1
Q
Name 3 hormones that are important in pregnancy.
A
Main hormones:
- hCG.
- Progestins.
- Oestrogens.
Other hormones:
- hPL.
- Prolactin.
- Oxytocin.
2
Q
Where is hCG produced?
A
The trophoblast.
3
Q
Function of Progestins
A
- It signals the presence of the blastocyst.
- It prevents the corpus luteum from dying - luteal regression.
4
Q
Where are progestins produced?
A
Initially from the corpus luteum and then from the placenta from week 7.
From trophoblast cells in the placenta.
5
Q
Give 3 functions of progestins.
A
- Prepares the endometrium for implantation.
- Promotes myometrial quiescence.
- Increases maternal ventilation.
6
Q
How do progestins prepare the endometrium for implantation?
A
Progestins stimulate the proliferation of cells, vascularisation and the differentiation of endometrial stroma.
7
Q
Where are oestrogens produced?
A
Initially in the ovary and then from a combination of fetal and maternal sources.
8
Q
Give 2 functions of oestrogens in pregnancy.
A
- Promotes a change in the CV system.
2. Alters carbohydrate metabolism.
9
Q
What is the main oestrogen in pregnancy?
A
E3 - it indicates fetal well-being.
10
Q
What is the role of E2 in pregnancy?
A
E2 is responsible for proliferation of the endometrial epithelium. It also facilitates progesterone action.
11
Q
What is the role of human placental lactogen (hPL)?
A
- Mobilises glucose from fat.
- Acts as an insulin antagonist.
- Converts mammary glands into milk secreting tissues.
12
Q
What is the role of prolactin?
A
Prolactin is responsible for milk production.
13
Q
What is the role of oxytocin?
A
Oxytocin is responsible for milk secretion and uterine contractions.
14
Q
Where is prolactin produced?
A
In the anterior pituitary gland.
15
Q
Where is oxytocin produced?
A
It is produced in the Hypothalamus and is stored in the posterior pituitary gland.
16
Q
Where are FSH and LH produced?
A
In the anterior pituitary gland.
17
Q
What hormone does the hypothalamus release that acts on the anterior pituitary gland and stimulates the production of FSH and LH?
A
GnRH.
18
Q
What cells in the ovaries does FSH act on?
A
Granulosa cells -> oestrogen production.
19
Q
What cells in the ovaries does LH act on?
A
Theca cells -> androgen production.
20
Q
What hormone is released from the hypothalamus that acts on the anterior pituitary to inhibit prolactin release?
A
Dopamine.
21
Q
What is the principle foetal nutrient?
A
Glucose.
22
Q
Can the foetus produce any of its own glucose?
A
No, gluconeogenic enzymes are inactived in the foetus and so all its glucose has to come from its mother.
23
Q
In early pregnancy, is plasma glucose high or low?
A
Plasma glucose is lower because glucose is being stored.
24
Q
Why is plasma glucose lower in early pregnancy?
A
Because the mother is storing glucose.
25
In late pregnancy, is plasma glucose high or low?
Plasma glucose is higher. This is due to maternal insulin resistance and glucose sparing for the foetus.
26
Why is plasma glucose higher in late pregnancy?
1. Because of increasing maternal insulin resistance.
2. Glucose sparing for the foetus.
27
What are the consequences of maternal insulin resistance?
Maternal insulin resistance -> gestational diabetes -> increased risk of macrosomia and shoulder dystocia.
28
Why is the immune response suppressed in a pregnant lady?
It prevents foetal rejection.
29
Give 4 ways in which foetal rejection is prevented in a pregnant lady.
1. A TH2 bias is observed.
2. Syncytiotrophoblast has no self:non-self markers and so doesn't stimulate an immune response.
3. Extra-villous trophoblast cells have modified markers.
4. The overall immune response is suppressed.
30
In a normal pregnancy, a TH2 bias is observed, this helps prevent foetal rejection. Give 3 potential consequences if there is not a TH2 bias.
1. Pre-eclampsia.
2. IUGR.
3. Miscarriage.
31
How does the endometrial epithelium become adhesive to the blastocyst?
The blastocyst and endometrium communicate via the release of hormones -> 'sticky endometrium'.
