'Womens' health questions Flashcards
Between what ages if cervical cancer screening offered ?
25-64
How often are pts screened for cervical cancer ?
Sent screening appointment 6 months before 25
25-49 every 3 years
50-64 every 5 years
65 or older - only if previous screening is abnormal
What occurs if there is a positive hrHPV screen ?
Samples are examined cytologically
If cytology is abnormal then pt has colposcopy
What happens if cytology is normal following a hrHPV+ screen ?
Repeat at 12 months
If test is negative then return to normal recall
If repeat is still hrHPV+ with normal cytology then repeat again in 12 months
If hrHPV- at 24 months then return to normal recall
If hrHPV+ at 24 months then send for colposcopy
What happens if sample from smear is inadequate ?
Repeat sample within 3 months
If 2 inadequate samples then colposcopy
COCP Counselling - Harms and Benefits
99% effective if taken correctly
Small risk of blood clots
Very small risk of MI/stroke
Increased risk of breast and cervical cancer
When does COCP become effective when first taking ?
If started within the first 5 days of the cycle then there is no need for additional contraception needed. If not first 5 days then use additional contraception for 7 days.
Take at the same time everyday
21-day course
When would COCP be reduced in efficacy ?
Vomiting within 2 hours
Medication that induces diarrhoea or vomiting
Liver enzyme-inducing drugs
When is levonorgestrel effective ?
Up to 72 hours post unprotected sex
If the patient has asthma (ulipristal contraindicated)
COCP can be restarted immediately after (ulipristal must wait 5 days to take and then 7 days before effective again)
What are RFs for urinary incontinence ?
Advancing age
Previous pregnancy and childbirth
High BMI
Hysterectomy
FHx
Describe urge incontinence/overactive bladder
Urge to urinate quickly followed by uncontrolled leakage (few drops to complete bladder emptying)
Detrusor overactivity
Stress Incontinence
Leaking small amounts while coughing or laughing
Due to weakness of the pelvic floor and sphincter muscles
Overflow incontinence
Due to bladder outlet obstruction e.g. prostate
Straining, poor flow and incomplete emptying of the bladder
What is a normal bladder detrusor pressure and peak flow rate ?
Pressure rise of <70cm
Peak flow of >15ml/second
High pressure with low flow indicates bladder outlet obstruction
Urge incontinence first line treatment
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails
Stress incontinence first line treatment
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
In what percentage of mothers does baby blues occur ?
60-70%
When does baby blues typically occur ?
3-7 days postpartum
Typically in primips
What are the typical features of baby blues and how are they managed ?
Anxious, tearful and irritable
First line management is reassurance, support and follow up with a health visitor
In what percentage of mothers does postnatal depression occur ?
10%
When does postnatal depression typically occur ?
Most cases start within a month and typically peak at 3 months
What is the management for postnatal depression ?
Most pts will not require specific treatment other than reassurance
CBT and SSRIs may be beneficial e.g. paroxetine/sertraline may be used if severe (avoid fluoxetine due to long half-life)
After what day do pts require contraception postpartum ?
21 days
Can progesterone only pill be used postpartum ?
Yes it can be started anytime PP
After 21 days additional contraception should be used for the first 2 days
A small amount of progesterone enters the breast milk but this is not harmful
Can COCP be used PP ?
Absolutely contraindicated (UKMEC4) if breastfeeding <6 weeks PP
UKMEC2 if BF 6w-6m PP
COCP reduces breast milk production
Should not be used in first 21 days due to VTE risk
If not breastfeeding and post 21 days then additional contraception should be used for the first 7 days.
How effective can breastfeeding be as a contraception ?
98%
When can an IUD be inserted postpartum ?
48 hours after or 4 weeks after
What components are tested for on the antenatal quadruple test ?
AFP, Oestriol, hCG and Inhibin A
What would be seen in the quadruple test for Edward’s Syndrome ?
AFP reduced
Oestriol reduced
hCG reduced
Inhibin A normal
What are classical body features of Edward’s syndrome ?
Low set ears
Rocker bottom feet
Overlapping fingers
By what other name is Edward’s Syndrome known ?
Trisomy 18
The baby has 3 pairs of chromosome 18
What would be seen in the quadruple test for Down’s Syndrome ?
AFP reduced
Oestriol reduced
hCG increased
Inhibin A increased
What would be seen in the quadruple test for Neural Tube Defects ?
