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Phase 3a Jemima > Womens health > Flashcards

Womens health Flashcards

Obstetrics and Gynecology

1
Q

When is a fetus at term

A

37-42 weeks

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2
Q

what is a fetus called when it passes 42 weeks

A

post mature

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3
Q

what are the four stages of labour

A
  1. Latent phase
  2. First stage
  3. Second stage
  4. Third stage
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4
Q

what occurs in the latent phase of labour

A

intermittent/irregular contractions
the cervix begins to dilate up to 4cm

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5
Q

how long can the latent phase of labour last

A

days

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6
Q

what occurs in the first stage of labour

A

regular strong contractions
cervix fully dilates up to 10 cm

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7
Q

what occurs in the second stage of labour

A

full dilation of the cervix to the birth of the child

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8
Q

what occurs in the third stage of labour

A

the birth of the baby to the birth of the placenta

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9
Q

what is syntocin given for

A

it is a synthetic hormone given to increase contractions and move on labour

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10
Q

at what labour stage is there a risk of hypoxia to the fetus

A

the second stage (pushing)

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11
Q

what does oxytocin do during labour

A

it surges causing the onset of labour stimulating the ripening of the cervix and causes contractions of the uterus

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12
Q

what do prostaglandins do in labour

A

they cause cervical ripening

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13
Q

what does oestrogen do during labour

A

there is a surge at the beginning of labour that inhibits progesterone

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14
Q

what does prolactin do during labour

A

it initiates milk production

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15
Q

what do beta endorphins do during labour

A

they act as a natural pain relief for the mother (build up during the latent stage of labour)

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16
Q

what is the most common presentation of the foetus during labour

A

cephalic - head down and longitudinal

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17
Q

what are the different presentations foetus’ can be in during labour

A

cephalic
breech - bottom down or feet down
transverse

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18
Q

what can increase the chance of a foetus being breech

A
  • not enough amniotic fluid: not mobile enough
  • having too much amniotic fluid: too mobile
  • fibroids
  • history of a breech labour
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19
Q

where in the uterus do contractions start

A

in the fundus

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20
Q

what is cervical effacement

A

it is the thinning and shortening of the cervix.
this process occurs so that dilation can begin

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21
Q

what are the 4 different types of female pelvis

A

gynecoid
platypelloid
android
anthropoid

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22
Q

what are the mechanisms of labour

A

descent
flexion
internal rotation
extension
restitution
external rotation
delivery of the body

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23
Q

mechanisms of labour - what occurs during descent

A

the fetus descends into the pelvis

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24
Q

mechanisms of labour - what occurs during flexion

A

as the fetus descends through the pelvis contractions put pressure on the fetal spine towards the occiput of the womans pelvis
when this happens the fetal neck flexes allowing the circumference of the fetal head to reduce

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25
Q

Mechanisms of labour - what occurs during internal rotation

A

With each contraction, the fetal head is pushed onto the pelvic floor. Following each contraction, a rebound effect supports a small degree of rotation. Regular contractions eventually lead to the fetal head completing the 90° turn.

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26
Q

mechanisms of labour - what occurs during extension

A

The fetal occiput will slip beneath the suprapubic arch allowing the head to extend.
the fetal head is now born

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27
Q

mechanisms of labour - what occurs during restitution/external rotation

A

the head rotates externally left or right as the shoulders move downwards

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28
Q

mechanisms of labour - what occurs during the delivery of the body

A

downward traction can be conducted by the midwife to help the delivery of the shoulder

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29
Q

what are the two ways membrane rupture (waters breaking) can occur

A

spontaneous
artificial

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29
Q

what is delayed cord clamping

A

where the umbilical cord is not immediately clamped and cut at birth

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30
Q

what are the associated benefits with delayed cord clamping

A

allows baby time to transition to extra uterine life
increase in red cells, iron and stem cells (aids in growth)
reduced need for inotropic support

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31
Q

what non invasive analgesia can be given during labour

A

Entonox (gas and air)
paracetamol
codeine
diamorphine
pethidine
remifentanyl

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32
Q

what is an invasive pain medication that can be given during labour

A

epidural (mix of bupivacaine and fentanyl)

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33
Q

how long should you be taking pre-pregnancy vitamins for

A

at least 3 months pre pregnancy

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34
Q

what tests are done at the 12 week obstetric appointment

A

Blood pressure
Proteinuria
UTI testing
Weight
Height
Haemoglobinopathies
HIV
Hep B
Syphilis
FBC - look at RBC, platelets and MCH
Rhesus testing
Ultrasound

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35
Q

what is done during ultrasound to screen for down syndrome

A

Measure the nuchal translucency

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36
Q

what is the combined screening for downs syndrome

A

Nuchal translucency
Mums age
two blood tests (Pap A and HCG)

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37
Q

what are the three chromosomal abnormalities fetus’ are tested for in the UK

A

Trisomy 21
Trisomy 13 and 18 in combination

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38
Q

what history is important to get from a pregnant person

A

previous gestational diabetes
BMI
age
previous large baby
family history of diabetes
ethnicity
previous pre eclampsia
hypertension
renal disease
rheumatological disease

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39
Q

what is given to someone who is at high risk of pre eclampsia

A

put them on aspirin - 150mg daily

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40
Q

what puts the mother at risk of having a small baby

A

hypertension
renal disease
SLE/other autoimmune disease
cyanotic cardiac disease

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41
Q

what put a woman at medium risk of having a small baby

A

pregnancy over 40
previous small baby
early birth

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42
Q

what antenatal and newborn screening programmes are there in the UK

A

sickle cell and thalassemia
infectious disease screening
Down’s, Edwards and pataus syndrome
fetal anomaly scan
diabetic eye screening
newborn infant physical examination
newborn hearing screen
newborn blood spot

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43
Q

what are the key aspects of care in labour

A

one to one care
maternal comfort and hygiene
maternal monitoring
assessment of progression of labour
fetal monitoring
bladder care and urine output through out labour

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44
Q

what can change a mothers risk through out pregnancy

A

blood loss
rupture of membrane
pain
presence of meconium

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45
Q

what are red flags in gynecological history taking

A

cervical cancer: bleeding after sex and spotting
Uterine cancer: post menopausal bleeding
Ovarian cancer: abdo mass, pain, bloating, weight loss, change in bowel habit, tired all the time

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46
Q

what is antepartum haemorrhage

A

it is bleeding anywhere within the genital tract after the 24th week of pregnancy

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47
Q

what is a low lying placenta

A

it is when the placenta implants in the lower segment of the uterus

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48
Q

what are the classifications of a low lying placenta

A

major or minor depending on the implantation site

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49
Q

how is a low lying placenta treated

A

minor - many can move as pregnancy progresses
- come into the hospital if there is any pain or bleeding
- avoid sexual intercourse until 34 week scan
- cross match the mother in case of haemorrhage
- deliver baby by elective c section

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50
Q

what is placenta praevia

A

a condition in which the placenta partially or wholly blocks the neck of the uterus, thus interfering with normal delivery of a baby.

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51
Q

how do you treat a bleeding placenta praevia

A

start with ABCDE assessment
abdominal and general examination
foetal monitoring and potentially delivery
steroids if the baby is less than 34 weeks

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52
Q

what steroids are given with a bleeding placenta praevia if the fetus is less than 34 weeks

A

dexamethasone and magnesium sulphate

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53
Q

what is vasa praevia

A

this is when the fetal vessels are over the internal cervical opening leaving them unprotected by placental tissue

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54
Q

how do you treat vasa praevia

A

an elective c section at 37 weeks

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55
Q

what is a morbidly adherent placenta

A

this is a placental that invades abnormally though the uterus which can go through to the myometrium and onto other internal structures

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56
Q

how is a morbidly adherent placenta treated

A

elective c section at 36-37 weeks, sometimes with a hysterectomy as well if severe

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57
Q

what is placental abruption

A

early separation of the placenta from the uterine wall which can cause a concealed or revealed haemorrhage

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58
Q

what are signs of placental abruption

A

maternal shock is out of proportion of the bleeding present
fetal distress

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59
Q

what are antepartum haemorrhage complications

A

premature labour
transfusion
acute tubular necrosis
DIC
post partum haemorrhage
ARDS
fetal morbidity and mortality

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60
Q

what are the diagnostic criteria for severe pre eclapsia

A

hypertension and proteinurea
plus at least one of the following
- severe headache
- visual disturbance
- papilloedema
- clonus
- liver tenderness (HELLP syndrome)
- abnormal liver enzymes
- platelet count under 100 X10^9/L

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61
Q

what is HELLP syndrome

A

HELLP syndrome is a severe form of pre-eclampsia, and combines:
Haemolysis
Elevated liver enzymes
Low Platelets

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62
Q

how do you treat severe pre-eclampsia

A

stabilise BP (oral antihypertensives - labetalol)
Check bloods (HELLP syndrome)
fluid restriction (80mL/h)
magnesium sulphate (reduce seizure risk)

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63
Q

what is eclampsia

A

it is the onset of seizures in women with pre-eclampsia

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64
Q

how do you manage eclampsia

A
  • bolus magnesium sulphate and IV BP management
  • stabalise mum and then deliver baby
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65
Q

what can cause sepsis in pregnant people

A

Premature rupture of membranes
prolonged rupture of membrane
cervical cerclage
infection

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66
Q

what is fetal compromise

A

when there is abnormality within the CGT trace of the baby - babies HR is unstable

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67
Q

what is cord prolapse

A

this is when the cord comes out first and then the baby

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68
Q

why can cord prolapse lead to foetal compromise

A

because the exposure of the cord leads to vasospasm and reduce/prevent blood supply to the baby

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69
Q

what can cause cord prolapse

A

premature waters
polyhydramnios
long cord
fetal malpresentation
multiparity

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70
Q

how do you treat cord prolapse

A

trendelenburg position (feet higher than head)
emergency c section

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71
Q

what is shoulder dystocia

A

it is failure of the anterior shoulder to pass under the symphysis pubis

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72
Q

what are causes of shoulder dystocia

A

disproportion between mum and baby
post mature baby
maternal obesity
prolonged first or second stage of labour
instrumental delivery

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73
Q

how do you treat shoulder dystocia

A

call for help
evaluate for episiotomy
legs into Mc Roberts
Suprapubic pressure
enter the pelvis
- rotational maneuvers
- remove the posterior arm
replace the head and deliver by c section

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74
Q

what does shoulder dystocia increase the risk of in a baby

A

hypoxia
fits
cerebral palsy
injury to the brachial plexus

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75
Q

what are the two types of post partum haemorrhage

A

primary
secondary

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76
Q

what is a primary post partum haemorrhage

A

occurs within 24 hours of birth with over 500mls of blood

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77
Q

what is a secondary post partum haemorrhage

A

it occurs over 24 hours after birth and is split into minor and major haemorrhage

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78
Q

what can cause a post partum haemorrhae

A

retained tissue (placenta)
Uterus not fully contracting (tone)
trauma (tears)
low thrombin

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79
Q

what are the risk factors for having a post partum haemorrhage

A

larger baby
multiple babies
long labour
infection
operative delivery
APH
previous post partum haemorrhage