32
When in a woman's cycle does the endometrium become sticky?
This usually happens between days 20-24. This is called the window of implantation and outside of this time implantation will not occur.
33
What reaction occurs when a blastocyst implants into the endometrium?
A primary decidual reaction occurs.
34
What part of the blastocyst facilitates placental formation?
The cytotrophoblast.
35
Placenta formation: What does the cytotrophoblast go on to form?
Anchoring villi -> extra villous trophoblast.
Floating villi are also involved.
36
What can trigger the differentiation of anchoring villi into extra-villous trophoblast?
Hypoxia.
37
What is the role of extra villous trophoblast (EVT) cells?
EVT invade and remodel spiral arteries. This leads to more hypoxia and so more EVT; a positive feedback effect is observed.
38
Why do EVT cells invade and remodel spiral arteries?
To allow for optimum nutrient delivery for the baby.
39
Give 3 potential consequences of poor endovascular remodelling.
1. Pre-eclampsia.
2. IUGR.
3. Pre-term birth.
40
Where should normal placenta invade into?
The decidua.
41
What is placental accreta?
When the placenta invades into the superficial myometrium.
42
What is placental increta?
When the placenta invades into the deeper myometrium.
43
What is placental percreta?
Invasion of the placenta into nearby organs e.g. the bladder.
44
What are the potential consequences, if left untreated, of a rhesus negative mother having a rhesus positive foetus?
There is a risk of RBC lysis -> foetal anaemia and death.
45
Describe the pathophysiology of rhesus disease.
1. Foetal Rh+ RBC's leak through the placenta and interact with the mother's blood -> IgM reaction -> sensitisation.
2. IgM can't cross the placenta and so there is no RBC lysis but memory B cells are created.
2. On a subsequent pregnancy, IgG may cross the placenta and cause foetal RBC lysis.
46
What is the only antibody that can cross the placenta?
IgG.
47
How can foetal RBC lysis be prevented in rhesus negative mothers?
Anti-D prophylaxis can be given. This destroys Rh+ IgG and so no RBC are attacked.
48
What is quiescence?
When the myometrium is inactive, there are no contractions.
49
Describe the physiology behind quiescence?
Increased cAMP -> K+ extrusion -> myocyte hyperpolarisation -> muscle fibres are unable to contract.
There is also phosphorylation of intracellular proteins -> actin-myosin ATPase is inactivated -> smooth muscle relaxation.
50
Give 2 theories behind the induction of labour.
1. Placental clock theory.
2. Signals from the baby.
51
Induction of labour: describe the placental clock theory.
Increased release of CRH from the placenta -> foetal ACTH release -> release of oestrogens, formation of myometrial gap junctions -> regular and co-ordinated uterine contractions.
52
Induction of labour: describe the theory that suggests that there are signals from the baby.
Increased ACTH or increased foetal surfactant proteins activate amniotic fluid macrophages. These migrate to the uterine wall, there is up-regulation of inflammatory gene expression which stimulates labour.
53
Parturition: do progesterone levels fall when the cervix dilates and remodels?
Progesterone levels don't fall but it becomes ineffective -> contractions.
54
Parturition: what happens in the expulsion phase that triggers myometrial contractions?
Oxytocin release -> increased intracellular Ca2+ -> myometrial contractions.
55
Why can nifedipine be used to inhibit premature contractions?
Nifedipine is a CCB and so can block the rise of intracellular calcium therefore inhibiting muscle contraction.
56
Name 2 drugs that can inhibit uterine contractions.
1. Nifedipine - CCB.
2. Atosiban - oxytocin antagonist.
57
Name an oxytocin analogue that can indue labour.
Syntocinon.
58
Why is the incidence of breast cancer thought to be increasing?
1. Western lifestyle.
2. Screening.
3. Increasing life expectancy.
59
What percentage of women who have a mammogram will be called back for more tests?
4/100 will need more tests.
1/4 of these women will then be found to have cancer.
60
Breast cancer: what is the triple assessment?
1. Clinical examination e.g. palpation.
2. Mammogram/USS
3. Core needle biopsy.
61
Breast cancer: is a P1/2 lump that is described as soft, mobile and regular likely to be benign or malignant?
Benign. E.g. fibroadenoma.