AFP increased
Oestriol normal
hCG normal
Inhibin A normal
Typical features for Down’s syndrome
- Hypotonia (reduced muscle tone)
- Brachycephaly (small head with a flat back)
- Short neck
- Short stature
- Flattened face and nose
- Prominent epicanthic folds
- Upward sloping palpebral fissures
- Single palmar crease
When is the combined test for developmental conditions performed ?
Between 11 and 14 weeks
What is the combined test for developmental conditions ?
1st line most accurate test
Combines US and bloods
US measures nuchal translucency (thickness of back of neck)
Blood test measures
Beta-human chorionic gonadotropin (beta-hCG)
Pregnancy-associated plasma protein-A (PAPPA)
What results from the combined test indicate Down’s syndrome ?
Nuchal thickness >6mm
beta-HCG increased
PAPPA decreased
Pre-Eclampsia classic triad
New-onset hypertension
Proteinuria
Oedema
What BP and after which week of pregnancy are required for a diagnosis of Preeclampsia ?
(New onset) BP > 140/90 after 20 weeks
What is the diagnostic criteria for Pre-Eclampsia
(New onset) BP > 140/90 after 20 weeks
Proteinuria
Other organ involvement
Renal insufficiency (e.g. >90 umol/L)
Liver, neurological or haematological
Uteroplacental dysfunction
Classic signs and symptoms of pre-eclampsia
Hypertension >160/110 and proteinuria ++/+++
Headache
Visual disturbance e.g. papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100*10(6)
Abnormal liver enzymes
HELLP syndrome
What is HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
What complications can pre-eclampsia have on foetal development ?
Intrauterine growth reduction
Prematurity
What are complications of pre-eclampsia ?
Altered GCS
Blindness
Stroke
Clonus
Liver damage
Haemorrhage e.g. Intrabdominal, intra-cerebral, cardiac failure
High Risk factors for pre-eclampsia ?
Previous Hx
Autoimmune condition (e.g. SLE)
CKD
T1DM/T2DM
Chronic HTN
Moderate risk factors for pre-eclampsia ?
G1P0
>40yo
BMI > 35 kg/m2
FHx
Multiple pregnancy
Pregnancy interval of +10 years
What can be given during pregnancy to reduce the risk of developing pre-eclampsia ?
Aspirin 75-150 mg
Management of pre-eclampsia
Emergency secondary care assessment
BP > 160/110 should be admitted for observation
1st line medication = labetalol
2nd line = nifedipine or hydralazine (if asthmatic)
Delivery is the definitive management
What is the medical treatment for eclampsia ?
IV magnesium sulphate
What are the causes of antepartum bleeding in the first trimester
Spontaneous abortion
Ectopic
Hydatidiform mole
What are the causes of antepartum bleeding in the second trimester
Spontaneous abortion
Hydatidiform mole
Placental abruption
What are the causes of antepartum bleeding in the third trimester
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
Following a mole pregnancy for how long are patients recommended to avoid conceiving
6-12 months
What are the types of spontaneous abortion ?
Threatened miscarriage
Missed (delayed) miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
How would a threatened miscarriage present ?
Painless vaginal bleeding with a closed cervix and a foetus that is alive
Typically around 6-9 weeks
How would a missed (delayed) miscarriage present ?
Light vaginal bleeding
Symptoms of pregnancy disappear
How would an inevitable miscarriage present ?
Vaginal bleeding with an open cervix
How would an incomplete miscarriage present ?
Heavy bleeding and crampy lower abdominal pain
Retained products of conception remain in the uterus after the miscarriage
How would a complete miscarriage present ?
A full miscarriage has occurred, and there are no products of conception left in the uterus
Little bleeding
What is an anembryonic pregnancy ?
A gestational sac is present but contains no embryo
What 3 features would an US look for when investigating a potential miscarriage ?
Mean gestational sac diameter
Foetal pole and crown-rump length
Foetal heartbeat
What US finding would be consistent with a viable pregnancy ?
A foetal heartbeat is expected once crown rump length is 7mm or more
If foetal heartbeat is present then pregnancy is viable
If CRL is >7mm without a heartbeat then scan is repeated in a week.
What occurs if crown rump length is less then 7mm without a foetal heartbeat ?
Repeat scan at least one week to ensure a heartbeat develops
When is a foetal pole expected ?
Once the mean gestational sac diameter is 25mm or more
When there is a mean gestational sac diameter of 25mm or more, without a foetal pole then repeat the scan after a week before confirming anembryonic pregnancy
Under what conditions can a miscarriage be managed expectantly ?