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80
Q

what can you give prophylactically to help prevent a PPH

A

syntocinon

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81
Q

in a sexual health history what is important to focus on in women

A

mentrual history
pregnancy history
contraception use
cervical cytology history

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82
Q

what is it important to look at in a genital examination

A

genital skin
inguinal nodes
pubic hair

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83
Q

in a genital examination what do you focus on in women

A

vulva, perineum, vagina, cervix

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84
Q

in a genital examination what do you focus on in men

A

penis, scrotum, urethral meauts, perianal area, oropharynx

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85
Q

what asymptomatic STI screening tests are performed in women

A

a self taken vulvo-vaginal swab for gonorrhoea/chlamydia
blood test for HIV and STS

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86
Q

what asymptomatic STI screening tests are performed in heterosexual men

A

first void urine for gonorrhoea and chlamydia
blood for STS and HIV

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87
Q

what asymptomatic STI screening tests are performed in homosexual men

A

same as heterosexual men plus a pharyngeal and rectal swab as well as blood for STS, HIV, Hep B and C

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88
Q

what are common symptoms in females with STI/vaginal issues

A

discharge changes
vulval discomfort/soreness/itching
vulval lumps or ulcers
inter mentrual bleeding
post coital bleeding

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89
Q

what are common symptoms in men with STI/genital issues

A

pain or burning on urinating
sores or blisters
discharge
genital lumps or rash
testicular pain or swelling

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90
Q

what STI screening is done in symptomatic women

A

asymptomatic tests +
swab for bacterial vaginosis, thrush and TV
dipstick for urinalysis
bimanual examination
swabs and culture is performed

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91
Q

what STI screening is done in symptomatic heterosexual men

A

urethral swab before voiding
dipstick urinalysis

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92
Q

what STI screening is done in symptomatic homosexual men

A

urethral and rectal slides
urethral, rectal and pharyngeal culture plates

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93
Q

what testing is done on genital ulcers

A

HSV PCR
Dark ground microscopy

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94
Q

What at risk groups are tested for Hep B

A

men who have sex with men
sex workers
IVDU
people from high risk areas - africa, asia, eastern europe

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95
Q

what is PEP for HIV

A

it is HIV prophylaxis. You take it within 72 hours of exposure and you take it for one month
- combination of three antiretrovirals

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96
Q

what is PrEP for HIV

A

this is pre-exposure medication
it is offered to those who are identified as high risk of HIV exposure

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97
Q

what are risk factors of an ectopic pregnany

A

previous ectopic
tubular damage - pelvic inflammatory disease/STI
history of infertility
smoker
over 35
use of IUD/IUS/POP

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98
Q

what are symptoms of an ectopic pregnancy

A

PV bleeding
abdominal pain
shoulder tip pain
dizziness

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99
Q

How do you diagnose an ectopic pregnancy

A

abdominal ultrasound and beta HCG levels

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100
Q

what will you see on USS with an ectopic pregnancy

A

a mass that moves separately from the ovary
you may also see free fluid

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101
Q

how long do you have to wait to get pregnant again if youve had methotrexate

A

3 months

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102
Q

what pregnancy issue would you give methotrexate for

A

an ectopic pregnancy

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103
Q

when would you give methotrexate in an ectopic pregnancy

A

if their bHCG is below 1500

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104
Q

what monitoring needs to occur with a woman on methotrexate for an ectopic pregnancy

A

they must have bHCG monitoring on days 4-7 and then weekly until it is negative

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105
Q

when would surgery be an option in an ectopic pregnancy

A

in severe pain
mass >35mm
live ectopic
hcg > 5000
signs of rupture
haemodynamically unstable

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106
Q

what is a complete miscarriage

A

an empty uterus on USS
bleeding
follow up on beta hcg monitoring

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107
Q

what is an incomplete miscarriage

A

when a miscarriage begins, but some pregnancy tissue stays in the womb
diagnosed on USS
<35mm - expectant, medical, surgical
>35mm - surgical/medical

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108
Q

what is a delayed miscarriage

A

it requires visualisation of gestation sac, yolk sac, and fetal poles with no fetal heart activity

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109
Q

what is a molar pregnancy

A

problem with a fertilised egg, which means a baby and a placenta do not develop the way they should after conception

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110
Q

what is a complete molar pregnancy

A

it is caused by one/two sperm fertilise an egg which has lost its DNA

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111
Q

what is partial molar pregnancy

A

the father supplies two sets of DNA and the mum supplies one (2 sperm and 1 egg)

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112
Q

how is a molar pregnancy diagnosed

A

USS

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113
Q

how is a molar pregnancy treated

A

surgery only

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114
Q

what is ovarian torsion

A

it is when the ovary twists on its vascular and ligamentous supports which blocks the blood flow

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115
Q

how do you treat ovarian torsion

A

it is a surgical emergency !!!

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116
Q

what are the symptoms of ovarian torsion

A

severe abdominal pain
nausea and vomiting

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117
Q

what is pelvic inflammatory disease

A

an infection of the uterus, fallopian tubes and ovaries, causing pain around the pelvis or lower abdomen discomfort

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118
Q

what are symptoms of pelvic inflammatory disease

A

dyspareunia - painful sexual intercourse
pelvic pain
dysuria
change in discharge
IMB/PCB

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119
Q

what are risk factors of pelvic inflammatory disease

A

IUS/IUD
STI
UPSI

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120
Q

what are causes of pelvic inflammatory disease

A

infection
chlamydia
gonorrhoea
mycoplasma

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121
Q

what is the treatment for pelvic inflammatory disease

A

14 days of antibiotics - 1 dose ceftriaxone plus PO metronidazole and doxycycline

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122
Q

what emergency can occur due to an ovarian cyst

A

haemorrhage due to an increase in size or rupture of the cyst

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123
Q

how do you treat an ovarian cyst

A

removal of the ovary
removal of the cyst - can cause chemical peritonitis
can leave it and wait

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124
Q

how often does miscarriage occur

A

it occurs in 20% of cases

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125
Q

what is a threatened pregnancy

A

it is one associated with vaginal bleeding with or without pain

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126
Q

when is expectant management reasonable in miscarriage

A

where the miscarriage is incomplete and not associated with heavy bleeding/at an early stage (<8 weeks)

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127
Q

what is given in a miscarriage for a pregnancy that is over 12 weeks

A

start with anti - progestogen
then 36-48 hours later use synthetic prostaglandin (misoprostol)

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128
Q

where is the most common site for an ectopic pregnancy

A

the fallopian tube - in the ampulla

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129
Q

what is the maternal mortality rate in pregnancy

A

deaths per 100,000 maternities

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130
Q

what is the maternal mortality ratio

A

the number of maternal deaths with live births as the denominator

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131
Q

when do you give methotrexate in an ectopic pregnancy

A

when serum hcg <1500 and it is unruptured

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132
Q

when can a woman have methotrexate in an ectopic pregnancy

A

needs to have a good liver and renal function

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133
Q

what is hyperemesis gravidarum

A

it is excessive vomiting associated with dehydration and ketosis

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134
Q

how do you treat hyperemesis gravidarum

A

rehydrate with fluid, vitamins and nil by mouth until oral fluids can be tolerated
small frequent means are recommended once eating is tolerated

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135
Q

What is acute fatty liver of pregnancy

A

it is a rare complication that occurs in the third trimester/after delivery. it causes abdo pain, nausea, vomiting, headache, jaundice and hypoglycemia.

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136
Q

what helps support a diagnosis of acute fatty liver in pregnancy

A

an ALT of greater than 500 U/l

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137
Q

when is the best time to test serum progesterone

A

in a normal 28 day cycle check on day 21
(cycle length take 7 days)

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138
Q

at what point are those with PCOS advised to loose weight

A

when their BMI is over 30

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139
Q

What is a membrane sweep

A

this is when the cervix is assessed and if possible a finger is passed into the cervical opening to stretch it and separate the chorionic membranes from the cervix

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140
Q

who is offered membrane sweep

A

all women should be offered a vaginal examination and membrane sweep at 40 weeks gestation

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141
Q

what is it called when the placenta is adhered directly to the superficial myometrium without penetrating through the muscle

A

Placenta accreta

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142
Q

what are the dangers of placenta accreta

A

it can lead to severe haemorrhage at birth and the placenta failing to deliver spontaneously

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143
Q

what is placenta increta

A

this is when the villi of the placenta invade the myometrium

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144
Q

what is placenta percreta

A

this is when the villi of the placenta invade the full thickness of the myometrium to the serosa, and have the potential to attach to other organs

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145
Q

how do you treat anti-phospholipid syndrome in pregnancy

A

Low dose aspirin and low molecular heparin
- low dose aspirin started once pregnancy is confirmed
- LMWH started once a fetal heart is seen on ultrasound

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146
Q

if labetalol is contraindicated in pregnancy due to asthma what would you prescribe to treat high blood pressure

A

nifedipine (calcium channel blocker)

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147
Q

Why is oxytocin given post - partum

A

for prevention of post partum haemorrhage

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148
Q

what is the most common reason for a positive coombs test in a newborn

A

resus haemolytic disease of the newborn

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149
Q

what does the coombs test confirm in a newborn

A

that there is immune mediated haemolytic anaemia

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150
Q

what is the treatment of gestation diabetes if the women have a fasting plasma glucose of below 7mmol/litre

A

metformin 500mg OD

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151
Q

what is the treatment of gestational diabetes of the woman has a fasting glucose of 7 mmol/litre or over

A

isophane insulin injection OD in the morning

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152
Q

what is first line treatment of pelvic inflammatory disease

A

Doxycycline (100 mg orally twice a day for 2 weeks) plus ceftriaxone 500 mg intramuscularly (IM) for one dose or cefoxitin 2 g IM with probenecid (1g orally) for one dose or another parenteral third-generation cephalosporin.

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153
Q

what is a treatment for overactive bladder in adults

A

first line: lifestyle changes and bladder retraining
medical: Oxybutynin (anticholinergic)

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154
Q

what is Hydrops faetalis

A

this is when on ultrasound it shows foetal oedema in at least two compartments

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155
Q

how many stages of placenta praevia are there

A

there are 4 stages depending on how much the placenta is covering the cervical opening

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156
Q

what can an increase in blood volume cause during pregnancy

A

pitting oedema
flow murmurs

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157
Q

what does the corpus luteum degenerate into if fertilisation doesnt occur

A

the corpus albicans

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158
Q

what is gestational age

A

it is the age of the fetus starting from the date of the last period

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159
Q

what is gravida

A

this is the total number of pregnancies a person has had

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160
Q

what is primigravida

A

this is a patient who is pregnant for the first time

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161
Q

what is multigravida

A

this is a patient who is on her 2nd or more pregnancy

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162
Q

when is a womans first trimester

A

this is from the start of the last period until 12 weeks gestation

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163
Q

when is the second trimester

A

from 13 to 26 weeks

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164
Q

when is the third trimester

A

from 27 weeks until birth

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165
Q

when do fetal movements start

A

around 20 weeks

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166
Q

what are the key appointments during pregnancy

A

a 7-9 week booking clinic (community midwife)
a 10-13 week dating scan
a 16 week community midwife appointment
a 20 week anomaly scan
then further appointments are dependent on the risk status of the mother and baby

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167
Q

if a woman has suffered from gestational diabetes before when will she be tested for it in her current pregnancy

A

at 16 weeks she will have an oral glucose tolerance test
if this is negative she will have another one at 28 weeks