62
Breast cancer: is a P4/5 lump that is described as hard, fixed and irregular likely to be benign or malignant?
Malignant.
63
Name 3 modifiable RF's for breast cancer.
1. Alcohol intake.
2. Obesity.
3. Use of HRT/OCP.
64
Name 3 non-modifiable RF's for breast cancer.
1. Age of menarche/menopause.
2. Breast density.
3. Genetics e.g. BRCA1/2.
65
Approximately what percentage of breast cancers are ductal and what percentage are lobular?
- Ductal (70%).
- Lobular (10%).
66
Give 4 signs that you may find on clinical examination that are suggestive of breast cancer.
1. Palpable lump - irregular, hard, fixed, painless.
2. Discharge from the nipple.
3. Nipple in-drawing.
4. Skin changes e.g. peau d'orange.
67
If a patient has breast implants or high density breasts a mammogram can be difficult to interpret. What investigation can be done as an alternative?
An MRI.
68
Give 3 treatment options for patients with breast cancer.
1. Conservative surgery + radiotherapy.
2. Mastectomy + radiotherapy.
3. Mastectomy + reconstruction + radiotherapy (BUT can damage a lot of reconstructions).
4. Axillary lymph node removal - limited removal or clearance.
69
Why might a mastectomy be indicated as opposed to a lumpectomy in someone with breast cancer?
1. If the tumour is large relative to the size of breast.
2. If there are multiple tumours.
3. Patient preference.
70
What biopsy should you do to ensure that breast cancer hasn't spread to the axillary lymph nodes?
A sentinel node biopsy.
71
Name 2 adjuvant treatments that can be given to women with oestrogen receptor + cancer.
1. Tamoxifen (pre-menopausal).
2. Aromatase inhibitors eg anastrozole (post-menopausal).
72
Why might a woman with breast cancer have chemotherapy?
If she has a very aggressive cancer or to shrink a tumour prior to surgery.
73
Give 3 non-pharmacological therapies that can be used to help manage labour pain.
1. Trained support.
2. Acupuncture.
3. Hypnotherapy.
4. Massage.
5. Hydrotherapy.
74
Give 5 pharmacological therapies that can be used to help manage labour pain.
1. Gas and air - entonox.
2. Paracetamol.
3. Codeine.
4. Opioids e.g. pethidine, diamorphine.
5. Epidural.
6. Spinal anaesthesia.
75
Give 3 potential side effects of opioids.
1. Sedation.
2. Respiratory depression.
3. Nausea and vomiting.
4. They cross the placenta readily.
76
Where is spinal anaesthesia injected into?
The CSF.
77
Name an anaesthetic that can be given as an epidural.
Bupivacaine.
78
How does Bupivacaine work as an epidural?
It blocks sodium channels.
79
Give 3 indications for an epidural.
1. Maternal request.
2. Augmented labour.
3. Twins.
4. Existing co-morbidities.
80
Give 3 contraindications for an epidural.
1. Maternal refusal.
2. Local infection.
3. Allergy.
81
Why would a general anaesthetic be given for performing a c-section?
If there is a threat to the mum or the foetus and so a regional anaesthetic is contraindicated.
82
Give 2 disadvantages of using a general anaesthetic for a c-section.
1. Risk of aspiration.
2. Given IV and so the baby is anaesthetised too.
83
Give 3 advantages of using local anaesthetic when performing a c-section.
1. Safer.
2. You can see the baby immediately.
3. Partner present.
84
Give 3 disadvantages of using local anaesthetic when performing a c-section.
1. It can cause hypotension.
2. It can cause headaches.
3. The patient may experience discomfort from pressure sensations.
85
Define miscarriage.
The loss of a pregnancy before 24 weeks of gestation.
86
In approximately what percentage of pregnancies does miscarriage occur?
20%.
87
What is a threatened miscarriage?
When a lady experiences bleeding +/- pain but the cervical os is closed.
88
What is an inevitable miscarriage?
When a lady experiences heavy bleeding, clots, pain and the cervical os is open. But there are products on USS.
89
Define complete miscarriage.
When all the products of conception leave the body.
90
Define recurrent miscarriage.
>3 consecutive miscarriages.
91
Give 4 potential causes of miscarriage.