Less than 6 weeks
Provided there is no pain or other complications or risk factors (e.g. previous ectopic)
Before 6 weeks an US is unlikely to be helpful
A repeat urine pregnancy test is performed after 7-10 days and if negative can be confirmed
Additional pregnancy test 3 weeks after bleeding and pain settles to confirm
What are the 3 options for managing miscarriage ?
Expectant
Medical (misoprostol)
Surgical
What is misoprostol and how does it work ?
Prostaglandin analogue
Binds to receptors and causes softening of the cervix and uterine contraction
Can be given as vaginal suppository or oral dose
What are potential side effects of misoprostol ?
Heavier bleeding
Pain
Vomiting
Diarrhoea
What are the surgical procedures offered for miscarriage ?
Manual vacuum aspiration
Electric vacuum aspiration
Evacuation of retained products of conception (used in incomplete miscarriage)
What is the typical presentation of ectopic pregnancy
Typically, 6–8 weeks
Amenorrhoea with lower abdominal pain (usually unilateral) and vaginal bleeding later
Shoulder tip pain and cervical excitation may be present
What is the typical presentation of hydatidiform mole
Typically bleeding in the first or second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis
The uterus may be large for dates and serum-hCG is very high
What is the typical presentation of placental abruption
Constant lower abdominal pain with pt appearing more shocked than is expected by visible blood loss
Tender ‘‘woody’’ uterus with normal lie and presentation
What is the typical presentation of placenta previa
Vaginal bleeding, no pain
Non-tender uterus but lie and presentation may be abnormal
What is the typical presentation of vasa praevia
Rupture of membranes followed immediately by vaginal bleeding
Foetal bradycardia is classically seen
What can be given to prevent neural tube effects ? And for how long and how much ?
Folic acid
400mcg
From before conception to 12 weeks
Common causes of vaginal discharge
Candida
Trichomonas vaginalis
Bacterial vaginosis
Less common causes of vaginal discharge
Gonorrhoea
Chlamydia
Ectropion
Foreign body
Cervical cancer
Key features of vaginal discharge associated with candida
Cottage cheese discharge
Vulvitis
Itch
Key features of vaginal discharge associated with trichomonas vaginalis
Offensive yellow/green frothy discharge
Vulvovaginitis
Strawberry cervix
Key features of vaginal discharge associated with bacterial vaginosis
Offensive, thin, white/grey, fishy discharge
During which phase of the menstrual cycle would women experience premenstrual syndrome
Luteal phase
Day 15-period
Describe the signs and symptoms associated with premenstrual syndrome
Anxiety, stress, fatigue and mood swings
Bloating and breast pain
Management of premenstrual syndrome
Mild - lifestyle advice - sleep, exercise, no smoko or dranko
Moderate - COCP
Severe - Yasmin (drospirenone and ethinylestradiol) or SSRI’s
Management of menorrhagia secondary to fibroids
Levonorgestrel intrauterine system
NSAIDS e.g. mefenamic acid
Tranexamic acid
COCP
Oral progesterone
Injectable progestogen
Treatment to shrink/remove fibroids
Medical GnRH agonists may reduce the size of the fibroid but are used short term due to side effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Surgery: myomectomy (1st line) but also hysteroscopic endometrial ablation and hysterectomy or uterine artery embolization
Associated factors with placental abruption
Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
Clinical Features of Placental Abruption
Shock much worse then visible blood loss would suggest
Constant pain
Tender, ‘woody’ uterus
Normal lie and presentation
Foetal heart absent/distressed
Coagulation problems
When are fetal movements typically first noticed
18-20 weeks
And then increase until 32 weeks
16-18 weeks in multiparous women
Should be established by 24 weeks latest
What is the RCOG definition of reduced fetal movements ?
Less than 10 movements within 2 hours in pregnancies past 28 weeks gestation
RFs for reduced fetal movements
Posture - more prominent during lying down and less when sitting or standing
Distraction
Placental position - anterior position
Medication - sedative medications - alcohol, benzos or opioids
Foetal position - anterior foetal position means less noticeable
Body habitus - obese = less
Amniotic fluid volume - both oligohydramnios and polyhydramnios = less
Fetal size - small = less
How is reduced foetal movements assessed ?