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168
Q

when is placenta praevia tested for

A

this is tested for with ultrasound at 32 weeks

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169
Q

when is symphysis fundal height (babies growth) measured from

A

it is measured from 24 weeks

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170
Q

what is it a sign of if mothers urine has proteins in it

A

pre-eclampsia

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171
Q

when are vaccines given to mother during pregnancy

A

whooping cough - 16 weeks
influenza flu given during cold season

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172
Q

how long should a woman be taking folic acid for in an pregnancy

A

400mg three months before the pregnancy and then up to 12 weeks during the pregnancy

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173
Q

what supplements should a woman not take during pregnancy

A

multivitamins (unless specific pregnancy ones)
vitamin A

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174
Q

what food should women avoid during pregnancy

A

unpasteurized dairy and blue cheese
undercooked or raw poultry

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175
Q

what are the risks associated with drinking alcohol when pregnant

A

miscarriage
small fetus
preterm delivery
fetal alcohol syndrome

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176
Q

what features are associated with fetal alcohol syndrome

A

microcephaly
thin upper lip
smooth flat philtrum (space between lips and nose)
short palpebral fissure
learning disabilities
hearing and vision problems
cerebral palsy

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177
Q

what are the risks of smoking when pregnant

A

fetal growth restriction
miscarriage
stillbirth
premature labour
placental abruption
pre-eclampsia
cleft lip or palate
sudden infant death syndrome

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178
Q

at what point in an pregnancy should a woman stop flying

A

37 weeks in an single pregnancy
32 weeks in a twin pregnancy
after 28 weeks she will need a mote from a doctor or registered healthcare worker to fly

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179
Q

what blood tests are performed at a womans initial booking appointment

A

blood grouping
antibodies
resus D status
FBC to screen for anaemia, thalassaemia and sickle cell
also offered HIV, Hep B and syphilis screening

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180
Q

what risk assessments are performed on a pregnant person

A

rhesus D status
VTE risk
gestational diabetes risk
fetal growth restriction
pre-eclampsia risk

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181
Q

what is the combined test for downs syndrome screening in pregnancy

A

this is performed between 11-14 weeks and combines ultrasound results and blood tests
US - nucal translucency
bloods - beta hCG and pregnancy associated plasma protein

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182
Q

what is the triple test for downs syndrome screening in pregnancy

A

this is performed between 14 and 20 weeks and only uses maternal bloods
- beta hCG, alpha fetoprotein and serum oestriol

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183
Q

what is the quadruple test for downs syndrome screening in pregnancy

A

this is the same as the triple test but with inhibin A checked as well

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184
Q

if someone comes back as higher risk for downs syndrome what happens then

A
  • non invasive prenatal testing: bloods from mum and extract fetal DNA for testing
  • amniocentesis: testing amniotic fluid (after 15 weeks)
  • chronic villous sampling (before 15 weeks)
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185
Q

what issues can hypothyroidism in pregnancy lead to

A

miscarriage, anaemia. small gestational age and pre-eclampsia

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186
Q

what treatment should be given to women with hypothyroidism who are pregnant

A

levothyroxine is given - dose in pregnancy needs to be increased (usually by at least 30-50%)

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187
Q

what hypertension medications are contraindicated in pregnancy

A

Ace inhibitors
angiotensin receptor blockers (losartan)
thiazide diuretics

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188
Q

what hypertension medications are used in pregnancy

A

labetalol (only beta blocker that is safe)
calcium channel blockers (nifedipine)
alpha blockers (doxazosin)

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189
Q

what affect can pregnancy have on epilepsy

A

pregnancy may worsen seizure control due to lack of sleep, hormonal changes, and altered medications

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190
Q

what epilepsy medication is contraindicated in pregnancy

A

sodium valporate - neural tube defects and malformation
phenytoin - cleft lip or cleft palate

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191
Q

what epilepsy medication is safe in pregnancy

A

levetiracetam, lamotrigine, carbamazepine

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192
Q

what medication is used to treat thrush

A

oral fluconazole

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193
Q

what does the term dyskaryosis refer to

A

it means abnormal nuclei and refers to pre-cancerous changes in cells

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194
Q

what is the most common type of valvular cancer

A

squamous cell carcinoma

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195
Q

what is prescribes to pre-menopausal women with oestrogen receptor positive breast cancer

A

Tamoxifen (oestrogen receptor antagonist)

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196
Q

what are common causes of pelvic inflammatory disease

A

Chlamydia trachomatis
Neisseria gonorrhoeae

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197
Q

what is treatment for an eclamptic seizure

A

intravenous magnesium sulphate

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197
Q

what is cystic breast disease

A

this is when there are multiple fluid filled cysts within the breast tissue, which can change in size and tenderness with the menstrual cycle

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197
Q

what are common causes of an enlarged mobile uterus

A

uterine fibroids
adenomyosis
tumour

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197
Q

what is cyclical mastalgia

A

it is a cyclical pain and tenderness of the breasts being more severe in the days leading up to menstruation and resolving after the start of the period - common in premenopausal women

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198
Q

what is the most common cause of infections in newborns

A

Group B streptococcus

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199
Q

how is group B streptococcus treated during delivery

A

benzylpenicillin

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200
Q

what is paget’s disease of the nipple

A

this is an eczema like rash on the nipple and is associated with an underlying malignancy
- single lesion with discrete edges and nipple may appear ulcerated or destroyed

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201
Q

what is cervical ectropion

A

this is when there is enlargement of the cervix, and the columnar cells from inside the cervix grow outside where they can be seen with a speculum

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202
Q

what are symptoms of cervical extropian

A

post coital bleeding

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203
Q

how do you diagnose premature ovarian insufficiency

A

presence of menopausal symptoms (vaginal dryness, hot flushes, secondary amenorrhoea)
two elevated FSH levels

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204
Q

what does a molar pregnancy look like on ultrasound

A

a snowstorm appearance

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205
Q

when is anti-D given in a pregnancy (what weeks)

A

at 28 and 32 weeks

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206
Q

what is the treatment for bacterial vaginosis

A

metronidazole

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207
Q

what are symptoms of trichomoniasis

A

frothy yellow discharge accompanied by pruritis, vaginitis and post coital bleeding

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208
Q

What might a speculum examination show if someone has trichomoniasis

A

small punctuate haemorrhages - strawberry cervix

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209
Q

What is fitz hugh curtis syndrome

A

it is a complication of pelvic inflammatory disease where adhesions form due to inflammation of the liver capsule

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210
Q

what is an amniotic fluid embolism

A

it occurs when amniotic fluid is introduced into the vascular system leading to the obstruction of blood flow and impaired gas exchange

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211
Q

what are symptoms of an amniotic fluid embolism

A

shortness of breath
chest pain
hypotension

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212
Q

a womans smear has come back positive for HPV but no abnormalities were found in cytology. what is the next appropriate step

A

re-do the smear in 12 months

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213
Q

what is appropriate management for a lactational breast abscess

A

drainage of the abscess (needle aspiration)
course of antibiotics

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214
Q

what do bloods showing antibodies to Treponema pallidum suggest

A

that the person has syphilis

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215
Q

what is the most common type of breast cancer

A

invasive ductal carcinoma

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216
Q

how is a molar pregnancy treated

A

dilation of the cervix and removal with a curettage (scrapes away the molar pregnancy)
dilation of the cervix and suction

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217
Q

What is sheehans syndrome

A

this is post partum pituitary gland ischemic necrosis due to blood loss and hypovolemic shock after PPH. it causes hypopituitarism symptoms such as hypothyroidism, hypoadrenalism, hypogonadism and growth hormone deficiency

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218
Q

what herpes type causes cold sores

A

HSV-1

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219
Q

what is urge incontinence

A

it is when the patient suddenly feels an urgent need to pass urine, which cannot be controlled

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220
Q

what is urge incontinence due to

A

overactivity of the detrusor muscle (overactive bladder syndrome)

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221
Q

what is stress incontinence

A

this refers to leakage of urine when there is increased pressure in the pelvis and occurs due to weakness of the pelvic floor muscles

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222
Q

if a mother has a positive rubella status, what symptoms is the fetus most at risk of developing

A

sensorineural deafness
congenital cataracts
blueberry muffin rash
salt and pepper chorioretinitis
heart disease - PDA and pulmonary stenosis
learning disability

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223
Q

what blood tests do people with severe pre eclampsia need and how often

A

U+E, FBC, transaminases and bilirubin three times per week

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224
Q

what is the first line treatment for hyperemesis gravidarum

A

anti-histamines such as promethazine

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225
Q

what is a sign of placental separation during the third stage of labour

A

lengthening of the umbilical cord
a rush of blood

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226
Q

what is the first step taken if someone has been trying to conceive for one year and has been unsuccessful

A

test the woman’s serum progesterone on day 21 of her cycle

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227
Q

what is first line treatment for uncomplicated mastitis

A

keep breast feeding to help stop the milk building up

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228
Q

what is a grade 3 cervical intraepithelial neoplasia

A

this is when the full thickness of the cervical epithelium is affected by abnormal cells

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229
Q

what is axillary web syndrome

A

formation of fibrous cords that extend from the axilla to the ipsilateral hand
characterized by a visible and palpable cord like structure and the sensation of tightness and pulling in the chest area

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230
Q

what are risk factors for developing ovarian cancer

A

increased age
family history of ovarian and breast cancer
BRCA1 and 2 mutations
obesity
smoking
nulliparity
endometriosis

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231
Q

what are symptoms of obstetric cholestasis

A

intense pruritis worse on hands and feet
fatigue
nausea
abdominal pain
mild jaundice

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232
Q

what is the most common cause of multiple painful genital lesions in both males and females

A

Herpes simplex virus

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233
Q

what is used to treat pre-eclampsia if labetalol is contraindicated

A

nifedipine

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234
Q

how do you manage obstetric cholestasis

A

with an early delivery (37-38 weeks) as it can increase the chance of spontaneous fetal death and maternal haemorrhage

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235
Q

what are the most common type of uterine fibroid

A

intramural fibroid - located within the myometrium

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236
Q

what pharmacological management is given to those with PCOS to aid fertility

A

Clomiphene citrate - used to increase endogenous FSH and acts to induce ovulation

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237
Q

what is Mittelschmerz

A

it is mid cycle ovulatory pain

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238
Q

what type of cancer are the majority of vulval cancers

A

squamous cell carcinomas

239
Q

how does vulval cancer typically present

A

ulcerated lesion on labia
persistent soreness and itching

240
Q

what advice should be given in women with PCOS who take the COCP

A

they should induce a withdrawal bleed at least once every three months
- to reduce the risk of endometrial cancer

241
Q

what postnatal care will women receive in the days after delivery

A

analgesia as required
help establishing feeding
VTE risk assessment
monitoring for PPH
monitoring for sepsis
monitoring recovery after caesaren or tear
FBC
anti D in rhesus negative women
routine baby check

242
Q

after the initial postnatal period what is checked at routine follow up

A

general wellbeing
mood and depression
bleeding and menstruation
urinary incontinence and pelvic floor exercises
scar healing
contraception
breastfeeding
vaccines

243
Q

what is checked at the six week postnatal check in women

A

general wellbeing
mood and depression
bleeding and mensuration
scar healing
contraception
breast feeding
fasting blood glucose (after gestational diabetes)
blood pressure (after pre-eclampsia)
urine dipstick for protein (after pre-eclampsia)

244
Q

what is the vaginal bleed after pregnancy called

A

lochia - mix of blood, endometrial tissue and mucus

245
Q

When does fertility return after being pregnant

A

about 21 days post birth

246
Q

how effective is lactational amenorrhoea

A

it is over 98% effective up to 6 months after birth, but only if the woman is fully breastfeeding and amenorrhoeic

