WOMENS HEALTH - OBSTETRICS AND GYNAE Flashcards
MISCARRIAGE
What is the medical management of a miscarriage?
What is the follow up?
- PV/PO synthetic prostaglandin misoprostol
- Contact HCP if no bleeding in 24h
- Urinary beta-hCG 3w after to exclude ectopic or molar
HYPEREMESIS
What is the diagnostic triad for hyperemesis gravidarum?
Triad –
- >5% weight loss compared to before pregnancy
- Dehydration
- Electrolyte imbalance
ANTENATAL SCREENING
What screening is offered if the mother is too late for the combined test and when?
Triple or quadruple test 15–20w but only tests for Down’s syndrome –
- Beta-hCG
- Alpha-fetoprotein
- Oestriol
- Inhibin (quadruple)
PLACENTA PRAEVIA
What are some risk factors for placenta praevia?
- Embryos more likely to implant on lower segment scar from previous c-section
- Multiple pregnancy
- Multiparity
- Previous praevia
- Assisted conception
PLACENTAL ABRUPTION
What are the major risk factors for placental abruption?
What are some other risk factors?
- IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption
- Cocaine use, multiple pregnancy or high parity, trauma
VASA PRAEVIA
What are some risk factors for vasa praevia?
- Placenta praevia
- Multiple pregnancy
- IVF pregnancy
- Bilobed placentas
PRE-ECLAMPSIA
How can pre-eclampsia be classified?
- Mild-mod = pre-eclampsia without severe HTN (<160/110) and NO Sx, biochemical or haematological impairment
- Severe = pre-eclampsia w/ severe HTN ± Sx ± biochem ± haem impairment
- Early <34w, late >34w
PRE-ECLAMPSIA
What is the result of placental ischaemia?
- Pro-inflammatory protein + thromboplastin release leads to endothelial damage > vasoconstriction, clotting dysfunction + increased vascular permeability
- Ultimately leads to poor renal perfusion > RAAS activation > HTN, proteinuria ± oedema > pre-eclampsia + eclampsia (if continues)
PRE-ECLAMPSIA
What are the…
i) high risk
ii) moderate risk
factors for pre-eclampsia?
i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM)
ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2
PRE-ECLAMPSIA
What are the 2 main causes of symptoms in pre-eclampsia?
- Local areas of vasospasm leading to hypoperfusion
- Oedema due to increased vascular permeability + hypoproteinaemia
PRE-ECLAMPSIA
What blood investigations would you do in pre-eclampsia?
- FBC with platelets (thrombocytopenia)
- Serum uric acid levels (raised due to renal issues)
- LFTs (elevated liver enzymes ALT + AST)
PRE-ECLAMPSIA
What other investigations could you perform in pre-eclampsia?
- Proteinuria on dipstick (++ or +++ is severe)
- Protein:Creatinine ratio (PCR) ≥30ng/nmol = significant proteinuria
- Accurate dating + USS to assess foetal growth
IUGR
What are the 3 broad categories causing IUGR?
- Placental insufficiency (most common cause)
- Maternal factors
- Foetal factors
IUGR
What are some maternal causes of IUGR?
- Chronic disease (HTN, cardiac, CKD)
- Substance abuse (cocaine, alcohol) smoking, previous SGA baby
- Autoimmune
- Low socioeconomic status
- > 40
IUGR
When would you be concerned about IUGR?
What would you do?
- SFH < 10th centile, slow or static growth or crossing centiles
- Refer for serial growth scans (USS) every 2w, umbilical artery doppler + amniotic fluid volume
- MCA doppler performed after 32w
MULTIPLE PREGNANCY
What are some predisposing factors to multiple pregnancies?
- Previous twins,
FHx,
increasing parity + maternal age,
IVF,
race (Afro-Caribbean)
MULTIPLE PREGNANCY
What is the management of multiple pregnancies?
- Steroids if <34w
- Monochorionic/amniotic twins = elective c-section 32-34w
- Diamniotic twins = 37–38w, vaginal if presenting twin cephalic but may need c-section for second
OLIGOHYDRAMNIOS
What are some causes of oligohydramnios?
- PROM or SROM
- Renal agenesis (Potter’s syndrome) or non-functional kidneys
- Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output
- Genetic anomalies
- Obstructive uropathy
POLYHYDRAMNIOS
What are the causes of polyhydramnios?
- Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops
- Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)
RHESUS DISEASE
What is the pathophysiology of rhesus disease in the first pregnancy?
- Rh-ve woman exposed to Rh+ve foetal blood, her immune system recognises as foreign + produce antibodies against rhesus D (sensitisation)
- Usually no issues in 1st pregnancy as IgM produced that cannot cross placenta
RHESUS DISEASE
What is the pathophysiology of rhesus disease in subsequent pregnancies?
- Memory cells produce IgG which can cross placenta so if Rh+ve foetus will attack leading to haemolysis (haemolytic disease of newborn) with jaundice + hydrops fetalis (abnormal accumulation of fluid)
GESTATIONAL DIABETES
What are some anti-insulin hormones produced by the placenta?
- Main one is human placental lactogen (hPL)
- Also glucagon + cortisol
INFECTIONS + PREGNANCY
What are the risks of Varicella zoster?
- Maternal risk = 5x greater risk of pneumonitis
- Foetal varicella syndrome = skin scarring, microphthalmia, limb hypoplasia, microcephaly + learning difficulties
PROM
What is the management of PPROM?
- 1st line = IM corticosteroids if foetus <34w
- Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d or until labour is established if within 10d
- Consider induction at 34w (trade off)
STAGES OF LABOUR
What are 7 important hormones in labour?
- Prostaglandins
- Oxytocin
- Oestrogen
- Beta-endorphins
- Adrenaline
- Prolactin
- Relaxin
STAGES OF LABOUR
What position is the foetal head during engagement and descent?
- Occiput transverse
BREECH
What are some causes/risk factors for breech presentation?
- Idiopathic
- Prematurity as baby may not have turned itself yet
- Previous breech
- Uterine abnormalities (bicornuate uterus), fibroids
- Placenta praevia
- Foetal abnormalities (CNS malformation
- Multiple pregnancy
- Poly/oligohydramnios
BREECH
What are some contraindications for ECV?
- Absolute = pre-eclampsia, APH, oligohydramnios, foetal compromise
- Relative = maternal HTN, foetal abnormality, 1 previous c-section
CTG
What does reduced variability tell you?
- Reduced variability may be hypoxia, lactic acidosis, prematurity
- 40m reduced variability accepted as baby may be sleeping
SHOULDER DYSTOCIA
Explain what is the result of…
i) erb’s palsy?
ii) clavicle fracture?
i) Injury of C5/6 nerves causing paralysis of arm, looks limp, waiters tip position
ii) Painful movements, shoulder asymmetry
SHOULDER DYSTOCIA
What are the 3 rotational manoeuvres?
- Rubin II = pressure on post. aspect of ant. shoulder to help deliver under symphysis pubis
- Woods’ screw = Rubin II + pressure on ant. aspect of post. shoulder
- Reverse woods’ screw = pressure on ant. aspect of ant. shoulder + post. aspect of post. shoulder in opposite way
C-SECTION
What are the complications of c-sections?
- Surgical risk (bleeding, infection/endometritis, VTE)
- Damage risk (ureter, bladder, bowel, vessels)
- Future pregnancies (increased risk of uterine rupture, placenta praevia, stillbirth + repeat section)
- Baby (risk of lacerations, increased incidence in transient tachypnoea)
PAIN RELIEF
What causes labour pain in…
i) first stage?
ii) second stage?
i) Uterine contraction at T10-L1
ii) Perineum + vaginal stretching S2-4 (pudendal)
PAIN RELIEF
What are some complications of regional techniques?
- Potential for spinal cord damage
- Hypotension + bradycardia
- Haematoma/abscess at injection site
- Anaphylaxis if allergic
- Post-dural puncture headache
UTERINE RUPTURE
What are some risk factors for uterine rupture?
- VBAC
- Previous uterine surgery
- Increased BMI
- High parity
- Congenital uterine abnormalities
- Oxytocin use
PPH
What are the primary causes of PPH?
Primary (4Ts)–
- Tone (uterine atony = most common)
- Trauma (perineal tear)
- Tissue (retained products)
- Thrombin (clotting issue e.g. DIC in pre-eclampsia)
PPH
What are the risk factors for PPH?