Usually solely based on maternal perception
Doppler or ultrasonography
How should reduced foetal movements be assessed passed 28 weeks gestation
Initially doppler should be offered to confirm heartbeat
If not foetal heartbeat present then US should be offered
If present then CTG should be used for at least 20 minutes to monitor foetal heart rate and exclude foetal compromise
What are the 4T’s for primary post-partum haemorrhage
Tone e.g. uterine atony - vast majority of cases
Trauma e.g. perineal tear
Tissue e.g. retained placenta
Thrombin e.g. clotting/bleeding disorder
Risk Factors for PPH
PMHx
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydramnios
Emergency CS
Placenta praevia, placenta accreta
Macrosomia
Nulliparity
PPH Management - Immediate
Call senior
ABC - 2 peripheral 14 gauge cannulae, lie women flat, bloods (including group and save), warmed crystalloid infusion
PPH Management - Mechanical
Palpate uterine fundus and rub it to stimulate contractions
Catheterisation to prevent bladder distension and monitor urine output
PPH Management - Medical
IV oxytocin
Ergometrine (unless HTN Hx)
Carboprost IM (unless asthma Hx)
Misoprostol sublingual
PPH Management - Surgical
If medical options fail
Intrauterine balloon tamponade = 1st line when uterine atony is the only or main cause
B-lynch suture, ligation of uterine arteries or internal iliac arteries
If severe, uncontrolled then hysterectomy can be life-saving
Is COCP contraindicated in obese patients ?
UKMEC2 : BMI 30-34 kg/m2
UKMEC3 : BMI > 35 kg/m2
How long is normal for a foetus to ‘sleep’
40 mins
What is adenomyosis ?
The presence of endometrial tissue within the myometrium
Common in multiparous women towards the end of their reproductive years
What are the features of adenomyosis
Dysmenorrhea
Menorrhagia
Enlarged boggy uterus
What is first line when investigating adenomyosis ?
US
How would you manage adenomyosis ?
Symptomatic treatment - tranexamic acid to manage menorrhagia
GnRH agonist
Uterine artery embolisation
Hysterectomy is considered ‘definitive treatment’
When is abortion available until ?
24 weeks
What medication can be given to stimulate an abortion ?
Mifepristone
What are surgical interventions given for abortion ?
Vacuum aspiration
Electric vacuum aspiration
Dilation and evacuation
What is first line treatment for a mother where PE is suspected ?
LMWH
What investigations should be used in a patient with DVT before treatment is initiated ?
Compression duplex US
ECG and chest X-ray
At what age is peak incidence of ovarian cancer ?
60
What type of ovarian cancers are most common ?
~90% are epithelial in origin
70-80% are serous carcinomas
Risk factors for ovarian cancer
FHx: BRAC1 or BRAC2 gene
More ovulations e.g. early menarche, late menopause, nulliparity
Clinical Features of Ovarian cancer
Notoriously vague
Abdominal distension and bloating
Abdominal and pelvic pain
Urinary symptoms e.g. urgency
Early satiety
Diarrhoea
What investigations could be conducted if ovarian cancer suspected ?
CA125
US
Diagnosis is usually after a laparotomy
What is ovarian prognosis and why ?
All stage 5-year survival is 46%
80% of women have advanced disease at presentation
How should a 46mm ectopic pregnancy with a heart beat and b-hCG be managed ?
Salpingectomy
What is the only circumstance when a salpingectomy is not performed to remove a >35mm, heart beat or b-hCG >5000 ectopic pregnancy ?
Contralateral fallopian tube damage
What are the indications for medical management of an ectopic pregnancy ?
Size <35mm
Unruptured
Asymptomatic
No fetal heart beat
hCG<1000
Compatible if another intrauterine pregnancy
What are the indications for medical management of an ectopic pregnancy ?
Size <35mm
Unruptured
No significant pain
No fetal heartbeat
hCG<1500
Not suitable if intrauterine pregnancy
What are the indications for medical management of an ectopic pregnancy ?
Size >35mm
Can be ruptured
Significant pain
Fetal heart beat
hCG>5000
Compatible with another intrauterine pregnancy
What is expectant management for an ectopic pregnancy ?
Closely monitoring for 48 hours and if b-hCH rises or if symptoms manifest then interventions are performed
What is medical management of an ectopic pregnancy ?
Methotrexate
Can only be done is patient is able/willing to attend a follow-up
What is surgical management of an ectopic pregnancy ?
Salpingectomy
salpingotomy- indicated if risk factor for infertility e.g. contralateral tube damage
How does pregnancy change a pts cardiovascular system ?
SV up 30%, HR up 15% and cardiac output up 40%
Systolic BP unaltered but diastolic BP reduced in 1st and 2nd trimester returning to non-pregnant levels by term
Enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
How does pregnancy change a pts respiratory system
Pulmonary ventilation up by 40%, tidal volume from 500-700 (due to progesterone effect on respiratory centre)
Oxygen requirements increase by only 20%
BMR up 15%
How does pregnancy affect the pts blood ?