247
Q

what forms of contraception are considered safe in breastfeeding

A

the progesterone only pill and the implant
- can be started any time after birth

248
Q

can the combined oral contraceptive be given after birth

A

no - it should be avoided in breastfeeding

249
Q

can the copper coil/IUS be inserted after birth

A

yes but only within 48 hours of birth or more than four weeks after birth

250
Q

what is postpartum endometriositis

A

it is inflammation of the endometrium after birth usually caused by infection introduced into the vagina during the labour/delivery of a baby

251
Q

what are symptoms of postnatal endometriositis

A

foul smelling discharge or lochia
bleeding that gets heavier or doesnt improve with time
lower abdominal or pelvic pain
fever
sepsis

252
Q

how is postnatal endometriositis diagnosed

A

vaginal swabs and urine culture

253
Q

how is postnatal endometriositis treated

A

septic patients - sepsis 6, and broad spectrum antibiotics (clindamycin and gentamicin)
non septic patients - co-amoxiclav

254
Q

what are retained products of conception

A

this is when pregnancy related tissue (placental tissue or fetal membranes) remain within the uterus after delivery

255
Q

how does retained products of conception present

A
  • vaginal bleeding that gets heavier and doesnt improve
  • abnormal vaginal discharge
  • lower abdominal or pelvic pain
  • fever (if infection occurs)
256
Q

how do you diagnose retained products of conception

A

ultrasound

257
Q

how do you manage retained products of conception

A

ERPC - evacuation or retained products of conception

258
Q

what are two key complications of the treatment of retained products of conception

A

endometriositis
Ashermans syndrome - adhesions that form within the uterus due to scraping

259
Q

what are the baby blues

A

it is feeling low in the first week or so after birth and affects around 50% of women

260
Q

what are symptoms of the baby blues

A

mood swings, low mood, anxiety, irritability, tearfulness

261
Q

what are baby blues a result of

A

significant hormonal changes, recovery from birth, fatigue and sleep deprivation, the responsibility of caring for a neonate, establishing feeding

262
Q

what is postnatal depression

A

it is a classic triad of low mood, anhedonia (lack of pleasure in activities) and low energy

263
Q

when does postnatal depression typically effect women

A

around three months after birth - symptoms have to be at least two weeks for it to be classed as postnatal depression

264
Q

how is mild postnatal depression treated

A

additional support, self help and follow up

265
Q

how is moderate postnatal depression treated

A

antidepressant medications and CBT

266
Q

how is severe postnatal depression treated

A

specialist psychiatry services and rarely impatient care on the mother baby unit

267
Q

what screening tool is used to assess how a mother has felt over the past week

A

the Edinburgh postnatal depression scale
- ten questions with a total score of 30. anything over 10 suggests postnatal depression

268
Q

what is postnatal psychosis

A

a severe illness that typically has an onset of between two to three weeks post delivery where a woman experiences full psychotic symptoms

269
Q

what are symptoms of puerperal psychosis

A

delusions
hallucinations
depression
mania
confusion
thought disorder

270
Q

how is puerperal psychosis treated

A

admission to the mother and baby unit
CBT
medications - antidepressants, antipsychotics and mood stabilisers
electroconvulsive therapy

271
Q

what can SSRI intake during pregnancy cause

A

neonatal abstinence syndrome - presents a few days after birth with irritability and poor feeding

272
Q

what is mastitis

A

it is inflammation of the breast tissue and is a common complication for breast feeding

273
Q

what can mastitis be caused by

A

-obstruction in the ducts and accumulation of milk
- infection due to bacteria entering the nipple

274
Q

what is the most common infective cause of mastitis

A

staph aureus

275
Q

how does mastitis present

A

unilateral breast pain and tenderness
erythema in a focal area of breast tissue
local warmth and inflammation
nipple discharge
fever

276
Q

what is the management of mastitis

A
  • when mastitis is due to blockage of the ducts management is continues breastfeeding and expressing milk
  • when infection is suspected flucloxacillin is first line (or erythromycin if allergic to penicillin)
277
Q

what is a rare complication of mastitis

A

a breast abscess - may need surgical incision and drainage

278
Q

what is candida of the nipple

A

this often occurs after a course of antibiotics and leads to recurrent mastitis

279
Q

what is the presentation of candida of the nipple

A

sore nipples bilaterally
nipple tenderness and itching
cracked flaky and shiny areola
in the baby may have white patches in the mouth and on the tongue/candida nappy rash

280
Q

how is candida of the nipple treated

A

topical miconazole 2% after each feed
treatment for the baby - miconazole gel or nystatin

281
Q

what is post partum thyroiditis

A

this is a condition where there is changes in thyroid function within 12 months of delivery leading to hyper and hypothyroidism

282
Q

what are the stages of postpartum thyroiditis

A

thyrotoxicosis (usually in the first three months)
hypothyroid ( usually from months 3-6)
thyroid function gradually returns to normal (usually within 1 year)

283
Q

what are signs and symptoms of postpartum thyroiditis

A

hyperthyroid: anxiety and sweating, heat intolerance, tachycardia, weight loss, fatigue, frequent loose stools
hypothyroid: weight gain, fatigue, dry skin, coarse hair/hair loss, low mood, fluid retention, heavy or irregular periods, constipation

284
Q

what is the management of postpartum thyroiditis

A

referral to an endocrinologist for specialist management
thyrotoxicosis: symptomatic control such as propranolol
hypothyroidism: levothyroxine
patients will need annual monitoring to ensure they dont develop long term hypothyroidism

285
Q

what is sheehans syndrome

A

it is a rare complication of post partum haemorrhage where the drop in circulating blood volume leads to avascular necrosis of the anterior pituitary

286
Q

what blood supply does the anterior pituitary get its blood from

A

the hypothalamo-hypophyseal portal system

287
Q

what hormones are affected in Sheehans syndrome

A

TSH, ACTH, FSH, LH, GH, prolactin

288
Q

how does sheehans syndrome present

A

reduced lactation, amenorrhoea, adrenal insufficiency and adrenal crisis, hypothyroidism with low thyroid hormones

289
Q

how is sheehans syndrome managed

A

with hormone replacement therapy
- oestrogen and progesterone
- hydrocortisone
- levothyroxine
- growth hormone

290
Q

what is amenorrhoea

A

it lack of menstrual periods

291
Q

what is primary amenorrhoea

A

it when a patient has never developed periods

292
Q

what are reasons for primary amenorrhoea

A

abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
abnormal functioning of the gonads (hypergonadotropic hypogonadism)
structural pathology such as imperforate hymen

293
Q

what is secondary amenorrhoea

A

it is when the patient previously had periods which have subsequently stopped

294
Q

what can cause secondary amenorrhoea

A

pregnancy (MC)
menopause
phycological stress - excessing exercise, low body weight, chronic disease, psychosocial factors
polycystic ovarian syndrome
medications - hormonal contraceptives
premature ovarian insufficiency
thyroid hormone abnormalities
excessive prolactin
cushings

295
Q

what is irregular menstruation

A

it is when there is irregularities in the menstrual cycle affecting the frequency, duration and regularity of the length cycle and volume bled

296
Q

what are causes for irregular menstruation

A

extremes of reproductive age
polycystic ovarian syndrome
phycological stress
medications such as the progesterone only pill, antidepressants and antipsychotics
hormonal imbalance such as thyroid abnormalities, cushings and high prolactin

297
Q

what is intermenstrual bleeding

A

this is bleeding that occurs between menstrual periods - RED FLAG

298
Q

what are causes of intermenstrual bleeding

A

hormonal contraception
cervical ectropion, polyps or cancer
sexually transmitted infection
endometrial polyps or cancer
vaginal pathology including cancer
pregnancy
ovulation
medications such as SSRI and anticoagulants

299
Q

what is dysmenorrhoea

A

this is painful periods

300
Q

what can cause dysmenorrhoea

A

primary dysmenorrhoea (no cause)
endometriosis or adenomyosis
fibroids
pelvic inflammatory disease
copper coil
cervical or ovarian cancer

301
Q

what is menorrhagia

A

it refers to heavy menstrual bleeding

302
Q

what is menorrhagia caused by

A

dysfunctional uterine bleeding (no cause)
extremes of reproductive age
fibroids
endometriosis and adenomyosis
pelvic inflammatory disease
contraceptives such as the copper coil
bleeding disorders
anticoagulants
connective tissue disorder
endocrine disorders
endometrial hyperplasia or cancer
PCOS

303
Q

what are the causes for post coital bleeding

A

cervical cancer, ectropion or infection
trauma
atrophic vaginitis
polyps
endometrial cancer
vaginal cancer

304
Q

what are causes for pelvic pain

A

urinary tract infection
dysmenorrhoea
irritable bowel syndrome
ovarian cysts
endometriosis
pelvic inflammatory disease
ectopic pregnancy
appendicitis
Mittelschmerz
pelvic adhesions
ovarian torsion
inflammatory bowel disease

305
Q

what can cause excessive, discoloured or foul smelling discharge

A

bacterial vaginosis
candidiasis
chlamydia
gonorrhoea
trichomonas vaginalis
foreign body
cervical ectropion
polyps
malignancy
ovulation
hormonal contraception

306
Q

what is pruritus vulvae

A

it refers to itching of the vulva and vagina

307
Q

what can cause pruritis vulvae

A

irritants - soaps, detergents, barrier contraception
atrophic vaginitis
infections - candidiasis
skin conditions such as eczema
vulval malignancy
pregnancy related vaginal discharge
urinary or faecal incontinence
stress

308
Q

what is primary amenorrhoea defined as

A

not starting menstruation by
13 years when there is no other evidence of puberty
15 years when there are other signs of puberty

309
Q

what can cause hypogonadotropic hypogonadism

A

hypopituitarism - under production
damage to the hypothalamus or pituitary
significant chronic conditions - CF/IBD
excessive exercise or dieting
constitutional delay in growth and development
endocrine disorders
kallman syndrome - failure to start puberty plus loss/reduced sense of smell

310
Q

what can cause hypergonadotropic hypogonadism

A

previous damage to the gonads - torsion, cancer, infections (mumps)
congenital absence of the ovaries
turners syndrome

311
Q

what is congenital adrenal hyperplasia

A

it is an ender production of cortisol and aldosterone and an overproduction of androgens caused by a congenital deficiency of the 21 hydroxylase enzyme

312
Q

what are typical features of congenital adrenal hyperplasia

A

tall for their age
facial hair
absent periods (primary)
deep voice
early puberty

313
Q

what is androgen insensitivity syndrome

A

this is where the tissues are unable to respond to androgen hormones (testosterone) so typical male sexual characteristics do not develop. This results in a female phenotype other than the internal female pelvic organs

314
Q

what structural abnormalities can prevent someone getting their period

A

imperforate hymen
transverse vaginal septae
vaginal agenesis
absent uterus
female genital mutilation

315
Q

how can patients with hypogonadotropic hypogonadism be treated

A

with pulsatile GnRH to induce ovulation and menstruation

316
Q

why does hyperprolactinaemia cause suppression of the menstrual cycle

A

as high levels of prolactin act on the hypothalamus to prevent release of GnRH, thus preventing the release of LH and FSH

317
Q

what condition is important to remember when a patient has amenorrhoea associated with low oestrogen