- Before birth = previous PPH, APH, twins/triplets, pre-eclampsia, obesity, polyhydramnios
- Labour = prolonged, c-section, perineal tear or episiotomy, macrosomia
MENTAL HEALTH
Why can mental health disorders be difficult to detect in the puerperium?
- Fear of treatment
- Fear of children being removed
- Cultural lack of recognition
- Denial
- Stigma
HYPEREMESIS
What are some associations of hyperemesis gravidarum?
- nulliparity,
- hyperthyroid,
- obesity,
- decreased in smokers
ANAEMIA + PREGNANCY
What are some risk factors?
Menorrhagia,
malaria,
hookworm,
twins,
poor diet
HELLP
what are the risk factors for HELLP?
➢ White ethnicity
➢ Maternal age >35 yrs.
➢ Obesity
➢ Chronic hypertension
➢ DM
➢ Autoimmune disorders
➢ Abnormal placentation and multiple gestation
➢ Previous pregnancy with preeclampsia
HELLP
what is the management for HELLP?
➢ Seizure prophylaxis (magnesium sulfate), IV dexamethasone, labetalol. IM beclametasone
when patient <36wks
➢ Delivery is definitive treatment (should be done when patient is 37+ wks)
SICKLE CELL DISEASE IN PREGNANCY
what is the management?
- Pre-Pregnancy counselling
- Stop iron chelating agents before pregnancy
- Give folic acid and penicillin prophylaxis for hypersplenism
- Screen for UTI infections each visit
- Crisis Treatment: Analgesics, oxygen, hydration, and
antibiotics if infection is suspected - Regular foetal monitoring
- Aim for vaginal delivery
FOETAL HYDROPS
what are the causes of non-immune foetal hydrops
- severe anaemia (parvovirus B19, thalassaemia, G6PD)
- cardiac abnormalities
- chromosomal abnormalities (trisomies 13, 18 and 21)
- genetic conditions
- other infections (toxoplasmosis, rubella, CMV, varicella)
- structural abnormalities (CCAM, diaphragmatic hernia)
- twin-to-twin transfusion syndrome
- chorioangioma
FOETAL HYDROPS
what is the management?
depends on the cause
- anaemia = in-utero blood transfusion
- pleural effusions/CCAM = shunt
- twin-to-twin transfusion syndrome = laser photocoagulation of placental anastomoses
- cardiac arrhythmias = maternal digoxin + flecanide
LOW BIRTH WEIGHT
what are the causes of low birth weight?
➢ Preterm birth (before 37 weeks gestation)
➢ Genetics (could be chromosomal abnormalities…)
➢ Uteroplacental insufficiency
➢ Multiple pregnancy
➢ Substance abuse (smoking, drinking alcohol, illicit drug) causing IUGR
➢ Chronic conditions and infections (hypertension, rubella, CMV, syphilis, toxoplasmosis, BV…)
➢ Medications (sodium valproate, ramipril, warfarin…)
UTEROPLACENTAL INSUFFICIENCY
what are the causes of uteroplacental insufficiency?
➢Abnormal trophoblast invasion:
▪ Pre-eclampsia
▪ Placenta accreta
➢ Abruption
➢ Infarction
➢ Placenta previa
➢ Tumor: chorioangiomas
➢ Abnormal umbilical cord or cord insertion (i.e., two vessel cord)
➢ Maternal diabetes
➢ Maternal hypertension
➢ Anemia
➢ Smoking
➢ Drug abuse (cocaine, heroin, methamphetamine)
➢ Antiphospholipid syndrome
➢ Renal disease
➢ Advanced age
UTEROPLACENTAL INSUFFICIENCY
what are the investigations?
➢ USS
➢ Maternal alpha fetoprotein levels
➢ CTG
PUERPERAL INFECTION
what is the management?
➢ Supportive (analgesics/NSAIDS, wound care, ice packs…)
➢ Antibiotics (for endometritis – IV clindamycin and gentamicin until >24hrs afebrile)
➢ Surgical (drain abscess, secondary repair of wound, drainage of hematomas…)
OBSTRUCTED LABOUR
What are the different types of causes of obstructed labour?
- Power (most common)
- Passage
- Passenger
- Psyche (maternal exhaustion in second stage)
CHORIONIC VILLUS SAMPLING
when is chorionic villus sampling performed?