Maternal blood volume up 30%
Red cells up 20% but plasma up 50^ therefore Hb falls
Low grade increase in coagulant activity
Prepares mother for placental delivery but increases risk of VTE
Platelet count falls
WCC and ESR rise
How does pregnancy affect the urinary system ?
Blood flow increase by 30%
GFR increase by 30-60%
Salt and water reabsorption increased by elevated sex steroid levels
Urinary protein losses increases
Trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose
How does pregnancy affect the pts liver ?
Hepatic blood flow doesn’t change
ALP raised 50%
Albumin levels fal
How does pregnancy affect the uterus
100g to 1100g
Hyperplasia → hypertrophy later
Increase in cervical extropian and discharge
Non-painful practice contractions occur in late pregnancy >30wks
RFs for Endometrial cancer
Excess oestrogen:
Nulliparity, early menarche, late menopause
Metabolic syndrome - obesity, DM or PCOS
Tamoxifen
Protective Factors for endometrial cancer
Multiparity
Combined oral contraceptive pill
Smoko
Features of endometrial cancer
Classic = postmenopausal bleeding - usually slight and intermittent initially before becoming heavier
Pain is not common typically signifies extensive disease
Investigations for suspected endometrial cancer
All women >= 55 years with postmenopausal bleeding should be referred using the suspected cancer pathway
1st line is trans-vaginal ultrasound (normal thickness < 4mm)
Hysteroscopy with endometrial biopsy
Management of endometrial cancer
Mainstay of management is surgery
Localised disease is treated with total abdominal hysterectomy with
bilateral salpingo-oophorectomy
Pts with high-risk disease may have postoperative radiotherapy
What is the most common cause of pelvic pain in women ?
Primary dysmenorrhea
DDs for acute (usually) pelvic pain
Ectopic
UTI
Appendicitis
PID
Ovarian torsion
Miscarriage
DDs for chronic pelvic pain
Endometriosis
IBS
Ovarian cyst
Urogenital prolapse
Typical pain presentation for ectopic pregnancy
6-8 weeks amenorrhoea
Lower abdo pain
Later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen
Typical pain presentation for UTI
Dysuria and frequency are common but women may also experience suprapubic burning secondary to cystitis
Typical pain presentation for appendicitis
Pain initially in the central abdomen before localising to the right iliac fossa
Anorexia is common
Typical pain presentation for PID
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Typical pain presentation for ovarian torsion
Sudden onset unilateral lower abdominal pain
Onset may coincide with exercise
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Typical pain presentation for miscarriage
Vaginal bleeding and crampy, lower abdominal pain following a period of amenorrhoea
Typical pain presentation for endometriosis
Chronic pelvic pain
Dysmenorrhea
Pain often starts days before bleeding
Deep dyspareunia
Subfertility
Typical pain presentation for IBS
Extremely common
Abdominal pain
Bloating and change in bowel habit
Lethargy, nausea, backaches and bladder symptoms
Typical pain presentation for Ovarian cyst
Unilateral dull ache which may be intermittent or only occur during intercourse
Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on bladder
Typical pain presentation for urogenital prolapse
Seen with older patients
Sensation of pressure, heaviness, bearing down
Urinary symptoms of incontinence, frequency and urgency
Describe a 1st degree perineal tear
Superficial damage with no muscle involvement
Does not require repair
Describe a 2nd degree perineal tear
Injury to the perineal muscle but no involving the anal sphincter
Requires suturing on the ward by a suitably experienced midwife or clinician
Describe a 3rd degree perineal tear
Injury to the perineum involving the anal sphincter complex
3a = 50% external anal sphincter tear
3b = more than 50% EAS torn
3c = internal anal sphincter torn
Requires repair in theatre
Describe a 4th degree perineal tear
Injury to perineum involving the anal sphincter complex (EAS and IAS and rectal mucosa
Requires repair in theatre
RFs for perineal tears
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
Features of hydatidiform mole
Uterus size greater than expected for gestational age and abnormally high serum hCG
What analgesic is contraindicated in breastfeeding patients and associated with Reye’s syndrome
Aspirin
What are non-drug related contraindications for breastfeeding ?
Galactosemia
Viral infections e.g. HIV
What drugs are not contraindicated in breastfeeding ?