A

osteoporosis - lack of oestrogen increases their risk
if they have had amenorrhoea longer than 12 months then ensure there is adequate vitamin D and calcium intake and put on hormone replacement therapy

318
Q

what is premenstrual syndrome

A

this is the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle. these symptoms can be distressing and significantly impact patients quality of life

319
Q

when do symptoms of pre menstrual syndrome resolve

A

they resolve once menstruation begins

320
Q

what is the presentation of pre menstrual syndrome

A

low mood
anxiety
mood swings
irritability
bloating
fatigue
headache
breast pain
reduced confidence
cognitive impairment
clumsiness
reduced libido

321
Q

how is premenstrual syndrome diagnosed

A

made based on a symptom diary spanning two menstrual cycles
definitive diagnosis may be made by giving GnRH analogues which halt the menstrual cycle and temporarily induce menopause to see if symptoms improve

322
Q

how is premenstrual syndrome managed

A
  • general healthy lifestyle changes
    -combined oral contraceptive pill
    -SSRI antidepressants
  • CBT
    in severe cases an MDT team gets involved
    GnRH analogues can be used
    Hysterectomy with oophorectomy can be done
    danazole and tamoxifen can be used to help cyclical breast pain
    spironolactone can be used to help with breast swelling, water retention and bloating
323
Q

what are fibroids

A

they are benign tumours of the smooth muscle of the uterus
- oestrogen sensitive

324
Q

what are the different types of fibroids

A

intramural
subserosal
submucosal
pedunculated

325
Q

what is an intramural fibroid

A

this is a fibroid that grows within the myometrium and as they grow they change the shape and distort the uterus

326
Q

what is a subserosal fibroid

A

this fibroid grows just below the outer layer of the uterus, they grow outward and can become large filling the abdominal cavity

327
Q

what is a submucosal fibroid

A

this grows just below the lining of the uterus

328
Q

what is a pedunculated fibroid

A

this is a fibroid that grows on a stalk

329
Q

how do fibroids present

A

heavy menstrual bleeding
prolonged menstrual bleeding
abdominal pain
bloating or full feeling
urinary or bowel symptoms
deep dyspareunia
reduced fertility

330
Q

how are fibroids managed

A

fibroids less than 3cm
- Mirena coil (1st line)
- symptomatic management
- combined oral contraceptive
- cyclical oral progestogens

for those larger than 3cm
- surgical management first line: uterine artery embolism, myomectomy, hysterectomy
- medical management is: symptomatic, mirena coil, cocp, progestogens

331
Q

what are complications of fibroids

A

heavy menstrual bleeding
reduced fertility
pregnancy complications - miscarriages, premature labour, obstructive delivery
constipation
urinary outflow obstruction/UTI
red degeneration of the fibroid
torsion of the fibroid
malignant change to a leiomyosarcoma

331
Q

what can be given to reduce the size of fibroids before surgery

A

GnRH agonists: goserelin or leuprorelin

332
Q

what is red degeneration of fibroids

A

red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
- more likely to occur in larger fibroids during the second and third trimester of pregnancy
- can occur as the fibroid rapidly enlarges during pregnancy

333
Q

how does red degeneration of fibroids present

A

severe abdominal pain, low grade fever, tachycardia and often vomiting

334
Q

what is endometriosis

A

it is a condition where there is ectopic endometrial tissue outside the uterus

335
Q

what is adenomyosis

A

endometrial tissue within the myometrium of the uterus

336
Q

how does endometriosis present

A

cyclical abdominal or pelvic pain
deep dyspareunia
dysmenorrhoea
infertility
cyclical bleeding from other sites
can also have urinary and bowel symptoms

337
Q

what will examination reveal in endometriosis

A

endometrial tissue visible in the vagina on speculum examination (posterior fornix)
a fixed cervix on bimanual examination
tenderness in the vagina, cervix and adnexa

338
Q

how do you diagnose endometriosis

A

pelvic ultrasound - large endometriomas and chocolate cysts
laparoscopic surgery (GOLD)

339
Q

what is the American Society of Reproductive Medicine staging of endometriosis

A

stage 1: small superficial lesions
stage 2: mild but deeper lesions than stage 1
stage 3: deeper lesions, with lesions on the ovaries and mild adhesions
stage 4: deep and large lesions affecting the ovaries with extensive adhesions

339
Q

what is the treatment for endometriosis

A

initial management involves
- analgesia as required

hormonal management
- COCP / POP
- medroxyprogesterone acetate injection
- nexplanon implant
- mirenal coil
- GnRH agonists

Surgical
- laparoscopic surgery to excise and ablate the tissue
- hysterectomy

340
Q

what is tamoxifen used for

A

it is used to treat oestrogen receptor positive breast cancer in those who are pre/peri menopausal

341
Q

why is tamoxifen not used in post menopausal women

A

because it is a partial agonist for oestrogen so increases the risk of endometrial cancer
increases the risk of thrombosis

342
Q

how is genital herpes treated in pregnancy

A

oral acyclovir 400mg three times a day

343
Q

what are the risks of having untreated bacterial vaginosis in pregnancy

A

pre term delivery
late miscarriage

344
Q

what is adenomyosis

A

when endometrial tissue is inside the myometrium (muscle layer of the uterus)

345
Q

how does adenomyosis present

A

painful periods
heavy periods
pain during intercourse
may alsoe be related with infertility or pregnancy related complications

346
Q

How does adenomyosis present on examination

A

enlarged and tender uterus
more soft than a uterus containing fibroids

347
Q

how is adenomyosis diagnosed

A

transvaginal ultrasound
MRI/transabdominal ultrasound
golf standard is histological examination of the uterus post hyperectomy

348
Q

how is adenomyosis managed

A

when a woman doesnt want contraception
- tranexamic acid to reduce bleeding
- mefenamic acid when there is associated main

when contraception is wanted
- mirena coil is first line
- combined oral contraceptive pill
- cyclical oral progestogens

can also do GnRH analogues, endometrial ablation, uterine artery embolism, hysterectomy

349
Q

what is adenomyosis associated with in pregnancy

A

infertility
miscarriage
preterm birth
small for gestational age
preterm premature rupture of membranes
malpresentation
need for cs
postpartum haemorrhage

350
Q

what does a diagnosis of menopause mean

A

it is when a woman has had no periods for 12 montsh and is defined as a permanent end to mentruation

351
Q

what is postmenopause

A

it is the period from 12 months after the final menstrual period onwards

352
Q

what is perimenopause

A

this refers to the time around the menopause where the woman may be experiencing vasmotos symptoms and irregular periods

353
Q

what is premature menopause

A

it is menopause before the age of 40 years, it is a result of premature ovarian insufficiency

354
Q

what is menopause caused by

A

it is caused by a lack of ovarian follicular function resulting in low oestrogen and progesterone, and high FSH and LH

355
Q

what are perimenopausal symptoms

A

hot flushes
emotional lability or low mood
prementrual syndrome
irregular periods
joint pains
heavier or lighter periods
vaginal dryness and atrophy
reduced libido

356
Q

what are risks associated with menopause

A

cardiovascular disease and stroke
osteoporosis
pelvic organ prolapse
urinary incontinence

357
Q

how is a diagnosis of menopause made

A

made in women over 45 with typical symptoms without performing investigations

FSH blood tests to help diagnosis in women under 40 with suspected premature menopause, or women ages 40-45 with menopausal symptoms

358
Q

how long do women need to use effective contraception for

A
  • two years after the last menstrual period in women under 50
  • one year acter the last menstrual period in women over 50
359
Q

what are good contraception options for women approaching menopause

A

barrier methods
mirena or copper coil
progesterone only pill
progesterone implant
progesterone depot injection (under 45)
sterilisation

combined oral contraceptive pill can be used after 40 and up to 50 if there are no other contraindications

360
Q

how can perimenopausal symptoms be managed

A

HRT
tibolone - continuous HRT (only after 12 months of amenorrhoea)
- Clonidine - agonists of alpha adrenergic and imidazole receptors
- CBT
- SSRI antidepressants
- testosterone
- vaginal oestrogen
- vaginal moisturizers

361
Q

what is premature ovarian insufficiency characterised by

A

hypergonadotropic hypogonadism - lack of negative feedback on the pituitary gland resulting in excess of gonadotropins

362
Q

what are causes of premature ovarian syndrome

A

idiopathic
iatrogenic - chemotherapy, radiotherapy, surgery
autoimmune - coeliac disease, adrenal insufficiency, T1DM, thyroid disease
genetic - i.e turners
infections - mumps, tuberculosis, cytomegalovirus

363
Q

what other conditions are also associated with premature ovarian failure

A

cardiovascular disease
stroke
osteoporosis
cognitive impairment
dementia
parkinsonism

364
Q

how is premature ovarian syndrome managed

A

hormone replacement therapy
- typical hormone replacement therapy (may be an increase in VTE with HRT under 50)
- combined oral contraceptive pill

365
Q

when is progesterone given in HRT

A

it needs to be given to women that have a uterus to prevent endometrial hyperplasia and endometrial cancer

366
Q

what type of HRT should a women who still has periods go on

A

they should go on cyclical HRT and have regular breakthrough bleeds

367
Q

what is clonidine

A

it is an alpha 2 adrenergic and imidazoline receptor agonist. it lowers blood pressure and reduces heart rate. it helps vasomotor symptoms and hot flushes

368
Q

what are common side effects of clonidine

A

dry mouth
headaches
dizziness
fatigue

369
Q

what alternative therapies can be used to help menopausal symptoms

A

black cohosh - helps with hot flushes
dong quai - acts like oestrogen
red clover - helps to improve blood flow, helps with hot flushes and night sweats
evening primrose oil - help relieve symptoms of menopause
ginseng - helps with hot flushes and symptoms

370
Q

what are risks of HRT

A

increased risk of breast cancer
increased risk of endometrial cancer
increased risk of VTW
increased risk of stroke and CAD (no increased risk of CAD with oestrogen only HRT)

371
Q

what are contraindications of HRT

A

undiagnosed abnormal bleeding
endometrial hyperplasia or cancer
breast cancer
uncontrolled hypertension
venous thromboembolism
liver disease
active angina or myocardial infarction
pregnancy

372
Q

what assessments need to be done before HRT

A

full history to ensure no contraindications
check BMI and BP
ensure cervical and breast screening is up to date
encourage lifestyle changes

373
Q

what 3 steps do you need to consider when choosing HRT formulation

A
  1. do they have local or systemic symptoms
  2. does the woman have a uterus
  3. have they had a period in the last 12 months
374
Q

what are the three options for delivering progesterone for endometrial protection

A

oral
transdermal - patch
intrauterine system - mirena coil

375
Q

what is tibolone

A

it is used as a form of continuous combined HRT - it is a synthetic steroid that stimulates oestrogen and progesterone receptors

376
Q

why is testosterone given in menopause

A

in menopause there is reduced testosterone in women which results in low energy and reduced libido, so it can be given as a transdermal replacement therapy

377
Q

how long does it take for HRT to gain its full effects

A

3-6 months

378
Q

what are side effect of oestrogen HRT

A

nausea and bloating
breast swelling
breast tenderness
headache
leg cramps

379
Q

what are side effects of progestogenic HRT

A

mood swings
bloating
fluid retention
weight gain
acne and greasy skin

380
Q

what are characteristic of PCOS

A

Multiple ovarian cysts
infertility
oligomenorrhoea
hyperandrogenism
insulin resistance

