarian cancer

A
  • vague GI symptoms
  • > 3 months
  • ascites
  • abdo distention
  • pelvic mass on examination
238
Q

investigations for ovarian cancer

A
  • CA 125 level >35 unitls/mL then:
  • pelvic US
  • CT scan
  • diagnostic: histopathology shows clusters of disorganised cells, w/ desmoplasia
239
Q

how do you get histopathology in ovarian cancer

A
  • do not biopsy because risk of cancer cell spillage into abdo cavity
  • usually surgical extirpation or paracentesis or thoracentesis
240
Q

ovarian cancer

how do you calculate risk of malignancy index?

A

RMI = U x M x CA125

U= USS score
M = menopausal status

RMI >=250, refer to specialist MDT

241
Q

stage 1 ovarian cancer

A

disease macroscopically confined to the ovaries

242
Q

stage 1a ovarian cancer

A

1 ovary affected, capsule intact

243
Q

stage 1b ovarian cancer

A

both ovaries affected, capsule intact

244
Q

stage 1c ovarian cancer

A

1/both ovaries affected. capsule not in contact or malignant cells in the abdo cavity

245
Q

stage 2 ovarian cancer

A

disease beyond the ovaries but confined in the pelvis

246
Q

stage 3 ovarian cancer

A

disease beyond the pelvis but confined to the abdo

247
Q

stage 4 ovarian cancer

A

disease is beyond abdomen

248
Q

what is grade in ovarian cancer

A

the degree of differentiation

249
Q

management of ovarian cancer in early stage 1a and b

A
  1. surgical staging inc: omentectomy, lymph node dissection (pelvic and para-aortic), and staging biopsies

NO CHEMO

250
Q

management of ovarian cancer in early stage 1c

A
  1. surgical staging
  2. and carboplatin
  3. and paclitaxel/docetaxel
251
Q

management of ovarian cancer stage 2,3 + 4

A

IV + intraperitoneal paclitaxel + cisplatin

252
Q

what drugs can be used for induction of labour

A
  1. Prostaglandin E2 : ripens cervix

2. oxytocin: stimulates contraction

253
Q

what is the Bishop’s score

A

used to predict whether induction of labour will be required

254
Q

what does a Bishop’s score of <=5 mean?

A

labour is unlikely to start without induction. Cervix is not ripe. needs prostaglandin

255
Q

what are the 3 main methods of induction of labour

A
  1. cervical ripening balloon
  2. propess or prostin: pessary prostaglandin inserted in vagina
  3. artificial rupture of membranes. May need IV syntocinon
256
Q

what can you give to a woman with PCOS and wanting a baby

A

1st line: Letrozole
2nd line: metformin
2nd line: laparoscopic ovarian diathermy

257
Q

RFs for perineal tears

A
  • primigravida
  • large babies
  • precipitant labour
  • shoulder dystocia
  • forceps delivery
258
Q

1st degree perineal tear

A

superficial damage w/ no muscle involvement

259
Q

2nd degree perineal tear

A

injury to the perineal muscle, but not involving the anal sphincter

260
Q

3rd degree perineal tear

A

injury to perineum involving the anal sphincter complex

261
Q

3a degree perineal tear

A

less than 50% of EAS thickness torn

262
Q

3b degree perineal tear

A

more than 50% of EAS thickness torn

263
Q

3c degree perineal tear

A

IAS torn

264
Q

4th degree perineal tear

A

injury to perineum involving the anal sphincter complex and rectal mucosa

265
Q

pregnant woman exposed to chicken pox but unsure if she has ever had it. What do you do?

A

if in doubt, check blood urgently for varicella antibodies

266
Q

if no antibodies to varicella and <=20w pregnant and exposed to chickenpox in pregnancy. What do you do?

A

give varicella-zoster immunoglobulin asap (up to 10d post exposure)

267
Q

if no antibodies to varicella and >20w pregnant and exposed to chickenpox in pregnancy. What do you do?

A

give VZIG

or aciclovir/valaciclovir 7-14d after exposure

268
Q

mother has chickenpox and is <20w gestation. what do you do?

A

consider with caution aciclovir

269
Q

mother has chickenpox and is >20w gestation. What do you do?

A

give PO aciclovir if she has presented within 24hrs of onset of rash

270
Q

what is included in the combined antenatal Down’s screening (3)

A
  1. Nuchal scan (thickened nuchal translucency)
  2. serum B-hcG (increased)
  3. PAPP-A (decreased)
271
Q

girl misses progesterone only pill after 3 hrs. what should she do

A

take pill asap then the next pill as usual.

use condoms until pill taking has been reastablished for 48 hrs

272
Q

girl misses desogesterel (cerazette) after 12 hrs. what should she do

A

take pill asap then the next pill as usual.

use condoms until pill taking has been reastablished for 48 hrs

273
Q

what are the SSRIs of choice in breastfeeding women?