Usually between 10-13 weeks
AMNIOCENTESIS
When is amniocentesis performed?
from 15 weeks onwards
CHLAMYDIA IN PREGNANCY
what is the management?
- azithromycin 1g OD followed by 500mg orally OD for 2 days
- erythromycin 500mg QD for 7 days
- amoxicillin 500mg TD for 7 days
UTIs IN PREGNANCY
why are UTIs more common in pregnancy?
due to dilation of the upper renal tract and urinary stasis (hypoactive bladder)
UTIs IN PREGNANCY
what is the management of pyelonephritis?
antibiotics (IV) for 10-14 days
- Pyelonephritis needs IV antibiotics until pyrexia settles and vomiting stops. IV fluids and antipyretics too.
UTIs IN PREGNANCY
what are the antenatal risk factors for UTIs?
- previous infection
- renal stones
- diabetes mellitus
- immunosuppression
- polycystic kidneys
- congenital abnormalites of renal tract
- neuropathic bladder
UTIs IN PREGNANCY
what is the management?
antibiotics (depends on sensitivities)
- penicillin amoxicillin
- cephalosporin
- gentamycin (have to monitor levels to minimise risk of ototoxicity)
UTIs IN PREGNANCY
which antibiotics should be avoided in the third trimester and why?
- nitrofurantoin - risk of haemolytic anaemia in newborn with G6PD
- sulfonamides - risk of kernicterus in newborn due to displacement of protein binding of bilirubin
UTIs IN PREGNANCY
which antibiotics are contraindicated in pregnancy?
- tetracyclines - cause permanent staining of teeth and problems with skeletal development
- ciprofloxacin - causes skeletal problems
FIBROIDS
What are the different types of fibroids?
- Intramural (most common) = within the myometrium
- Subserosal = >50% fibroid mass extends outside uterine contours
- Submucosal = >50% projection into the endometrial cavity
- Subserosal + submucosal can be pedunculated (on stalk = risk of torsion)
FIBROIDS
What are some risk factors for fibroids?
- Afro-Caribbean
- Obesity
- Early menarche
- FHx
- Increasing age (until menopause)
FIBROIDS
What is the first line non-hormonal management of fibroids <3cm?
- Tranexamic acid (antifibrinolytic) taken during bleeding to reduce it
- Mefenamic acid (NSAID) to reduce bleeding + pain
ENDOMETRIOSIS
What are 3 theories about the cause of endometriosis?
- Sampson’s = retrograde menstruation (endometrial lining flows backwards through fallopian tubes + into pelvis/peritoneum where endometrial tissue seeds itself
- Meyer’s = metaplasia of mesothelial cells
- Halban’s = via blood or lymphatics
ENDOMETRIOSIS
What are some risk factors for endometriosis?
- Early menarche,
- late menopause,
- obstruction to vaginal outflow (imperforate hymen)
PCOS
How does insulin resistance contribute to PCOS?
- Insulin resistance = pancreas produces more insulin
- Insulin mimics action of insulin-like growth factor 1 which augments androgen production by theca cells in response to LH
- Higher insulin = higher androgens (testosterone)
PCOS
How does high insulin levels contribute to PCOS?
- Insulin suppresses sex hormone-binding globulin (SHBG) produced by liver which normally binds to androgens + suppresses their function further promoting hyperandrogenism
- Also contribute to halting development of follicles in ovaries > anovulation + multiple partially developed follicles (polycystic ovaries)
PCOS
What are the 3 main presenting features of PCOS?
- Hyperandrogenism
- Insulin resistance
- Oligo or amenorrhoea + sub/infertility
PCOS
What are some differentials of hirustism?
- Ovarian or adrenal tumours that secrete androgens
- Cushing’s syndrome
- CAH
- Iatrogenic (steroids, phenytoin)
PCOS
How does insulin resistance present?
- Obesity, acanthosis nigricans (thickened, rough skin often axilla + elbows with velvety texture), psychological Sx
PCOS
What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) –
- Oligo- or anovulation (may present as oligo- or amenorrhoea)
- Hyperandrogenism (biochemical or clinical)
- Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
PCOS
What hormone tests may be used in PCOS?
