Women's Health (things I forget) Flashcards
1
Q
Describe HELLP syndrome
A
- Severe form of pre-eclampsia
- (H)aemolysis, (E)levated (L)iver enzymes, (L)ow (P)latelets
- Malaise/nausea/vomiting/headache
- HTN with proteinuria
- Epigastric/upper abdominal pain
2
Q
What is Sheehan syndrome?
A
Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock
- Agalactorrhoea
- Amenorrhoea
- Sx of hypothyroidism
- Sx of hypoadrenalism
3
Q
What is Asherman’s syndrome?
A
Intrauterine adhesions that commonly occur following dilation and curettage
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
4
Q
What are risk factors for endometrial hyperplasia?
A
- Unopposed oestrogen
- Tamoxifen (selective oestrogen receptor modulator)
- Obesity
- Early menarche/late menopause
- Age >35
- Smoking
- Nulliparity
- Sex cord stromal tumours (granulosa cell tumours/sertoli cell tumours/thecomas/fibromas)
5
Q
What are the clinical features of endometrial hyperplasia?
A
Abnormal bleeding = intermenstrual/post-menopausal/menorrhagia/irregular
6
Q
What is the management for endometrial hyperplasia?
A
- Simple = high dose progestogens (e.g. IUS)
- Hysterectomy
7
Q
What is the most common cause of post-menopausal bleeding?
A
Vaginal atrophy
8
Q
What are the investigations for post-menopausal bleeding?
A
- Transvaginal USS
- Pipelle biopsy
- Hysteroscopy with biopsy
9
Q
What is cervical ectropion?
A
Increased columnar epithelium on ectocervix due to elevated oestrogen levels
- Vaginal discharge
- Post-coital bleeding (most common cause)
- Inter-menstrual bleeding
10
Q
What is the most common cause of pyrexia in pregnancy?
A
Chorioamnionitis - usually the result of an ascending bacterial infection of amniotic fluid/membranes/placenta –> P-PROM
11
Q
What is the management for chorioamnionitis?
A
- Emergency delivery
- IV abx
12
Q
What increased risk is there when taking HRT + a progestogen?
A
Breast cancer
13
Q
What is lochia and how does it present?
A
- Bleeding present for first 2 weeks following giving birth
- Fresh bleeding –> colour change (brown) –> stops
14
Q
What is the main complication of induction of labour and how is it managed?
A
- Uterine hyperstimulation
- Administer tocolytic agents to relax uterus/slow contractions
15
Q
What is the first-line method of inducing labour?
A
Vaginal prostaglandins
16
Q
What are some causes of an increased nuchal translucency?
A
- Down’s syndrome
- Congenital heart defects
- Abdominal wall defects
17
Q
What findings of the combined test would suggest a high risk of Down’s syndrome?
A
- Thickened nuchal translucency
- High beta-hCG
- Low PAPP-A
18
Q
What findings of the quadruple test would suggest a high risk of Down’s syndrome?
A
- High hCG
- High inhibin A
- Low AFP
- Low oestriol
19
Q
What findings of the quadruple test would suggest a high risk of Edward’s syndrome?
A
- Low hCG
- Low oestriol
- Low AFP
- Normal inhibin A
20
Q
What findings of the quadruple test would suggest a high risk of neural tube defects?
A
- High AFP
- Normal hCG
- Normal inhibin A
- Normal oestriol
21
Q
What should be given to patients at moderate/high risk of pre-eclampsia?
A
Low-dose aspirin (75-150mg) daily for duration of pregnancy
22
Q
What is the management for eclampsia?
A
Magnesium sulphate (prophylaxis and treatment) = continue for 24 hours after delivery/last seizure
23
Q
What is the order of management for gestational HTN?
A
- Labetalol (beta blockers) - first line
- Nifedipine (CCB) - if asthma
- Methyldopa - contraindicated in depression
Admit if >160/110
24
Q
What is the management for hyperemesis gravidarum?