1. Abnormal foetal development.
2. Uterine abnormality.
3. Incompetent cervix.
4. Placental failure.
5. Multiple pregnancy.
92
Give 3 risk factors for miscarriage.
1. Age >30.
2. Smoking.
3. Excessive alcohol consumption.
4. Uterine surgery.
5. Poorly controlled diabetes.
93
What investigations might you do to determine whether someone has had a miscarriage?
1. Transvaginal USS.
2. Serum hCG.
94
Describe the management of a miscarriage.
1. Vaginal misoprostol (Prostaglandin)
2. Manual vacuum aspiration.
3. Counselling and support.
95
What is a molar pregnancy?
A molar pregnancy is a type of GTD. It occurs when there is an abnormality in chromosomal number during fertilisation. A non-viable fertilised egg implants and fails to come to term. It grows into a mass in the uterus.
96
What is gestational trophoblastic disease (GTD)?
GTD describes a group of pregnancy related tumours. These tumours can be pre-malignant and often benign e.g. molar pregnancies or malignant e.g. choriocarcinoma and invasive mole.
97
Describe a partial molar pregnancy.
Where an ovum is fertilised by two sperm -> produces cells with 69 chromosomes (triploidy).
98
Describe a complete molar pregnancy.
Where one ovum without any chromosomes is fertilised by one sperm which duplicates. There are 46 chromosomes all of paternal origin.
99
Which type of molar pregnancy results in 46 chromosomes all of paternal origin?
A complete molar pregnancy.
100
Give 3 risk factor's for GTD.
1. Maternal age <16 or >45.
2. Multiple pregnancy.
3. Previous GTD.
4. OCP.
101
Give 3 symptoms of molar pregnancies.
1. Vaginal bleeding in early pregnancy.
2. Abdominal pain in early pregnancy.
3. Hyperemesis and hyperthyroidism in late pregnancy due to high levels of B-hCG.
102
What investigations might you do in someone to determine if they have GTD?
1. Urine and blood B-hCG - will be very high.
2. USS - complete mole has 'snow storm' appearance.
103
What is the treatment for molar pregnancies?
Suction curettage.
Chemotherapy.
104
What is hyperemesis gravidarum?
Excessive vomiting, dehydration and ketosis in pregnancy.
105
With which placental hormone is hyperemesis gravidarum associated?
B-hCG.
106
How is hyperemesis gravidarum managed?
Rehydrate with IV fluids, vitamins and frequent small meals.
107
Give 2 methods used for monitoring the foetal heart rate.
1. Intermittent auscultation using a pinard stethoscope or a hand held doppler.
2. Continuous monitoring: cardiotocography (CTG).
108
FHR monitoring: give 2 advantages of intermittent auscultation.
1. Cheap.
2. Easy to do.
3. Non invasive.
4. Can be done at home.
109
FHR monitoring: give 2 disadvantages of intermittent auscultation.
1. Variability is not detected.
2. Long term monitoring is not possible.
3. Quality of FHR can be affected by the maternal HR.
110
FHR monitoring: give 2 advantages of continuous monitoring.
1. Gives lots of information e.g. variability, accelerations, decelerations etc.
2. Continuous.
3. Monitors FHR and uterine contractions.
111
FHR monitoring: give 2 disadvantages of continuous monitoring.
1. Not very mobile - the mum's abdomen is strapped.
2. Expensive.
112
CTG: what is a normal baseline HR?
110-160 bpm.
113
CTG: what is a non-reassuring baseline HR?
100-109 bpm.
114
CTG: what is an abnormal baseline HR?
<100 bpm.
| >180 bpm.
115
CTG: what is normal variability?
>5
116
CTG: what is non-reassuring variability?
<5 for 40-90 minutes.
Reduced variability could be due to foetal sleeping.
117
CTG: what is abnormal variability?
<5 for >90 minutes.
118
CTG: what is an acceleration?
An increase in the baseline HR by 10-15 bpm.
119
CTG: are accelerations reassuring or non-reassuring?
The presence of accelerations is reassuring.
120
CTG: are decelerations reassuring or non-reassuring?
Decelerations are non-reassuring.
121
CTG: what are early decelerations?
Early decelerations are seen just before a uterine contraction. They may be due to foetal head compression.