A

sertraline or paroxetine

274
Q

what can a UTI in pregnancy increase the risk of? (3)

A
  1. preterm labour
  2. premature rupture of membranes
  3. pyelonephritis
275
Q

why is nitrofurantoin avoided during 3rd trimester

A

haemolytic anaemia of the newborn

276
Q

how does a UTI cause preterm labour?

A

The ascent of a bacteria/virus through the vagina will u infect the amniotic sac and fluid. Rupture of the sac and premature labor and delivery follow.

277
Q

gonorrhoea management

A

IM ceftiaxone

278
Q

genital herpes management

A

aciclovir

279
Q

syphillis management

A

IM penicllin

280
Q

bacterial vaginosis and Trichomoniasis management

A

metronidazole

281
Q

candidiasis (thrush) management

A

topical imidazoles e.g. clotrimazole

282
Q

disadvantage of the implant

A

additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle

283
Q

what does HELLP stand for (pre-eclampsia)

A

Haemolysis
Elevated Liver enzymes
Low Platelets

284
Q

which medication is associated with endometrial hypelplasia

A

TAMOXIFEN

  • pro-oestrogenic effects on endometrium
  • anti-oestrogenic effects on breasts
285
Q

how would you manage endometrial hyperplasia?

A
  • progestogens

- if atypical: hysterectomy

286
Q

presentation of PROM

A
  • gushing of fluid and continual wetness in the underwear
287
Q

inx for PROM

A
  • speculum: pooling of amniotic fluid
  • unsure? fetal fibronectin test ot confirm rupture of membranes.
  • avoid digital vaginal exam
  • CTG + US to check health of fetus
288
Q

management for PROM

A
  • admission
  • regular observations to ensure chorioamnionitis is not developing
  • PO erythromycin 10 days
  • antenatal corticosteroids
  • delivery should be considered at 34 weeks of gestation
289
Q

up to what gestation can you terminate a pregnancy

A

24w

290
Q

what do you need to abort

A
  • 2 registered medical practioners to sign a legal document

- 1 if its an emergency

291
Q

where can a termination of pregnancy take place

A
  • NHS hospital or licenced premise
292
Q

method of abortion if <9w

A

mifepristone (ant-progestogen)

48hrs later, prostaglandins (stimulate contractions)

293
Q

method of abortion if <13w

A

surgical dilation + suction of uterine contents

294
Q

method of abortion if >15w

A
  • surgical dilation + evacuation of uterine contents

- or late medical abortion (induces mini labour)

295
Q

what are functional cysts

A
  • aka physiological cysts
  • only found in premenopausal women
  • can be split into follicular cysts + lutein cysts
296
Q

what are follicular cysts

A
  • a type of functional cyst
  • the most common cause of ovarian enlargement in women of a reproductive age
  • due to non-rupture of the dominant follicle
  • or failure of atresia in a non-dominant follicle
  • commonly regress after several menstrual cycles
297
Q

what are lutein cysts

A
  • a type of functional cyst
  • aka corpus luteum cyst
  • during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears.
  • If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
  • more likely to present with intraperitoneal bleeding than follicular cysts
298
Q

what is a dermoid cyst

A
  • a type of germ cell tumour
  • benign
  • young premenopausal women
  • lined with epithelial tissue: hair, teeth
  • commonly bilateral
  • ## aka cystic teratomas
299
Q

what is a Serous cystadenoma

A
  • a type of Benign epithelial tumour
  • contain Psammoma bodies
  • the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
  • bilateral in around 20%
300
Q

what is a mucinous cystadenoma

A
  • a type of benign epithelial tumour
  • they are typically large and may become massive
  • if ruptures may cause pseudomyxoma peritonei
301
Q

how does a ruptured ovarian cyst present as

A
  • sudden onset unilateral pelvic pain

- precipitated by intercourse or strenuous activity

302
Q

How long after giving birth do you not require any contraception?

A
  • 21 days if not breastfeeding

- use contraception if breastfeeding

303
Q

A confirmed miscarriage can be diagnosed on ultrasound by?

A
  • no cardiac activity and
  • crown-rump length > 7mm
  • OR gestational sack > 25mm
304
Q

women with gestational diabetes mellitus (GDM) who has a fasting plasma glucose level of ≥7.0mmol/L/. what do you give?

A

insulin +/- metformin

305
Q

when should you give metformin in gestational diabestes

A

if blood glucose targets are not met after 1-2 weeks using lifestyle modification.

3a (5 decks)

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