A
- Antihistamines - promethazine
- IV saline + potassium
- Ondansetron (risk of cleft lip/palate in first trimester)
- Metoclopramide/domperidone (extra-pyramidal side effects)
25
What is a threatened miscarriage?
- NOT A MISCARRIAGE
- Bleeding +/- pain
- Before 24 weeks
- Cervical os closed
- Fetus alive
26
What is a missed (delayed) miscarriage?
- Gestational sac contains dead fetus before 20 weeks without symptoms of expulsion
- Light vaginal bleeding/discharge
- Symptoms of pregnancy disappear
- Cervical os closed
27
What is the difference between an inevitable miscarriage and an incomplete miscarriage?
Inevitable:
- Heavy bleeding with clots
- Pain
- Cervical os open
- Possible foetus with heartbeat
Incomplete:
- Bleeding
- Pain
- Cervical os open
- Products of conception
28
What is a complete miscarriage?
- No cardiac activity
- Crown rump length >7mm
- Gestational sac >25mm
- Cervical os closed
29
What is the management for miscarriages?
- Missed = oral mifepristone + misoprostol 48 hours later
- Incomplete = single dose of misoprostol
IF EVIDENCE OF INFECTION/HAEMODYNAMIC INSTABILITY:
- Surgery = vacuum aspiration (suction curettage)
30
What is the management for ectopic pregnancies?
- Expectant management = monitor b-hCG levels over 48 hours
- Medical = methotrexate
- Surgical = salpingectomy/salpingotomy
31
What are the clinical features of uterine fibroids?
- Menorrhagia
- Anaemia
- Bulk-related symptoms e.g. bloating/urinary frequency
32
Describe uterine fibroids in pregnancy
- Sensitive to oestrogen --> can grow during pregnancy
- May undergo red or 'carneous' degeneration if growth outstrips blood supply
33
What is the management for fibroids?
- IUS/COCP/tranexamic acid = if <3 cm and not distorting uterine cavity
- GnRH agonists = shrink (induce menopausal-like state)
- Surgery = myomectomy
34
What are the investigations for PCOS?
- Pelvic USS
- LH + FSH
- Prolactin
- TSH
- Testosterone
- Sex hormone-binding globulin
35
Describe stereotypical PCOS findings
- raised LH:FSH ratio (raised LH)
- Testosterone normal/mildly elevated
- Serum sex hormone binding globulin (SHBG) normal/low
36
What criteria is used for PCOS?
Rotterdam criteria - 2 of 3 features:
- Oligomenorrhoea/amenorrhoea (oligoovulation/anovulation)
- Clinical/biochemical signs of hyperandrogenism (hirsutism/acne/elevated testosterone)
- Polycystic ovaries on USS (either >12 follicles or increased ovarian volume >10cm3)
37
What is the management for PCOS?
- Oligomenorrhoea/hirsutism/acne = COCP/oral progestogen/IUS
- Infertility = referral/clomifene citrate/metformin
38
How does metformin help in PCOS?
- Appetite reduction
- Decreases androgen production
- Decreases LH secretion from anterior pituitary
- Decreases SHBG in liver
39
Describe perineal tears
First degree:
- Superficial/no muscle involvement
- No repair required
Second degree:
- Injury to perineal muscle but not anal sphincter
- Suture on ward
Third degree:
- Injury to perineum involving anal sphincter complex
- Repair in theatre
Fourth degree:
- Injury to perineum involving anal sphincter complex and rectal mucosa
- Repair in theatre
40
What should be given to all patients with PPROM?
10 days oral erythromycin and antenatal corticosteroids
41
Describe placenta accrete spectrum
Placenta accreta = myometrium
Placenta increta = deep myometrium
Placenta percrata = past myometrium and perimetrium
42
What are the investigations for obstetric cholestasis?
- LFTs
- Bile acids
43
What is the management for intrahepatic cholestasis?