122
CTG: what are late decelerations?
Late decelerations are seen just after uterine contraction. They may be due to placental insufficiency and are often more sinister.
123
CTG: are early or late decelerations more concerning?
Late decelerations are more concerning.
124
CTG: what are variable decelerations?
When there is a mixture of early and late decelerations.
125
CTG: how would you determine if a CTG was overall normal, suspicious or abnormal?
- Normal: everything is normal and accelerations are present.
- Suspicious: one non-reassuring feature.
- Abnormal: >2 non-reassuring features and/or >1 abnormal feature.
126
How do you define a normal CTG? (BraVAD)
1. Baseline HR - 110-160 bpm.
2. Variability >5.
3. Accelerations present.
4. No decelerations.
127
What are the parameters used in determining whether a CTG is normal or abnormal?
1. Baseline HR.
2. Variability.
3. Accelerations.
4. Decelerations.
128
What is the gold standard method for direct FHR monitoring?
Scalp ECG.
129
Give a disadvantage of a scalp ECG for monitoring the FHR.
1. Invasive.
2. Membranes need to be broken and so cervix must be >2cm.
3. Risk of scalp injury and infection risk.
130
What is the role of p53?
p53 is a tumour suppressor gene. It is a transcription factor that regulates cell division and death.
131
What is the role of Rb?
Rb is a tumour suppressor gene. It alters the activity of transcription factors and so controls cell division.
132
If there is a mutation in either p53 or Rb what might happen?
If a mutation occurs in these genes a patient may have uncontrolled cell growth -> cancer.
133
What are the roles of oncogenes?
Oncogenes stimulate excessive cell growth and cell division -> cancer development.
134
Give an example of an oncogene.
HER2.
135
What is the most common type of gynaecological cancer?
Endometrial cancer.
136
What is the pathophysiology behind endometrial cancer?
Unopposed oestrogen leads to endometrial hyperplasia and so an increased risk of endometrial adenocarcinoma.
137
Give 9 risk factors for developing endometrial cancer.
1. Obesity - Increased rate of peripheral aromatization of androgens into oestrogen.
2. Diabetes.
3. Nulliparity.
4. Anovulation- Early Menarche or Late menopause.
5. HRT.
6. Pelvic irradiation.
7. PCOS
8. Tamoxifen
9. Family History
138
What is the most common type of endometrial cancer?
Endometrial adenocarcinoma.
139
What is the red flag symptom for endometrial cancer?
Post menopausal bleeding!
140
What investigations might you do if you suspect that a patient may have endometrial cancer?
1. Pelvic and abdominal examination.
2. Transvaginal USS - Endometrial thickness >4mm.
3. Endometrial biopsy.
4. Hysteroscopy.
141
What type of staging is used for endometrial cancer?
FIGO staging.
142
Describe the treatment for endometrial cancer.
1. Hysterectomy +/- pelvic lymph node removal.
2. Adjuvant radio/progesterone therapy.
143
Define adenocarcinoma.
A malignant tumour of glandular epithelium.
144
Why is the incidence of cervical cancer decreasing?
1. Screening - cervical smears.
| 2. HPV vaccine.
145
Name 2 oncoproteins associated with HPV.
1. E6 - blocks p53.
2. E7 - blocks Rb.
146
HPV: Which oncoprotein blocks p53?
E6.
147
HPV: Which oncoprotein blocks Rb?
E7.
148
Give 5 risk factors for HPV and so cervical cancer.
1. Early age intercourse (<16).
2. Multiple sexual partners.
3. STI's.
4. Smoking.
5. Multiparity.
6. OCP.
149
What is the most common type of cervical cancer?
Squamous (90%).
150
What type of staging is used for cervical cancer?
FIGO staging.
151
What is the red flag symptom for cervical cancer?
Post-coital bleeding.
152
Describe the treatment for cervical cancer.
1. <2cm - loop removal, just removing part of the uterus.
2. >2cm - radical hysterectomy.
3. >4cm - radiotherapy, chemotherapy, palliative care.
153
What must you consider when treating cervical cancer?
Fertility - is the patient likely to want children in the future?
154
Give 3 potential risks of performing a radical hysterectomy.