ABs e.g. penicillins, cephalosporins and trimethoprim
Endocrine: glucocorticoids, levothyroxine
Epilepsy: sodium valproate, carbamazepine
Asthma: salbutamol, theophyllines
Psychiatric drugs: TCAs, antipsychotic drugs
HTN: BBs and hydralazine
Anticoagulants: warfarin, heparin
Digoxin
Which drugs are contraindicated in breastfeeding ?
ABs: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Psychiatric drugs: lithium, benzos
Aspirin
Carnimazole
Methotrexate
Sulfonylureas
Cytotoxic drugs
Amiodarone
How long after giving birth would a pt have before needing contraception
21 days
Menorrhagia causes
Dysfunctional uterine bleeding: absence of clear pathology
Anovulation cycles: these are more common at the extremes of womens reproductive life
Uterine fibroids
Hypothyroidism
IUD
PID
Clotting disorders e.g. von Willebrand disease
Menorrhagia
Menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy.
What is androgen insensitivity syndrome ?
An x-linked condition due to end-organ resistance to testosterone causing genotypically male children (XY) to have female phenotype
What are the features of androgen insensitivity syndrome ?
Primary amenorrhoea
Little or no axillary and pubic hair
Undescended testes causing groin swelling
Breast development may occur as a result of the conversion of testosterone to oestradiol
How is diagnosis of androgen insensitivity syndrome done ?
Buccal smear or chromosomal analysis to reveal 46XY genotype
After puberty, testosterone concentration are in the high-normal to slightly elevated reference range to postpubertal boys
What would positive antiphospholipid Antibodies s mean for a patient taking COCP
They would have to cease contraceptive medication as now UKMEC 4
What is the treatment for obstetric cholestasis
Urodeoxycholic acid
What does a Bishop score of < 5 indicate ?
Labour is unlikely to start without induction
What does a Bishop score of > 8 indicate ?
Indicates that the cervix is ripe or favorable and there is a high chance of spontaneous labour
Indications for CS
Fetal distress in labour
Prolapsed cord
Failure of labour to progress
Placenta praevia grades ¾
Pre-eclampsia
Prolapsed cord
Brow: malpresentations
Vaginal infection e.g. active herpes
Cervical cancer
Indications for a Cat 1 CS
Immediate threat to the life of mother or baby
Delivery should occur within 30 mins of decision
Suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or fetal persistent bradycardia
Indications for Cat 2 CS
Maternal or fetal compromise which is not immediately life-threatening
Delivery of the baby should occur within 75 mins of the decision
What serious complications should pts be made aware of for a CS
Emergency hysterectomy
Need for further surgery at a later date including curettage (e.g. for retained placental tissue)
Admission to ITU
Thromboembolic disease
Bladder injury
Ureteric injury
Death (1/12000)
What frequent complications should pts be made aware of for a CS
Persistent wound and abdominal discomfort in the first few months post
Increased risk of repeat caesarean section if vaginal delivery attempted in subsequent pregnancies
Readmission to hospital
Haemorrhage
Infection (wound, endometritis, UTI)
Fetal lacerations (1 or 2 babies every 100)
What impacts on future pregnancies should pts be made aware of for a CS
Increased risk of uterine rupture during subsequent pregnancies/deliveries
Increased risk of antepartum stillbirth
Increased risk in subsequent pregnancies of placenta praevia and accreta
What is post-partum thyroiditis ?
When there are changes to thyroid function within 12 months of delivery, affecting women without a prior Hx of thyroid disease
It can involve thyrotoxicosis or hypothyroidism or both
What are the 3 stages of postpartum thyroiditis ?
Thyrotoxicosis
Hypothyroid
Thyroid function gradually returns to normal (usually within 1 year)
Signs of symptoms of thyrotoxicosis
Anxiety and irritability
Sweating and heat intolerance
Tachycardia
Weight loss
Fatigue
Frequent loose stools
Signs and symptoms of hypothyroidism
Weight gain
Fatigue
Dry skin
Coarse hair and hair loss
Low mood
Fluid retention (oedema, pleural effusions, ascites)
Heavy or irregular periods
Constipation
What TSH, T3 and T4 levels would you expect with thyrotoxicosis/hyperthyroidism
T3 raised
T4 raised
TSH suppressed
What TSH, T3 and T4 levels would you expect with hypothyroidism
T3 low
T4 low
TSH high
Treatment for postpartum thyrotoxicosis ?
Symptomatic control - propranolol
Treatment for postpartum hypothyroidism
Levothyroxine
What is Sheehan’s Syndrome ?
When the pituitary gland undergoes ischaemic necrosis following PPH
Can manifest as hypopituitarism in which a lack of milk production and amenorrhoea occurs following delivery
Most common cause of meningitis in ages 0-3 months
E.coli
Listeria monocytogenes
What virus causes rubella ?