381
Q

what does oligoovulation mean

A

it refers to irregular infrequent ovulation

382
Q

what is hirsutism

A

refers to the growth of dark thick hair often in a male pattern

383
Q

what criteria is used to make a diagnosis PCOS

A

the rotterdam criteria

384
Q

what does a diagnosis of PCOS require

A

it requires two of the three key features
- oligoovulation or anovulation presenting with irregular or absent menstrual periods
- hyperandrogenism - hirsutism and acne
- polycystic ovaries on ultrasound (volume or more than 10cm3)

385
Q

how does PCOS present

A

oligomenorrhoea or amenorrhoea
infertility
obesity (in about 70% of patients)
hirsutism
acne
hair loss in a male pattern

386
Q

what other features pay someone with PCOS present with

A

insulin resistance and diabetes
acanthosis nigricans
cardiovascular disease
hypercholesterolaemia
endometrial hyperplasia and cancer
obstructive sleep apnoea
depression and anxiety
sexual problems

387
Q

what investigations are performed to diagnose PCOR

A
  • blood tests to look at testosterone, sex hormone binding globulin, luteinizing hormone, FHS, prolactin and TSH
  • pelvic ultrasound (string of pearls)
  • OGTT
388
Q

what general management can be done for people with PCOS

A

weight loss
calorie controlled diet
exercise
smoking cessation
antihypertensive medications were required
statins where indicated

389
Q

what are people with PCOS at risk of developing

A

endometrial cancer

390
Q

how are the risk factors for endometrial cancer managed in PCOS

A

mirena coil for continuous endometrial protection
inducing withdrawal bleed every 3-4 months if they are on cyclical progestogens or the COCP

391
Q

what risk factors for endometrial cancer do people with PCOS have

A

obesity
diabetes
insulin resistance
amenorrhoea

392
Q

how can infertility be managed in those with PCOS

A

weight loss (1st initial step)
clomifene - stimulates ovaries to release egg each month
laparoscopic ovarian drilling
in vitro fertilitsation

393
Q

how is hirsutism managed in those with PCOS

A

weight loss
Co-cyprindiol - COCP
topical eflornithine - treat facial hirsutism
electolysis
laser hair removal
spirololactone (anti-androgen effects)
finasteride (5a reductase inhibitor)
flutamide (non steroidal ani-androgen)
cyproterone acetate (anti-androgen and progestin)

394
Q

how is acne managed in PCOS

A

COCP (1st line)
Co-cyprindiol
topical adapalene (retinoid)
topical antibiotics (clindamycin)
topical azelaic acid
oral tetracycline antibiotics

395
Q

how do ovarian cysts present

A

most are asymptomatic - found incidentally
pelvic pain
bloating
fullness in the abdomen
palpable pelvic mass
pain if there is ovarian torsion, haemorrhage or rupture

396
Q

what are functional ovarian cysts

A

follicular cyst - developing follicle, when they fail to rupture the cyst persists. these are harmless and tend to disappear

corpus luteum cysts - when the corpus luteum fails to break down and fills with fluid instead

397
Q

what are types of ovarian cysts

A
  • serous cystadenoma (benign tumours)
  • mucus cystadenoma (benign tumour -become large)
  • endometrioma (lumps of endometrial tissue)
  • dermoid cysts/germ cell tumours
  • sex cord stromal tumours
398
Q

what history should be established from someone with ovarian cysts

A

abdominal bloating
reduced appetite
early satiety
weight loss
urinary symptoms
pain
ascites
lymphadenopathy

399
Q

what are risk factors for ovarian malignancy

A

age
postmenopause
increased number of ovulations
obesity
hormone replacement therapy
smoking
breastfeeding (protective)
family history and BRCA1/2

400
Q

what blood tests should be done in someone with an ovarian cyst to rule out malignancy

A

CA 125
lactate dehydrogenase
alpha fetoprotein
HCG

401
Q

what are managements for ovarian cysts

A

possible ovarian cancer needs a two week wait referral
possible dermoid cysts require referral to gynaecologist for further investigation

simple ovarian cysts can be managed based on their size
- less than 5cm are left alone. 5-7 have yearly monitoring, over 7 consider MRI or surgical evaluation

in post menopausal women look at ca 125 and refer to gynaecologist

402
Q

how can cysts be treated

A

any persistent or enlarged cysts may require surgery (laparoscopy)
may need to remove affected ovary
small cysts just need monitoring

403
Q

what are complications of ovarian cysts

A

torsion
haemorrhage
rupture

404
Q

what is meigs syndrome

A

this is a triad of ovarian fibroma (benign tumour)
plural effusion
ascites

occurs in older women

405
Q

what is ovarian torsion

A

where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply

406
Q

what can ovarian torsion lead to

A

ischaemia and necrosis of the ovary

407
Q

how does ovarian torsion present

A

sudden severe unilateral pelvic pain
nausea and vomiting
localised tenderness
palpable mass

408
Q

how is ovarian torsion diagnosed

A

history
pelvic ultrasound
transvaginal ultrasound - whirlpool sign
laparoscopic surgery - definitive diagnosis

409
Q

how is ovarian torsion managed

A

emergency admission
laparoscopic surgery to either untwist and fix the ovary or to remove the affected ovary depending on visual inspection

410
Q

what are complications of an ovarian torsion

A

delay in treatment can lead to loss of function
if not removed it may become infected and develop into an abscess and lead to sepsis
may rupture leading to peritonitis

411
Q

what is Ashermans syndrome

A

this is where adhesions form within the uterus following damage to the uterus
- can bind the walls together or bind the endocervix shut

412
Q

what can cause ashermans syndrome

A

after pregnancy related dilation and curettage procedure (scraping)
uterine surgery
several pelvic infections

413
Q

How does Ashermans syndrome present

A

secondary amenorrhoea
significantly lighter periods
dysmenorrhoea
infertility

414
Q

how is Ashermans syndrome diagnosed

A

hysteroscopy (GOLD STANDARD)
hysterosalpingography (contrast and Xray)
Sonohysterography (USS)
MRI scan

415
Q

how is Ashermans syndrome managed

A

dissecting the adhesions during hysteroscopy

416
Q

what can early infection with toxoplasma gondii lead to in the fetus

A

hydrocephalus
seizures
visual and hearing impairment

417
Q

what is the best treatment for pelvic inflammatory disease

A

Ceftriaxone, doxycycline, metronidazole
- covers chlamydia, gonorrhoea and anaerobic vaginal commensals

418
Q

What is bacterial vaginosis

A

it is an overgrowth of bacteria in the vagina -anaerobic caused by a loss of the lactobacilli in the vagina

419
Q

what is the main component of the healthy vaginal bacterial flora

A

lactobacilli - produce lactic acid that keeps vaginal pH low (under 4.5)

420
Q

what bacteria are associated with bacterial vaginosis

A

gardnerella vaginalis - most common
mycoplasma hominis
prevotella

421
Q

what are risk factors of bacterial vaginosis

A

multiple sexual partners
excessive vaginal cleaning products
recent antibiotics
smoking
copper soil

422
Q

how does bacterial vaginosis present

A

fishy smelling watery grey or white vaginal discharge

423
Q

what investigations can be done to diagnose bacterial vaginosis

A

vaginal pH
charcoal vaginal swab
clue cells from epithelial cells on microscopy

424
Q

how is bacterial vaginosis treated

A

asymptomatic doesnt require treatment
metronidazole - orally or vaginal gel

425
Q

what are complications of bacterial vaginosis

A

increases the risk of catching STIs
complications in pregnant women:
miscarriage
preterm delivery
premature rupture of membranes
chorioamnionitis
low birth weight
postpartum endometritis

426
Q

what is Balanitis

A

it is inflammation of the glans penis and foreskin

427
Q

what can infections cause balanitis

A

Non specific dermatitis with infection: candida albicans (blotchy redness), group A beta haemolytic strep and staph aureus (painful redness of penis)
other infections can cause balanitis - Gardnerella, chlamydia, gonorrhoea, herpes, HPV, trichomonas, syphilis, scabies

428
Q

what skin conditions can cause balanitis

A

irritant or allergic contact dermatitis - soap, lubricants, latex (pain and rash)
seborrhoeic dermatitis
psoriasis
lichen sclerosus
lichen planus
plasma cell balanitis

429
Q

other than skin conditions and infection what else can cause balanitis

A

mechanical irritation
poor hygiene
over washing
systemic disease - crohns or sarcoidosis

430
Q

what is chancroid

A

it is a sexually transmitted infection most common in poor resource countries

431
Q

what is chancroid caused by

A

fastidious gram negative coccobacillus haemophilus ducreyi

432
Q

how long is the incubation period for chancroid

A

three to seven days

433
Q

what are symptoms of chancroid

A

raised and painful bumps of genital skin
ulcers with ragged soft edges that develop from bumps
reddened and shiny skin of the sores
leakage of pus
lymphadenitis and buboes

434
Q

what are risk factors for chancroid

A

multiple sexual partners
sexual contact with a sex worker
unprotected intercourse
substance abuse

435
Q

what investigations are done in someone with suspected chancroid

A

gram stain of ulcer swabs and bubo aspirates
culture of ulcer swabs
PCR
syphilis serology
HIV testing

436
Q

how is chancroid treated

A

Azithromycin 1g orally - one dose
ceftriaxone 250 mg IM
ciprofloxacin 500mg orally BD for 3 days
erythromycin 500mg orally TD for 7 days

437
Q

what is the national chlamydia screening programme

A

it is a programme that aims to screen every sexually active person under the age of 25 for chlamydia annually or when they change their sexual partner

438
Q

what are the two types of swabs used for diagnosing chlamydia

A

charcoal swabs - microscopy
NAAT swabs

439
Q

what infections can charcoal swabs be used to diagnose

A

bacterial vaginosis
candidiasis
gonorrhoea
trichomonas vaginalis
group B streptococcus

440
Q

how does chlamydia present in men and women

A

asymptomatic
In women: abnormal vaginal bleeding, pelvic pain, abnormal vaginal bleeding, painful sex, painful urination
in men: urethral discharge or discomfort, painful urination, epididymo-orchitis, reactive arthritis

441
Q

what will be found on examination of someone with chlamydia

A

pelvic or abdominal tenderness
cervical motion tenderness
inflamed cervix
purulent discharge

442
Q

how is chlamydia treated

A

doxycycline 100mg BD for 7 days
in breastfeeding/pregnant women:
azithromycin 1g stat and then 500mg OD for 2 days
erythromycin 500mg QD for 7 days
erythromycin 500mg BD for 14 days
amoxicillin 500mg TD for 7 days

443
Q

what other factors should be considered when treating chlamydia

A

abstain from sex for 7 days of treatment of all partners to reduce risk of re infection
refer all patients to GUM for contact tracing
test for and treat any other STI

444
Q

what are complications of chlamydia

A

PID
chronic pelvic pain
infertility
ectopic pregnancy
epididymo-orchitis
conjunctivitis
lymphogranuloma venereum
reactive arthritis

445
Q

what is lymphogranuloma venereum

A

it is a condition affecting the lymphoid tissue around the site of infection with chlamydia
- commonly occurs in MSM

446
Q

what are the three stages of lymphogranuloma vanereum

A

primary - painless ulcer
secondary stage - lymphadenitis: swelling, inflammation and pain in the lymph nodes infected with the bacteria
tertiary - inflammation of the rectum and anus