1. Bowel problems.
2. Sexual problems.
3. Bladder problems.
4. Lymphoedema.
155
Describe the aetiology of vulval cancer.
Vulval intraepithelial neoplasia (VIN - skin disease).
Abnormal cells develop in the surface layers of the skin covering the vulva.
It is not vulval cancer but may turn into cancer - pre-malignant.
Usual type is associated with HPV infection.
156
What is the most common type of vulval cancer?
Squamous.
157
Give 5 symptoms of vulval cancer.
1. Itching.
2. Soreness.
3. Lump.
4. Bleeding.
5. Pain on micturition.
158
Describe the treatment for vulval cancer.
1. Surgery - radical or conservative.
2. Radiotherapy.
3. Chemotherapy.
159
Give 4 risk factors for developing ovarian cancer.
1. Early menarche.
2. Late menopause.
3. Nulliparity.
4. Genetics e.g. BRCA1/2.
160
Describe the epidemiology of ovarian cancer.
More common in women >50; post-menopausal. Often people present late and so it is advanced at presentation.
161
What are the commonest types of ovarian cancer?
1. Epithelial (85%).
2. Sex cord.
3. Germ cell.
162
Give 5 symptoms of ovarian cancer.
1. Bloating.
2. Abdominal pain.
3. Change in bowel habit.
4. Urinary frequency.
5. Bowel obstruction.
6. Can often be asymptomatic.
163
What investigations might you do in a patient who you suspect has ovarian cancer?
1. Measure CA125.
2. Trans-vaginal USS.
3. Calculate the RMI (risk of malignancy index) - if this is >250 the patient should be referred under the 2 week wait system.
164
How is cervical cancer treated?
Surgery and chemotherapy should be offered.
165
Define incontinence.
The involuntary leakage of urine.
166
Incontinence: What is OAB?
**Over-active bladder.**
There are involuntary detrusor contractions -> urgency.
167
Give 3 symptoms of OAB.
1. Urgency.
2. Frequency.
3. Nocturia.
4. 'Key in door' urgency.
168
What is stress incontinence?
Stress incontinence occurs in patients with a week urethral sphincter. Anything that increases intra-abdominal pressure e.g. coughing, laughing, exercise results in the leakage of urine.
169
If a patient has a good bladder capacity and small volume leakage would this be more in keeping with a diagnosis of OAB or stress incontinence?
Stress incontinence.
170
What is the functional bladder capacity?
400ml.
171
Describe the epithelium of the detrusor muscle.
Smooth muscle with transitional epithelium.
172
Describe the innervation of the detrusor muscle.
Sacral parasympathetic innervation.
173
What investigations might you do in a patient complaining of incontinence?
1. Bladder diary (frequency volume chart).
2. Urinalysis.
3. Residual urine measurement e.g. catheter or USS.
4. ePAQ.
174
What information can you obtain from a bladder diary?
1. Frequency.
2. Quantity of urine.
3. Fluid intake.
4. Diurnal variation.
175
Investigating incontinence: what is ePAQ?
A questionnaire regarding urinary, bowel, vaginal and sexual symptoms.
176
Describe the non-pharmacological treatments for managing OAB.
1. Lifestyle changes e.g. weight loss, stop smoking, reduce caffeine, avoid straining.
2. Bladder drill.
3. Pads.
177
Describe the non-pharmacological treatments for managing stress incontinence.
1. Lifestyle changes e.g. weight loss, stop smoking, reduce caffeine, avoid straining.
2. Physiotherapy e.g. pelvic floor exercises.
178
How do pelvic floor exercises work in treating someone with stress incontinence?
Pelvic floor muscle contraction -> urethra compression -> increased urethral pressure -> reduced leakage.
Vaginal cones can also be used.
179
What surgical options can be offered to patients with stress incontinence?
1. Sling.
2. Suspension - restores pressure to the urethra and supports the urethra.
180
Name 3 drugs that can be used to treat OAB.
1. Oxybutynin.
2. Mirabegron.
3. Botulinum Toxin.
181
How does oxybutynin work in treating OAB?
Oxybutynin is anticholinergic, it is an M2/3 receptor antagonist. It works by reducing detrusor muscle innervation and so its activity.