Togavirus
After how many days can a pt pass on rubella post infection ?
7 days
When is the risk highest for damage to the fetus from rubella infection
First 8-10 weeks
Risk of damage is as high as 90%
What are features of congenital rubella syndrome
Sensorineural deafness
Congenital cataracts
Congenital heart disease e.g. patent ductus arterious
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
Salt and pepper chorioretinitis
Microphthalmia
Cerebral palsy
What should be your next step following rubella infection ?
Discuss immediately with the local health protection unit
A 67-year-old women presents with a heavy dragging sensation in the suprapubic region. She also has frequency and urgency
Urogenital prolapse
Typical Hx is a 6-8 weeks amenorrhoea and abdominal pain that later develops vaginal bleeding. Shoulder tip pain and cervical excitation may be seen
Ectopic pregnancy
Pain initially in the central abdomen before localising to the right iliac fossa. Anorexia is common. Tachycardia, low-grade pyrexia, tenderness in RIP. Rovsing’s sign: more pain in RIF then LIP when palpating LIF
Appendicitis
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur. Cervical excitation may be found on examination
PID
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common. Unilateral, tender adnexal mass on examination
Ovarian torsion
Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Miscarriage
Chronic pelvic pain, Dysmenorrhea - pain often starts days before bleeding , Deep dyspareunia, Subfertility
Endometriosis
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain. Large cysts may cause abdominal swelling or pressure effects on the bladder
Ovarian cyst
RFs for cord prolapse
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Cephalopelivc disproportion
Abnormal presentations e.g. breech, transverse lie
Management of cord prolapse
Insert urinary catheter and fill bladder with saline (500-700ml of saline)
Ask patient to go on all fours until emergency CS
Tocolytics may reduce uterine contractions
Risk factors for VTE in pregnancy
Age >35
BMI > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
FHx
Low risk thrombophilia
IVF
When and what treatment is initiated for high VTE risk in pregnancy ?
4 or more RFs
Give immediate low molecular weight heparin continued until 6 weeks postnatal
If 3 or more RFs then give LMWH from 28 weeks until 6 weeks postnatal
Take MORE (5mg) folic acid if
M- Metabolic disease (DM or coeliac)
Obesity
Relative or personal Hx of NTD
Epilepsy (taking meds)
Components of a Bishop score
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Fetal station
At how many weeks should A rhesus negative pt be given anti-D ?
28 weeks
A 44 year old women who has undergone a hysterectomy for severe dysmenorrhoea. A few months later she suffers from a vaginal prolapse. What is the most appropriate surgical intervention ?
Sacrocolpopexy
What is a urogenital prolapse ?
The descent of one of the pelvic organs resulting in protrusion of the vaginal walls
Impacts 40% of postmenopausal women
What are the main different types of prolapse ?
Cystocele, cystourethrocele
Rectocele
Uterine prolapse
RFs for prolapse
Increasing age
Multiparity, vaginal deliveries
Obesity
Spina bifida
Presentation of prolapse ?
Sensation of pressure, heaviness, dragging or bearing down
Urinary symptoms: incontinence, frequency, urgency
Management of prolapses
If asymptomatic and mild then prolapse needs no treatment
Conservative: weight loss, pelvic floor muscle exercise
Ring pessary
Surgery
Surgical options for prolapse
Cystocele/Cystourethrocele: anterior colporrhaphy, colposuspension
Uterine prolapse: hysterectomy, sacrohysteropexy
Rectocele: posterior colporrhaphy
What is a Cystocele/Cystourethrocele prolapse
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.
What is a uterine prolapse
Uterine prolapse is where the uterus itself descends into the vagina.
What is a rectocele prolapse
Caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
Rectoceles are particularly associated with constipation.
What is 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.
What is an antidote for magnesium sulfate associated respiratory distress ?
Calcium gluconate
Causes of primary amenorrhoea
Gonadal dysgenesis e.g. Turner’s syndrome
Testicular feminisation
Congenital malformations of the genital tract
Function hypothalamic amenorrhoea e.g. secondary to anorexia
Congenital adrenal hyperplasia
Imperforate hymen
Secondary amenorrhoea
Hypothalamic amenorrhoea e.g. secondary stress/excessive exercise
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Investigations of amenorrhoea
Exclude pregnancy with urinary or serum bHCG
FBC, U&E, coeliac screen, thyroid function tests
Gonadotrophins (low = hypothalamic, raised = gonadal dysgenesis (Turner’s syndrome))
Prolactin
Androgen levels (rasied in PCOS)
Oestradiol
What chromosome is effected in Patau syndrome ?