- Induction of labour at 37-38 weeks (to avoid risk of stillbirth)
- Ursodeoxycholic acid
- Chlorphenamine and aqueous cream
- Vitamin K supplementation
- Antihistamines
44
What is the first line emergency contraception?
Copper IUD
- Must be inserted within 5 days of UPSI
OR
- May be fitted up to 5 days after likely ovulation date
45
Describe the hormonal forms of emergency contraception
Levonorgestrel:
- Must be taken within 72 hours of UPSI
- Single dose (doubled if BMI >26/weight >70kg/enzyme-inducing drugs)
- Repeat dose if vomiting within 3 hours
- Hormonal contraception can be started immediately after
- No effect on breastfeeding
Ulipristal:
- Must be taken within 120 hours (5 days) of UPSI
- Hormonal contraception started 5 days after
- Breastfeeding should be delayed for one week
46
What are some contraindications for prescribing ulipristal acetate?
- Diseases of malabsorption e.g. crohns
- Allergy
- Asthma
- Breastfeeding
- Severe hepatic dysfunction
47
What is the guidance for folic acid?
- All women = 400mcg of folic acid until 12th week
- Higher risk = 5mg of folic acid from before conception until 12th week
^ higher risk = taking antiepileptic drugs/coeliac/diabetes/thalassaemia/obesity/neural tube defects
48
What are the basic investigations for infertility?
- Semen analysis
- Serum progesterone 7 days prior to expected next period
49
What is the management for infertility due to ovulation disorders?
- Exercise/weight loss
- Letrozole
- Clomifene citrate
- GnRH therapy
50
What is a complication of ovulation induction?
Ovarian hyperstimulation syndrome - ovarian enlargement and formation of multiple cystic spaces
- Hypovolaemic shock
- Acute renal failure
- VTE
51
What are the investigations for endometriosis?
- Vaginal examination = fixed retroverted uterus/tender uterus/visible vaginal endometriotic lesions
- Laparoscopy + biopsy = gold standard
52
What is the management for endometriosis?
- FIRST LINE = NSAIDs + COCP
- GnRH analogues
53
What is RMI?
Risk malignancy index - estimates risk of ovarian mass being malignant
- Menopausal status
- USS findings
- CA125 levels
54
What is secondary dysmenorrhoea associated with?
- PID
- Endometriosis
- Adenomyosis
- Fibroids
REFER
55
What is the most common causative organism, investigation and management for BV?
- Anaerobic bacteria - Gardnerella vaginalis
- Whiff test +ve
- Clue cells on microscopy
- pH >4.5
- Oral metronidazole
56
What is the causative organism and management for trichomonas vaginalis?
- Trichomonas vaginalis = protozoan
- Oral metronidazole
57
What is the causative organism and management for gonorrhoea?
- Neisseria gonorrhoea - gram-negative diplococcus
- IM ceftriaxone
58
What is the causative organism and management for chlamydia?
- Chlamydia trachomatis - gram-negative bacteria
- Doxycycline
59
What are the investigations for urinary incontinence?
- Bladder diaries
- Vaginal examination
- Urinalysis
- Urodynamic studies
60
What medications are used in urinary incontinence?
Urge = muscarinic antagonists e.g. oxybutynin/tolterodine/solifenacin
Stress = duloxetine
61
What medical management is used for menopause?
- Uterus = oral/transdermal combined HRT
- No uterus = oral/transdermal oestrogen
- Vasomotor symptoms = fluoxetine/citalopram/venlafaxine
62
What are the genotypes for common causes of primary amenorrhoea?
45XO = Turner syndrome
46XY = Androgen insensitivity syndrome
63
What are the clinical features of hydatidiform moles?
- Large uterus
- Significantly elevated serum hCG levels
- HTN
- Severe N+V --> hyperemesis gravidarum
64
What are the stages of labour?