- Testosterone (raised)
- SHBG (low)
- LH (raised) + raised LH:FSH ratio (LH>FSH)
- Prolactin (normal), TFTs (exclude causes)
PCOS
What is the gold standard for visualising the ovaries?
What might it show?
- TVS
- “String of pearls” appearance where follicles arranged around periphery of ovary (≥12 cysts or >10cm^3 ovarian volume)
- Can also visualise endometrial thickness
PCOS
What are some associations and complications of PCOS?
- DM, CVD + hypercholesterolaemia
- Obstructive sleep apnoea, MH issues, sexual problems
- Endometrial hyperplasia or cancer
PCOS
Why does PCOS increase risk of endometrial hyperplasia + cancer?
- Oligo/anovulation means endometrial lining continues proliferating with unopposed oestrogen as no corpus luteum releasing progesterone
PCOS
How is the risks of obesity, T2DM, CVD etc. managed in PCOS?
- Lifestyle > diet + exercise, weight loss to reduce insulin resistance, smoking cessation
- Orlistat (lipase inhibitor that stops fat absorption in intestines) may be given to assist weight loss if BMI >30kg/^m2
PCOS
What are the PCOS risk factors for endometrial cancer?
How is the risk of endometrial cancer managed in PCOS?
- Obesity, DM, insulin resistance, amenorrhoea
- Mirena coil for continuous endometrial protection
- Induce withdrawal bleed AT LEAST every 3m with COCP or cyclical progesterones medroxyprogesterone 10mg 14d)
PCOS
How is hirsutism + acne managed?
- Hair removal cream, topical eflornithine to treat facial hirsutism
- Co-cyprindiol is COCP licensed for hirsutism + acne as anti-androgen effect but only used for 3m as increased VTE risk
- Spironolactone by specialist (mineralocorticoid antagonist with anti-androgen effects)
CERVICAL CANCER
What has a strong association with development of cervical cancer?
- Human papillomavirus (HPV) types 16 + 18 primarily a STI
- Also associated with anal, vulval, vaginal, penis, mouth + throat cancers
CERVICAL CANCER
How would you confirm a diagnosis of cervical cancer?
Colposcopy –
- Acetic acid causes abnormal cells to appear white “acetowhite”
- Schiller’s iodine test = healthy cells stain brown, abnormal do not stain
- Punch biopsy or large loop excision of transformation zone (LLETZ) for histology
OVARIAN CANCER
What are the 4 types of ovarian cancer?
- Epithelial cell tumours (85–90%)
- Germ cell tumours (common in women <35)
- Sex cord-stromal tumours (rare)
- Metastatic tumours
OVARIAN CANCER
What are some risk factors of ovarian cancer?
Unopposed oestrogen + increased # of ovulations –
- Early menarche
- Late menopause
- Increased age
- Endometriosis
- Obesity + smoking
Genetics (BRCA1/2, HNPCC/lynch syndrome)
OVARIAN CANCER
Hence, what are some protective factors of ovarian cancer?
- COCP
- Early menopause
- Breast feeding
- Childbearing
OVARIAN CANCER
What warrants a 2ww gynae oncology referral?
- Ascites
- Abdo or pelvic mass (unless clearly fibroids)
- ≥250 risk of malignancy index score
OVARIAN CANCER
How is the risk of malignancy index calculated?
- Menopausal status = 1 (pre) or 3 (post)
- Pelvic USS findings = 1 (1 feature) or 3 (>1 feature)
- CA-125 levels IU/mL as marker for epithelial cell ovarian cancer
OVARIAN CANCER
What can cause falsely elevated CA-125 levels?
- Endometriosis
- Fibroids + adenomyosis
- Pelvic infection
- Pregnancy
- Benign cysts
OVARIAN CYST
What are some risk factors of ovarian cysts?
- Obesity, tamoxifen, early menarche, infertility
- Dermoid cysts = most common in young women, can run in families
- Epithelial cysts = most common in post-menopausal (?malignant)
OVARIAN CYST
What is Meig’s syndrome?
Who is it commonly seen in?
What is the management?
- Triad of fibroma, pleural effusion + ascites
- Older women
- Removal of fibroma = complete solution
OVARIAN CYST
What are the germ cell tumour markers?
- Lactate dehydrogenase
- Alpha-fetoprotein
- Human chorionic gonadotropin
OVARIAN CYST
What is the management of simple cysts in pre-menopausal women?