447
Q

what are the symptoms of the tertiary stage of LGV

A

anal pain
change in bowel habit
tenesmus - feeling of needing to empty the bowels even after they are empty
discharge

448
Q

what is the first line treatment for LGV

A

doxycycline 100mg BD for 21 days
- erythromycin, azithromycin and ofloxacin are alternatives

449
Q

what are the two infections that herpes simples virus is responsible for

A

cold sores - herpes labialis
genital herpes

450
Q

what are the common sensory nerve ganglia HSV becomes latent in

A

trigeminal nerve ganglion with cold sores
sacral nerve ganglia with genital herpes

451
Q

how is herpes simples virus spread

A

direct contact with affected mucous membranes or viral shedding in mucous secretions

452
Q

what type of herpes simplex typically causes genital herpes and cold sores

A

genital herpes - HSV2
cold sores HSV 1

453
Q

how does genital herpes present

A

may display no symptoms or develop symptoms years after an initial infection
- ulcers or blistering lesions
- tingling, burning or shooting pain (neuropathic)
- flu like symptoms
- dysuria
- inguinal lymphadenopathy

454
Q

how is genital herpes diagnosed

A

clinically - history and exam
viral PCR

455
Q

how is genital herpes managed

A

GUM referral
Acyclovir
manage symptoms: paracetamol, lidocaine (2% gel), cleaning with warm salt water, Vaseline, additional oral fluids, wear loose clothing, avoid intercourse with symptoms

456
Q

what is the main issue of genital herpes during pregnancy

A

neonatal herpes simplex infection
- high risk of morbidity and mortality

457
Q

what are genital warts

A

small lumps that develop on the genitals and or around the anus

458
Q

what are anal warts caused by

A

human papillomavirus 6 and 11

459
Q

how is genital warts spread

A

sexual contact - close skin to skin contact to pass on the virus

460
Q

where to genital warts appear in men and women

A

in men: outer skin of the penis
in women: vulva, just outside the vagina, sometimes can develop in the vagina or on the cervix
warts may also develop on the skin round the anus in both men and women

461
Q

what is the appearance of genital warts

A

small skin coloured lumps on the skin
can be red/pink/white looking
warts that develop on skin that is war/moist/non hairy tend to be soft
warts that develop on dry and hairy skin tend to be firm

462
Q

what are symptoms of genital warts

A

often no symptoms other than a lump on the skin being noticed
they can sometimes cause irritation and soreness especially round the anus
can bleed or cause pain on intercourse
can be itchy

463
Q

how are genital warts diagnosed

A

history and examination
swabs - NAAT

464
Q

how are genital warts treated

A

can take several weeks to clear the infection
Chemical treatments: podophyllotoxin or imiquimod cream
physical treatments: freezing warts with liquid nitrogen, surgical removal under local anaesthetic, electrocautery, laser

465
Q

what type of bacteria is N. gonorrhoea

A

gram negative diplococcus

466
Q

what type of cells does N. gonorrhoea infect

A

mucous membranes with a columnar epithelium such as the endocervix in women, urethra, rectum, conjunctiva and pharynx

467
Q

how does N. gonorrhoea present

A

females: odourless purulent discharge, possible green or yellow, dysuria, pelvic pain
males: odourless purulent discharge, dysuria, testicular pain or swelling

468
Q

how is N. gonorrhoea diagnosed

A

NAAT testing
- endocervical, vulvovaginal or urethral swabs or first catch urine
- rectal and pharyngeal swab are recommended in all men who have sex with other men
charcoal swab should be taken for MCS before initiating antibiotics

469
Q

how is N. gonorrhoea managed

A

GUM clinic for contact tracing
Uncomplicated: single dose IM ceftriaxone 1g if sensitivities not known, or single dose oral ciprofloxacin 500mg if they are known
- all patients should have a follow up test of cure which is with NAAT testing

470
Q

how long after treatment of gonorrhoea should someone be followed up with test of cure

A

72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT

471
Q

what are complications of N. gonorrhoea

A

PID
chronic pelvic pain
infertility
epididymo-orchitis
prostatitis
conjunctivitis
urethral strictures
disseminated gonococcal infection
skin lesions
fitz-hugh-curtis syndrome
septic arthritis
endocarditis

472
Q

what is disseminated gonococcal infection

A

it is a complication of intreated gonococcal infection where the bacteria spreads to the skin and the joints

473
Q

what are symptoms of disseminated gonococcal infection

A

skin lesions
polyarthralgia
migratory polyarthritis
tenosynovitis
systemic symptoms - fever and fatigue

474
Q

what type of virus is HIV

A

RNA retrovirus

475
Q

how is HIV transmitted

A

unprotected anal, vaginal or oral sexual activity
mother to child at any stage of pregnancy, birth or breastfeeding
mucus membrane, blood or open wound exposure

476
Q

what are examples of AIDs defining illnesses

A

kaposis sarcoma
pneumocystis jjrovecii pneumonia
cytomegalovirus infection
candidiasis
lymphomas
tuberculosis

477
Q

how is HIV screened for

A
  • need verbal consent to perform test
    fourth generation tests check for antibodies to HIV and the p24 antigen. Have a 45 window period
  • point of cade tests for HIV antibodies give results within 90 minutes they have a 90 day window
  • home kits: self sampling or point of care tests
478
Q

how is HIV monitored

A

the CD4 count
- 500-1200 cells/mm3 is normal
< 200 cells/mm3 puts patient at risk of opportunistic infections
testing HIV RNA per ml of blood indicates the viral load

479
Q

how is HIV treated

A

GUM centre referral
antiretroviral therapy - two NRTIs (tenofovir +emtricitabine) plus a third agent

480
Q

what are the different classes of antiretroviral therapy

A

protease inhibitors
integrase inhibitors
nucleoside reverse transcriptase inhibitors
non nucleoside reverse transcriptase inhibitors
entry inhibitors

481
Q

other than antiretroviral therapy what other management is given to those diagnosed with HIV

A
  • prophylactic co-trimoxazole given to all HIV positive patients with CD4<200
  • close monitoring of CV risk factors - lipids
  • yearly cervical smears
  • vaccines up to date (done give live attenuated)
482
Q

how is HIV transmission prevented during birth

A

viral load under 50 copies/ml - normal birth
“ “ over 50 copies/ml - consider pre labour caesarean section
over 400 copies/ml pre labour caesarean is recommended

483
Q

what is given as an infusion during labour and delivery in a mum with HIV

A

IV zidovudine if the viral load is over 1000

484
Q

what is given to a baby after birth if the mother has HIV

A

prophylaxis
low risk given zidovudine for 2-4 weeks
high risk babies given zidovudine, lamivudine and nevirapine for four weeks

485
Q

what HIV prophylaxis is there?

A

post exposure prophylaxis - ART therapy
Pre-exposure prophylaxis

486
Q

what is the ART regime for PEP

A

emtricitabine/tenofovir and raltegravir for 28 days

487
Q

what is the ART regime for PrEP

A

emtricitabine/tenofovir

488
Q

What are symptoms of crabs

A

physically being able to see them
itching - worse at night
small red or blue spots on your skin
white/yellow dots attached to your hair
dark red or brown spots in your underwear
crusted or sticky eyelashes if they are affected

489
Q

what is the treatment for pubic lice

A

medicated creams/shampoos: malathion, ivermectin (pills)
- use treatment on whole body and leave it on for a few hours before washing it off
- will need to repeat after a week to ensure all the lice have been killed

490
Q

how are pubic lice spread

A

very close body contact - sexual contact

491
Q

will condoms prevent you getting lice

A

no

492
Q

what is sexual dysfunction

A

it is persistent physical issues, psychological issues or both that prevent someone engaging in sexual activities - can affect any phase of the sexual response from arousal to orgasm

493
Q

what is the diagnostic criteria for sexual dysfunction

A
  • be present 75-100% of the time
  • last for at least 6 months
  • have caused significant distress
494
Q

what are the four categories of sexual dysfunction

A
  1. desire disorder - hypoactive sexual desire disorder in which a person lacks sexual desire
  2. arousal disorder - may find it difficult or impossible to respond to sexual stimuli despite desire for sexual activity
  3. orgasm dysfunction
  4. pain disorders - vaginismus, dyspareunia, painful ejaculation
495
Q
A
496
Q

what is erectile dysfunction

A

this is a condition that prevents a person from getting or maintaining an erection firm enough for enjoyable sexual activity

497
Q

what are the three main types of ejaculation disorder

A

premature ejaculation
delayed ejaculation
retrograde ejaculation - semen passes backward into the bladder

498
Q

what are the common types of sexual dysfunction in females

A

pain and discomfort during sex
difficulty reaching orgasm

499
Q

why might a woman experience pain or discomfort during sex

A

lack of arousal, vaginal dryness or irritation
vaginismus - vagina tightens when a person attempts to insert something in there
STI
endometriosis
PID
genital injury
fibroids
cystitis
ovarian cysts
IBS
uterine prolapse

500
Q

what are the two types of difficulty reaching orgasm

A

primary: person has never had an orgasm
secondary: had orgasms in the past but cant reach them any more

501
Q

what are some physical causes of sexual dysfunction

A

hormone change - thyroid disorders, menopause, decrease in testosterone
metabolic conditions - obesity, high cholesterol
heart conditions
neurological disorders
substance use
medications - birth control pills, antidepressants, blood pressure medication

502
Q

what psychological issues can cause sexual dysfunction

A

stress
anxiety
depression
trauma
relationship issues
strict sexual beliefs
low self esteem
fear of sexual performance

503
Q

how to diagnose sexual dysfunction

A

bloods - TFTs, FBC etc
samples of vaginal discharge
hormone profile
cholesterol level tests

504
Q

what can be given for erectile dysfunction

A

alprostadil
PDE5 inhibitors such as sildenafil
penis pumps to stimulate blood flow/surgical penile implants

505
Q

what can be given for hypoactive sexual desire disorder

A

flibanserin - female Viagra
Bremelanotide

506
Q

what can be given for delayed ejaculation

A

buspirone - anxiety medication

507
Q

what can be given to prevent premature ejaculation

A

topical creams, gels, sprays or wipes that contain numbing agents such as lidocaine

508
Q

what can be done psychologically to help sexual dysfunction

A

sex education and therapy
couples counselling
cognitive behavioural therapy
relaxation therapy

509
Q

what is syphilis caused by

A

bacteria treponema pallidum
- spirochete bacteria

510
Q

how is syphilis transmitted

A

oral, vaginal or anal sex
vertical transmission from mother to baby
intravenous drug use
blood transfusions and other transplants

511
Q

what are the stages of syphilis

A

primary
secondary
latent
tertiary
neurosyphilis

512
Q

what occurs during primary syphilis

A

there is a painless ulcer called a chancre which resolves over 3-8 weeks
there is local lymphadenopathy

513
Q

what happens during secondary syphilis

A

systemic symptoms:
- maculopapular rash
- condylomata lata (grey wart like lesions around genitals and anus)
- low grade fever
- lymphadenopathy
- alopecia
- oral lesions
these symptoms can resolve after 3-12 weeks

514
Q

what is latent syphilis

A

this occurs after the secondary phase where the symptoms disappear and the patient becomes asymptomatic.
- early latent is within two years of initial infection
- late latent is after two years

515
Q

how does tertiary syphilis present

A

it affects many organs of the body
key features are:
Gummatous lesions - granulomatous lesions affecting the skin, organs and bones
Aortic aneurysms
neurosyphilis