Stage 1 = onset of true labour to fully dilated cervix
- Latent phase = 0-3/4 cm
- Active phase = 4-10 cm
Stage 2 = full dilation to delivery of fetus
Stage 3 = delivery of fetus to completed delivery of placenta/membranes
65
What is symphysis-fundal height and what should it be?
- Top of pubic bone to top of uterus (cm)
- Should match gestational age in weeks to within 2cm after 20 weeks
66
What are the instructions for missed POP?
- Take missed pill ASAP and then take next pill at usual time
- Continue with rest of pack
- Extra precautions until pill-taking has been resumed for 48 hours
67
What are the instructions for 1 missed COCP?
- Take missed pill ASAP and then take next pill at usual time
- No additional contraception needed
68
What are the instructions for 2+ missed COCP?
- Take missed pill ASAP and then take next pill at usual time
- Extra precautions until pill-taking has been resumed for 7 days
- Days 1-7 = emergency contraception
- Days 8-14 = no need for emergency contraception
- Days 15-21 = finish pills and start new pack without pill-free interval
69
What are contraindications to the COCP?
- >35 and smoking >15 cigarettes/day
- Migraine with aura
- History of thromboembolic disease
- History of stroke/IHD
- Breastfeeding <6 weeks post-partum
- Uncontrolled HTN
- Current breast cancer
- Major surgery with prolonged immobilisation
- Positive antiphospholipid antibodies e.g. SLE
70
What is the mechanism of action of the COCP?
- Oestrogen and progesterone
- Inhibits ovulation
- 7 days to become effective
71
What is the mechanism of action of the POP?
- Progesterone only
- Thickens cervical mucus and inhibits ovulation (desogestrel)
- Takes 48 hours to become effective
72
What is the mechanism of action of the injectable contraceptive?
- Progesterone only
- Inhibits ovulation and thickens cervical mucus
- Effective immediately if given during days 1-5 - if not takes 7 days to become effective
- Lasts 12 weeks
73
What is the mechanism of action of the implantable contraceptive?
- Progesterone only
- Inhibits ovulation and thickens cervical mucus
- Effective immediately if given during days 1-5 - if not takes 7 days to become effective
- Lasts 3 years
74
What is the mechanism of action of the IUS?
- Progesterone only
- Prevents endometrial proliferation and thickens cervical mucus
- 7 days to become effective
- Lasts 5 years
75
What is the mechanism of action of the IUD?
- No hormones
- Decreases sperm motility and survival
- Effective immediately
- Lasts 5 years (copper on stem only) or 10 years (copper on stem and arms)
76
What methods of contraception are recommended in patients with epilepsy?
IUD/IUS/injection
77
What methods of contraception can be continued past 50 years of age?
Implant/POP/IUS
78
What is the management for PMS?
- Lifestyle
- COCP
- SSRI (severe)
79
What is the investigation for premature ovarian insufficiency?
Elevated FSH levels on 2 samples taken 4-6 weeks apart
80
What is Mittelschmerz?
- Usually mid cycle pain
- Often sharp onset
- Little systemic disturbance
- May have recurrent episodes
- Usually settles over 24-48 hours
81
What is the management for shoulder dystocia?
- McRobert's manoeuvre (flexion and abduction of hips - bringing thighs towards abdomen)
- Suprapubic pressure used to improve effectiveness of McRoberts manoeuvre
82
What is the management for chickenpox in pregnancy?
1. Check for varicella antibodies
2. Oral aciclovir (or valaciclovir) at day 7-14 after exposure
3. Oral aciclovir if >20 weeks and presents within 24 hours of onset of rash
83
What is the investigation for gestational diabetes?
Oral glucose tolerance test:
- Fasting glucose >5.6mmol/L
- 2-hour glucose >7.8mmol/L
If fasting glucose >=7mmol/L, commence insulin (short acting only)
84
What are the investigations for premature rupture of membranes?