13
What occurs at a 10 week check ?
Assess BMI
Urine culture if dipstick is normal
Check for red cell alloantibodies
Hep B testing
Treatment for ectopic pregnancy located in the adnexa with a fetal heart beat ?
Surgical management - salpingectomy or salpingotomy
A 67-year-old women presents with a heavy dragging sensation in the suprapubic region. She also has frequency and urgency
Urogenital prolapse
Typical Hx is a 6-8 weeks amenorrhoea and abdominal pain that later develops vaginal bleeding. Shoulder tip pain and cervical excitation may be seen
Ectopic pregnancy
Pain initially in the central abdomen before localising to the right iliac fossa. Anorexia is common. Tachycardia, low-grade pyrexia, tenderness in RIP. Rovsing’s sign: more pain in RIF then LIP when palpating LIF
Appendicitis
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur. Cervical excitation may be found on examination
PID
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common. Unilateral, tender adnexal mass on examination
Ovarian torsion
When is hyperemesis gravidarum (HG) most common ?
8-12 weeks but persists up to 20 weeks
Risk Factors for HG ?
Increased b-hCG
Multiple pregnancies
Trophoblastic disease
Nulliparity
Obesity
FHx
PMHx
When would you consider admission for HG ?
Continued nausea and vomiting and is unable to keep liquids or oral antiemetics down
Continued nausea and vomiting with ketonuria and/or weigh loss > than 5% body weight despite oral antiemetics
A confirmed or suspected comorbidity e.g. UTI
Royal Collage Triad for HG
5% pregnancy weight loss
Dehydration
Electrolyte imbalance
Lifestyle advice for HG
Rest and avoid triggers
Ginger and bland plain food
P6 wrist pressure
Medical Management of HG
1st line oral antiemetics
Antihistamines: oral cyclizine or promethazine
Phenothiazines: oral prochlorperazine or chlorpromazine
2nd line
Oral ondansetron (cleft pallet) or oral dompenidone (extrapyramidal)
3rd line - admission for IV hydration
Complications of HG
AKI
Wernicke’s encephalopathy
VTE
Oesophagitis
Mallory Weiss tear
Which virus is responsible for chickenpox ?
Varicella-zoster
What is shingles ?
The reactivation of dormant varicella zoster virus in the dorsal root ganglion
How does shingles present ?
The first signs of shingles can be: a tingling or painful feeling in an area of skin or a headache or feeling generally unwell
A rash will appear a few days later.
Usually you get the shingles rash on your chest and tummy, but it can appear anywhere on your body including on your face, eyes and genitals.
The rash appears as blotches on your skin, on 1 side of your body only.
What complications can chickenpox infection have on fetus development ?
Skin scarring
Microphthalmia
Limb hypoplasia
Microcephaly
Learning disabilities
How is chickenpox during pregnancy managed ?
Check maternal blood for ABs
If < 20 weeks and not immune then varicella-zoster immunoglobulin asap
If > 20 weeks and not immune then either VZIG or aciclovir or valaciclovir
If > 20 weeks with rash then give aciclovir
What is endometrial hyperplasia ?
Abnormal proliferation of the endometrium in excess of normal proliferation that occurs during the menstrual cycle
Presents as abnormal vaginal bleeding
RFs for endometrial hyperplasia
Taking oestrogen unopposed by progesterone
Obesity
Late menopause
Early menarche
>35yo
Current smoko
Nullpairty
Tamoxifen
Management of endometrial hyperplasia
Simple (without atypia) = high dose progesterone - Levonorgestrel IUD may be used
Complex (with atypia) = hysterectomy
UKMEC3 conditions for COCP
> 35 and smoko > 15 per day
Hx of clots/strokes/ischaemic disease
FHx of clots in first relative
Migraine with aura
BMI > 35
Controlled HTN
Immobility
Breast cancer BRAC1/BRAC2
Current gallbladder disease
UKMEC4 conditions for COCP
> 35 and smoko >15 per day
Hx of clots/stroke/MI/Ischaemic disease
Breastfeeding <6 weeks postpartum
Uncontrolled hypertension
Current breast cancer
Major surgery with immobilisation
What is Mittelschmerz
Midcyle pain often sharp at onset
Little systemic disturbance
May have recurrent episodes but usually settles over 24-48 hours
FBC normal
US may show a small quantity of free fluid