516
Q

what is neurosyphilis

A

it is infection of the CNS with syphilis and it can occur at any stage of infection

517
Q

what are symptoms of neurosyphilis

A

headache
altered behaviour
dementia
tabes dorsalis - demyelination affecting the spinal cord posterior columns
ocular syphilis - Argyll-robertson pupil
paralysis
sensory impairment

518
Q

what is a Argyll-Robertson pupil

A

it is a specific finding of neurosyphilis which is a constricted pupil that accommodates when focusing on a near object but doesnt react to light
- often irregularly shaped

519
Q

how is syphilis diagnosed

A

antibody testing
samples from sites of infection - dark field microscopy and PCR

520
Q

what are two tests used to assess for active syphilis infection

A

rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)
- these are non specific but sensitive

521
Q

what is the management for syphilis

A

GUM referral
- deep IM dose of benzathine benzylpenicillin

522
Q

what is mycoplasma genitalium

A

it is a bacterial that causes non gonococcal urethritis - STI

523
Q

what can Mycoplasma genitalium infection lead to

A

most cases do not cause symptoms
- urethritis
- epididymitis
- cervicitis
- endometritis
- PID
- reactive arthritis
- preterm delivery in pregnancy
- tubal infertility

524
Q

what are the symptoms of Mycoplasma genitalium similar to

A

chlamydia

525
Q

what investigations are done for someone with suspected mycoplasma genitalium

A

NAAT testing
- first urine sample
- vaginal swabs
need to test for macrolide resistance and perform a test of cure as well

526
Q

what is the management for mycoplasma genitalium

A

doxycycline - 100mg BD for 7 days
azithromycin - 1g stat then 500mg OD for 2 days

527
Q

what is used to treat complicated infections of mycoplasma genitalium

A

moxifloxacin
azithromycin in pregnancy

528
Q

what is vaginal candidiasis

A

thrush - caused by yeast infection

529
Q

what are risk factors for developing candidiasis

A

increased oestrogen - pregnancy, lower pre puberty and post menopause
poorly controlled diabetes
immunosuppression
broad spectrum antibiotics

530
Q

how does candidiasis present

A

thick while discharge that doesnt typically smell
vulval and vaginal itching, irritation and discomfort
in severe infection: erythema, fissures, oedema, pain during sex, dysuria, excoriation

531
Q

what investigations are done for vaginal candidiasis

A

testing vaginal pH
charcoal swab with microscopy, culture and sensitivities

532
Q

what is the management of candidiasis infection

A

antifungal cream - clotrimazole
antifungal pessary - clotrimazole
oral antifungal tablets - fluconazole

533
Q

how are recurrent (more than 4 a year) candidiasis infections treated

A

induction and maintenance regime over six months with oral or vaginal antifungal medications

534
Q

what is trichomonas vaginalis

A

it is an infection caused by a parasite (protozoan - flagella) that is spread through sexual intercourse

535
Q

what can trichomonas infection increase the risk of

A

contracting HIV- damaging vaginal mucosa
bacterial vaginosis
cervical cancer
PID
pregnancy related complications

536
Q

how does trichomonas vaginalis present

A

up to 50% asymptomatic
- vaginal discharge: frothy, green-yellow, fishy
- itching
- dysuria
- dyspareunia
- balanitis (inflammation of glans penis)

537
Q

what clinical examination findings would you seen in someone with trichomonas vaginalis

A

strawberry cervix - tiny haemorrhages across surface of the cervix
high vaginal pH

538
Q

how is trichomonas vaginalis diagnosed

A

charcoal swab with microscopy
- swab should be taken from the posterior fornix of the vagina
urethral swab or first catch urine in men

539
Q

what is the management of trichomonas vaginalis

A

referral to GUM
metronidazole

540
Q

what are nabothian cysts

A

they are fluid filled cysts that are often seen on the surface of the cervix
- also called nabothian follicles or mucinous retention cysts

541
Q

what causes nabothian cysts

A

The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

542
Q

how do nabothian cysts present

A

often found incidentally on speculum examination
dont typically cause symptoms, rarely if large can cause feeling of fullness in pelvis
appear as smooth round bumps on the cervix usually near to the OS, can range in size and have a whitish or yellow appearance

543
Q

how are nabothian cysts managed

A

often no treatment is required as they dont cause harm and often resolve spontaneously
if diagnosis is uncertain refer for colposcopy and they can be excised and biopsied

544
Q

what is vault prolapse

A

Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.

545
Q

what is rectocele

A

defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina

546
Q

what symptoms are rectocele often associated with

A

constipation
foacal loading
urinary retention
palpable lump

547
Q

what is a cystocele

A

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

548
Q

what are risk factors for developing pelvic organ prolapse

A

Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

549
Q

how does prolapse present

A

A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

550
Q

what speculum can be used to examine prolapse

A

a sims speculum - U shaped
support the anterior or posterior wall while the other walls are examined

551
Q

what are the grades of uterine prolapse

A

Pelvic organ prolapse quantification system:
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina

552
Q

what is conservative management for pelvic organ prolapse

A

Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream

553
Q

what are the different types of vaginal pessaries

A

Ring pessaries: ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn: flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries: cube shape
Donut pessaries: thick ring, similar to a doughnut
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.

554
Q

what is the definitive option for treating pelvic organ prolapse

A

surgery

555
Q

what are mesh repairs

A

Mesh repairs involve inserting a plastic mesh to support the pelvic organs. After review, NICE recommend that mesh procedures should be avoided entirely

556
Q

what are complications associated with mesh repairs

A

Chronic pain
Altered sensation
Dyspareunia (painful sex) for the women or her partner
Abnormal bleeding
Urinary or bowel problems

557
Q

what is atrophic vaginitis

A

it is dryness and atrophy of the vaginal mucosa related to lack of oestrogen

558
Q

what causes atrophic vaginitis

A

epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions,
as oestrogen falls the mucosa becomes thinner, less elastic and more dry
also contributes to pelvic organ prolapse and stress incontinence

559
Q

how does atrophic vaginitis present

A

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
recurrent UTI
stress incontinence
pelvic organ prolapse

560
Q

what is seen on examination in atrophic vaginitis

A

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

561
Q

what is management of atrophic vaginitis

A

vaginal lubricants - sylk, replens, YES
topical oestrogen cream: estriol cream, pessaries, tablets, ring

562
Q

what are contraindications to topical oestrogen

A

breast cancer
angina
VTE

563
Q

what are Bartholins glands

A

pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.

564
Q

what is a bartholins cyst

A

When the ducts become blocked, the Bartholin’s glands can swell and become tender, causing a Bartholin’s cyst. The swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm.

565
Q

what is a bartholins abscess

A

it is when a bartholins cyst becomes infected

566
Q

how are bartholins cysts managed

A

good hygiene, analgesia, warm compresses
biopsy may be required if malignancy needs to be excluded

567
Q

how is a bartholins abscess managed

A

antibiotics - E.coli is most common cause
surgical interventions - word catheter (pus drained and balloon put into abscess to prevent refilling) or marsupialisation (drained and abscess is sutured open to allow drainage and prevention of recurrence)

568
Q

what is lichen sclerosis

A

chronic inflammatory skin condition that presents with patches of shiny, porcelain white skin commonly affecting the labia, perineum and perianal skin in women

569
Q

what is lichen simplex

A

chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

570
Q

what is lichen planus

A

autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

571
Q

how does lichen sclerosis present

A

45-60 year old women with vulval itching and skin changes:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

572
Q

what does lichen sclerosis look like

A

“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques
may be associated fissures, cracks, erosions or haemorrhages under the skin

573
Q

how is lichen sclerosis managed

A

cant be cured, symptom management
potent topical steroids: clobetasol propionate 0.05% - used once a day for 4 weeks then weaned
regular use of emollients

574
Q

what are complications of lichen sclerosis

A

The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.

Other complications include:

Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings

575
Q

what is female genital mutilation

A

surgically changing the genitals of a female for non-medical reasons.
Female genital mutilation is illegal as stated in the Female Genital Mutilation Act 2003, and there is a legal requirement for healthcare professionals to report cases of FGM to the police.

576
Q

what countries have highest rates of FGM

A

Many african countries - Somalia = highest
ethiopia, sudan, eritrea
yemen, kurdistan, indonesia, south and western asia

577
Q

what are the our types of FGM

A

Type 1: Removal of part or all of the clitoris.
Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
Type 3: Narrowing or closing the vaginal orifice (infibulation).
Type 4: All other unnecessary procedures to the female genitalia.

578
Q

what are scenarios where it is worth considering FGM

A

Pregnant women with FGM with a possible female child
Siblings or daughters of women or girls affected by FGM
Extended trips with infants or children to areas where FGM is practised
Women that decline examination or cervical screening
New patients from communities that practise FGM

579
Q

what are immediate complications of FGM

A

Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence

580
Q

what are long term complications of FGM

A

Vaginal infections, such as bacterial vaginosis
Pelvic infections
Urinary tract infections
Dysmenorrhea (painful menstruation)
Sexual dysfunction and dyspareunia (painful sex)
Infertility and pregnancy-related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening

581
Q

how is FGM managed

A

education of patients
mandatory to report all cases of FGM in patients under 18 to the police - contact social services, paeds, specialist gynaecological or FGM services, counselling
de-infibulation may be performed by a specialist in FGM cases of type 3

582
Q

what do the paramesonephric ducts (mullerian ducts) develop into

A

upper vagina
cervix
uterus
fallopian tubes

583
Q

what is a bicornate uterus

A

where there are two ‘horns’ in the uterus giving the uterus a heart shaped appearance

584
Q

what are complications of a bicornate uterus

A

miscarriage
premature birth
malpresentation

585
Q

what is an imperforate hymen

A

when the hymen at the entrance of the vagina is fully formed without an opening

586
Q

how does an imperforate hymen present

A

imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

587
Q

how is imperforate hymen treated

A

surgical incision to make opening

588
Q

what can happen if an imperforate hymen isnt treated

A

Theoretically, if an imperforate hymen is not treated retrograde menstruation could occur leading to endometriosis.

589
Q

what is transverse vaginal septae

A

the septum forms transversely across the vagina, which can either be perforate or imperforate
- where it is perforate girls will still menstruate but have difficulty with intercourse or tampon use
- imperforate will present similarly to imperforate hymen

590
Q

how is transverse vaginal septae managed and what are the complications

A

surgery
- vaginal stenosis and recurrence

591
Q

what is vaginal hypoplasia

A

abnormally small vagina

592
Q

what is vaginal agenesis

A

absent vagina

593
Q

what is management of vaginal hypoplasia

A

vaginal dilator over a prolonged period to create adequate vaginal size or surgery

594
Q

what is androgen insensitivity syndrome

A

cells are unable to respond to androgen hormones due to a lack of androgen receptors. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome

595
Q

what are the clinical features of androgen insensitivity syndrome

A

. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics, while being genetically male
patients have testes in abdomen or inguinal canal and absence of uterus, upper vaginal, cervix, fallopian tubes and ovaries
lack of pubic hair, facial hair and male type muscle development
infertile

596
Q

how does androgen insensitivity syndrome often present

A

inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.
The results of hormone tests are:
Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)

597
Q

how is androgen insensitivity syndrome managed

A

MDT approach
Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

598
Q
A

Phase 3a Jemima (16 decks)

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