- Speculum examination = pooling of amniotic fluid in posterior vaginal fornix/absence of vaginal discharge
- Test fluid for PAMG-1 (amnisure) or insulin-like growth factor binding protein 1
- USS = may show oligohydramnios
85
What is the management for premature labour?
Tocolytic medication - stop labour
Steroids (dexamethasone) - help foetal lungs mature in case labour continues and delivery is required
86
What are the risk factors for cord prolapse?
- Prematurity
- Multiparity
- Polyhydramnios
- Multiple pregnancy
- Abnormal presentations e.g. breech/transverse
87
What is the management for cord prolapse?
- Presenting part of fetus may be pushed back into uterus to avoid compression
- Minimal handling/keep warm and moist if cord past level of introitus
- Patient on all fours
- Tocolytics to reduce uterine contractions
- Retrofilling bladder with 500-700ml of saline
88
What scoring system is used for labour?
Bishop score - evaluating cervical readiness for labour
<5 = indicates labour unlikely to start without induction
>8 = indicates cervix is ripe/favourable and high chance of spontaneous labour
89
How does ovarian cancer commonly present and what is the initial investigation?
>50 years with IBS-like symptoms in the last 12 months
- Bloating
- Abdominal/pelvic pain
- Early satiety
- Diarrhoea/urinary symptoms
- CA-125 level
90
What is the management for pelvic organ prolapse?
- Weight loss
- Pelvic floor muscle exercises
- Ring pessary
- Surgery
91
What is the difference between OA and OP
Occiput anterior - head down and facing mother's spine
Occiput posterior - head down and facing mother's naval
92
How does labour differ in OA and OP presentation?
OA:
- Ideal
OP:
- Labour likely to be longer and more painful
- Earlier urge to push
- May rotate spontaneously to OA
93
What is the classic presentation for vasa praevia?
- Rupture of membranes
- Painless vaginal bleeding
- Foetal bradycardia (foetal distress)
94
What is the classic presentation for placenta praevia?
- Painless vaginal bleeding
- No foetal distress
95
What are the risk factors for placenta praevia?
- Multiparity
- Previous c-section
- Multiple pregnancy
- Increased age
- IVF
- Maternal smoking
- Structural uterine abnormalities e.g. fibroids
96
What are the risk factors for placental abruption?
- Multiple pregnancy
- Smoking
- Previous abruption
- Maternal smoking
- Pre-eclampsia
- HTN
97
When is AFP raised in pregnancy?
- Abdominal wall defects e.g. gastroschisis/omphalocele
- Multiple pregnancy
- Neural tube defects
98
When is AFP decreased in pregnancy?
- Down's syndrome
- Trisomy 18 (Edward's)
- Maternal diabetes mellitus
99
What are the findings for molar pregnancy?
- High beta hCG
- Low TSH
- High T4
100
What are normal laboratory findings in pregnancy?
- Reduced urea
- Reduced creatinine
- Increased urinary protein loss
101
Describe the bishop score
0-3
- Cervical position
- Cervical consistency
- Cervical effacement (thinning/shortening of cervix)
- Cervical dilation
- Foetal station (position of head)
<5 unlikely to start without induction
>8 high chance of spontaneous labour/response to interventions
102
What are the mechanisms of labour?
- Descent
- Flexion
- Internal rotation
- Extension
- Restitution
- External rotation
- Delivery of body
103
What is the management for induction of labour?
<6 = vaginal prostaglandins
>6 = amniotomy and IV oxytocin infusion
104
Why is misoprostol not used in induction?
Too strong - can cause hyperstimulation and foetal distress
105
What is human chorionic gonadotrophin (HCG)?
- Secreted by syncytiotrophoblast into maternal bloodstream
- Acts to maintain production of progesterone by corpus luteum in early pregnancy
- Can be detected from day 8 after conception
106
What is the management for cord prolapse?