- Small <5cm = likely to resolve within 3 cycles, no follow up
- Mod 5–7cm = routine gynae referral + yearly USS
- Large >7cm = ?MRI + surgical evaluation
OVARIAN CYST
What is the management of post-menopausal women presenting with an ovarian cyst?
- Risk of malignancy index calculation
- Simple cysts <5cm + normal CA-125 = monitor with 4–6m USS
- Complex cyst or raised CA-125 = 2ww gynae oncology referral
ENDOMETRIAL CANCER
What is the most common histological type of endometrial cancer?
What are some others?
- Adenocarcinoma (80%)
- Adenosquamous, squamous, papillary serous, clear cell + uterine sarcoma
ENDOMETRIAL CANCER
What are some risk factors for endometrial cancer?
Unopposed oestrogen –
- Obesity (adipose tissue contains aromatase)
- Nulliparous
- Early menarche
- Late menopause
- Oestrogen-only HRT
- Tamoxifen
- PCOS
- Increased age
- T2DM
- HNPCC (Lynch syndrome)
ENDOMETRIAL CANCER
What are some protective factors for endometrial cancer?
- COCP
- Mirena coil
- Multiparity
- Cigarette smoking (Seem to have anti-oestrogenic effect)
ENDOMETRIAL CANCER
What other investigations is recommended in endometrial cancer?
- Pipelle biopsy via speculum (highly sensitive so useful for exclusion in low risk)
- Hysteroscopy with endometrial biopsy
- 2WW urgent gynae oncology referral if PMB in ≥55y
ENDOMETRIAL POLYP
What are some risk factors of endometrial polyps?
- Being peri or post-menopausal
- HTN
- Obesity
- Tamoxifen
VULVAL CANCER
What is vulval cancer?
What is the most common histological type?
- Rare compared to other cancers
- Squamous cell carcinomas (90%), malignant melanoma less common
VULVAL CANCER
What are some risk factors for vulval cancer?
- Vulval intraepithelial neoplasia (VIN) due to HPV in younger women
- Lichen sclerosus in older women
VAGINAL CANCER
What is the most common histological type of vaginal cancer?
- 90% squamous
MENOPAUSE
What is the management of menopause in more severe cases?
- HRT first-line for vaso-motor Sx as most effective
- Clonidine (alpha adrenergic receptor agonist) second line with low-dose antidepressants like venlafaxine (not C/I in breast cancer Tx) or fluoxetine
- CBT
- Vaginal oestrogen cream/tablets + moisturisers for dryness
MENOPAUSE
What is the mechanism of action of clonidine?
- Alpha-adrenergic receptor agonist
HRT
What are some contraindications to HRT?
- Undiagnosed PV bleeding
- Current or past breast cancer
- Any oestrogen sensitive cancer (endometrial)
HRT
What are the side effects associated with oestrogen?
- Nausea,
- bloating,
- headaches,
- breast swelling or tenderness,
- leg cramps
ATROPHIC VAGINITIS
What are some risk factors for atrophic vaginitis?
- Menopause
- Oophorectomy
- Anti-oestrogen (tamoxifen, anastrozole)
URINARY INCONTINENCE
What is the physiology of micturition?
- Detrusor = smooth muscle, transitional epithelium normally only contracts during micturition = sacral parasympathetic innervation from S2-4
- M2+3 muscarinic receptors with ACh
- Sympathetic nerve fibres from T11-L2 maintain relaxation of bladder for storage
URINARY INCONTINENCE
What are the 6 main types of incontinence?
- Overactive bladder/urge incontinence
- Stress incontinence
- Mixed incontinence (of the 2 above)
- Overflow incontinence
- Fistula
- Neurological
URINARY INCONTINENCE
What are some risk factors for urinary incontinence?
- Increasing age
- Multiparity
- High BMI
- FHx
- Previous pelvic surgery (hysterectomy)
URINARY INCONTINENCE
What are some investigations in urinary incontinence?
- Hx most important
- Bladder diary (frequency volume chart) first line
- Urine dipstick + MSU
- Residual urine measurement
- Electronic Personal Assessment Questionnaire
- Urodynamics
- Cystogram with contrast
URINARY INCONTINENCE
What is the mechanism of action of anti-muscarinics?