- Presenting part of foetus may be pushed back into uterus
- Keep cord warm and moist
- Patient go on all fours
- Tocolytics = reduce uterine contractions (relax uterine muscles)
- Retrofilling bladder with 500-700ml of saline
- C-section
107
What medication can be used to improve success rate of external cephalic version?
- Tocolytic agent with beta-mimetic effect
- E.g. terbutaline, ritodrine, salbutamol
108
What medication is used for suppressing lactation?
Cabergoline
109
What are the categories of caesarean sections?
1:
- Immediate threat to life e.g. uterine rupture/major placental abruption/cord prolapse
- Delivery within 30 minutes
2:
- Maternal/foetal compromise which is not immediately life-threatening
- Delivery within 75 minutes
3:
- Delivery is required but mother and baby are stable
4:
- Elective
110
Describe amniotic fluid embolisms
Foetal cells/amniotic fluid enters the mother's bloodstream
- Chills/shivering/sweating
- Anxiety
- Coughing
- Cyanosis
- Hypotension
- Bronchospasms
- Tachycardia/arrhythmia/MI
111
What are the different types of breech presentation?
Complete - both legs flexed at hip/knees (looks cross-legged)
Frank (most common) - both legs flexed at hip and extended at knees
Footling - one or more legs extended at hip (foot is presenting part)
112
What is en caul?
- Foetus is born still inside amniotic sac
- Sac is opened by midwife/doctor
113
What is delayed cord clamping?
Cord clamping delayed 1-2 to allow blood to be transferred to baby - increases RBCs/iron/stem cells
114
What are signs on examination of pelvic inflammatory disease and what is the management?
- Cervical motion tenderness and adnexal tenderness
- IM ceftriaxone (single dose) + doxycycline (14 days) + metronidazole (14 days)
- Leave coil in and only take out if no improvement after 72 hours
115
When is axillary node clearance done in breast cancer?
When >3 sentinel nodes are involved in sentinel node biopsy
116
When are patients referred via the 2 week wait pathway for breast cancer?
- >30 with unexplained breast/axilla lump with or without pain
- >50 with symptoms in one nipple: discharge/retraction/changes of concern
117
Describe the triple assessment process?
1. History and examination
2. Imaging (USS or mammogram)
3. Biopsy (core or fine needle aspiration)
118
What is an investigation for teratomas (dermoid cyst)?
Histopathological analysis - Rokitansky's protuberance
119
What is given in premature labour?
Vaginal progesterone - decreases myometrium activity and prevents cervix remodelling
If not - steroids and abx (10 days abx in PPROM)
120
What are the clinical features of ovarian tumours?
- Acute abdomen
- Amenorrhoea
- Hirsutism
- Thyrotoxicosis
- Rupture/haemorrhage
121
What is haematocolpos?
Accumulation of blood in vagina usually due to imperforate hymen
122
When may CA-125 be raised?
- Adenomyosis
- Ascites
- Endometriosis
- Menstruation
- Breast cancer
- Ovarian cancer
- Ovarian torsion
- Endometrial cancer
- Liver disease
- Metastatic lung cancer
123
Which antibiotics are safe in pregnancy and breastfeeding?
Cephalosporins e.g. ceftriaxone and cefotaxime
124
What are the cut off values for amniotic fluid index?
5 < x < 24
<5 = oligohydramnios
>24 = polyhydramnios
125
What are the most common types of vaginal cancer?
Majority = secondary cancer
Most common primary = squamous cell carcinoma
126
What is the most common type of ovarian cancer?
Epithelial - serous carcinoma
127
What is CIN grade 1 and what is the management?
Low grade cervical intraepithelial neoplasia - low grade abnormal changes in transformation zone
- No treatment necessary
- Follow up in 12 months
128
What are some physiological changes of pregnancy?
- Increased blood volume
- Increased CO
- Increased HR
- Decreased vascular resistance
- Increased tidal volume
- Increased intra-gastric pressure
- Decreased gut motility
- Increased uterine size