- Parasympathetic so Pissing = decreases need to urinate + spasms
URINARY INCONTINENCE
What is the mechanism of action of beta-3-adrenergic agonists?
- Sympathetic so Storage = relaxes detrusor + increases bladder capacity
URINARY INCONTINENCE
What are last resort options for urge incontinence?
- Augmentation cystoplasty with bowel tissue
- Bypass (urostomy)
- Botox can paralyse detrusor + block ACh release
URINARY INCONTINENCE
What are the surgical interventions for stress incontinence?
- Colposuspension
- Tension free vaginal tape (TVT)
- Autologous sling procedures (TVT but strip of fascia from abdo wall)
PELVIC ORGAN PROLAPSE
What are some risk factors of pelvic organ prolapse?
- Age
- BMI
- Multiparity (vaginal)
- Spina bifida
- Pelvic surgery
- Menopause
PELVIC ORGAN PROLAPSE
What surgical intervention is provided for cystocele/cystourethrocele?
Anterior colporrhaphy or colposuspension
ASHERMAN’S SYNDROME
What is the pathophysiology of Asherman’s?
- Damage to basal layer of endometrium, damaged tissue may heal abnormally, creating scar tissue (adhesions)
- Adhesions can bind uterine walls together or endocervix, sealing it shut causing obstruction > infertility, 2* amenorrhoea
ASHERMAN’S SYNDROME
What causes Asherman’s syndrome?
- Pregnancy-related dilatation + curettage procedures
- After uterine surgery
- Pelvic infection like endometritis
ASHERMAN’S SYNDROME
What is the clinical presentation of Asherman’s syndrome?
- Secondary amenorrhoea
- Infertility
- Significantly lighter periods
- Dysmenorrhoea
CERVICAL CANCER
What is cervical cancer?
What is the histological type of cervical cancer?
- Most common cancer in women <35
- Squamous cell carcinoma 80%, then adenocarcinoma (small cell rare)
MENOPAUSE
What can urogenital atrophy lead to?
Urinary incontinence + pelvic organ prolapse
HRT
What are the side effects associated with progesterone?
Mood swings,
fluid retention,
weight gain,
acne
greasy skin
PELVIC ORGAN PROLAPSE
What surgical intervention is provided for uterine prolapse?
Hysterectomy or sacrohysteropexy
PELVIC ORGAN PROLAPSE
What surgical intervention is provided for rectocele?
Posterior colporrhaphy
HYDATIDIFORM MOLE
What are some risk factors for hydatidiform mole?
- Extremes of reproductive age
- Previous molar pregnancy
- Multiple pregnancies
- Asian women
- OCP
PELVIC INFLAMMATORY DISEASE
What are the non-infective causes of PID?
- Post-partum (retained tissue),
- uterine instrumentation (hysteroscopy, IUCD),
- descended from other organs (appendicitis)
PELVIC INFLAMMATORY DISEASE
What are the non-STI infective causes of PID?
Gardnerella vaginalis,
H. influenzae,
E. coli.
GENITAL TRACT FISTULA
what are the different types?
➢ Vesicovaginal fistula
➢ Ureterovaginal fistula
➢ Urethrovaginal fistula
➢ Rectovaginal fistula
➢ Enterovaginal fistula
➢ Colovaginal fistula
GENITAL TRACT FISTULAS
what are the investigations for genital tract fistulas?
➢ Vaginal/anal examination (could use proctoscope or
speculum)
➢ Contrast tests (barium enema)
➢ Blue dye test ➔ put a tampon in the vagina then blue
dye in rectum. If tampon is stained = test positive
➢ CT, MRI, Ultrasound, Manometry
OVERACTIVE BLADDER
what are the risk factors for overactive bladder?
➢ Old age
➢ Pregnancy/childbirth
➢ Hysterectomy
➢ Obesity
➢ Family history
URINARY INCONTINENCE
what can cause stress incontinence?
- low oestrogen in menopause
- weakened pelvic floor
- parity
- pelvic surgery
URINARY INCONTINENCE
What are some side effects of anti-muscarinics?
- “Can’t see, spit, pee or shit” > caution in elderly as falls esp oxybutynin immediate release in frail
URINARY INCONTINENCE
What is a caution of beta-3-adrenergic agonists?
- C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