182
Give 3 potential side effects of oxybutynin.
1. Dry mouth.
2. Constipation.
3. Blurred vision.
4. Cognitive impairment.
183
How does mirabegron work in treating OAB?
It is beta 3 agonist. It relaxes the detrusor muscle and increases bladder capacity.
184
How does botulinum toxin work in treating OAB?
It blocks ACh release and so reduces destrusor muscle contraction.
185
Give 3 symptoms of prolapse.
1. Pain.
2. Lump.
3. Discomfort.
4. Sexual symptoms.
186
Describe the management for a patient presenting with a prolapse.
1. Reassurance.
2. Symptom management.
3. Vaginal pessaries e.g. ring.
4. Surgery can be offered if symptoms are severe.
187
Is the detrusor muscle relaxed or contracted during storage?
Relaxed.
188
Is the detrusor muscle relaxed or contracted during voiding?
Contracted.
189
Describe the physiology of micturition.
The bladder fills and stretch receptors are stimulated. Afferent impulses stimulate the parasympathetic action of detrusor muscle; it contracts. The urethral sphincters relax; this is mediated by inhibition of the neurones to them. The PAG is stimulated.
190
How does the COCP work as a contraceptive?
The COCP prevents ovulation and alters the cervical mucus, it also thins the endometrium.
191
Give 5 advantages of the COCP as a contraceptive.
1. Reversible.
2. Reliable.
3. Regular cycle.
4. Reduces menorrhagia.
5. Helps with acne.
6. Reduces post-menopausal symptoms.
7. Protective against some kinds of cancer.
192
Give 3 disadvantages of the COCP as a contraceptive.
1. No protection against STI's.
2. Drug interactions.
3. Increased risk of breast and cervical cancer.
4. VTE risk.
193
How does the POP work as a contraceptive?
It thickens the cervical mucus and thins the endometrium.
Newer POPs can inhibit ovulation.
194
Give 2 advantages of the POP as a contraceptive.
1. Prevents oestrogenic side effects e.g. breast tenderness.
2. Suitable for smokers; those with obesity; those at increased risk of VTE etc.
195
Give 3 disadvantages of the POP as a contraceptive.
1. Less effective than the COCP.
2. Increased risk of ectopic pregnancy.
3. Disrupts menstrual pattern.
4. Functional ovarian cysts may development.
196
What are the Fraser guidelines?
A doctor can proceed to give contraceptive advice and treatment to someone <16 provided he is satisfied in the following criteria:
1. The patient will understand his advice.
2. The doctor cannot persuade the patient to inform their parents.
3. The patient is very likely to continue having sexual intercourse with or without contraception.
4. If the patient does not receive contraceptive advice their physical/mental health will suffer.
5. It is in the patients best interests to receive contraceptive advice and treatment without parental consent.
197
Why is contact tracing important with regards to sexually transmitted infections?
1. Prevents re-infection.
2. Breaks the chain of infection.
3. Allows treatment of asymptomatic individuals.
198
Give 5 questions that are important to ask when taking a sexual health history.
1. When was last intercourse?
2. Regular/casual partners?
3. Male/female partners?
4. Contraceptive use?
5. Type of intercourse?
6. How many partners in the last 3 months and 12 months?
199
Give 5 symptoms of STI's that are seen in women.
1. Abnormal discharge.
2. Itching.
3. Soreness.
4. Ulcers and lumps.
5. Post intercourse bleeding.
200
Give 5 symptoms of STI's that are seen in men.
1. Pain on micturition.
2. Urethral pain.
3. Abnormal discharge.
4. Ulcers and blisters.
5. Swelling.
201
What are the Wilson and Jungner screening criteria?
1. The condition should be a serious health problem.
2. The natural history of the condition should be understood.
3. There should be a detectable early stage.
4. There should be a treatment available.
5. Facilities for diagnosis and treatment should be available.
6. There should be a suitable test.
7. The test should be acceptable to the population.
8. There should be an agreed policy on whom to treat.
9. The cost of testing should be balanced against the benefits.
10. Screening should be a continuous process not just a one off.
202
Define screening.
The process of identifying apparently healthy individuals who may be at increased risk of developing a disease.
203
Antenatal care: When would a woman have her booking appointment and what is the purpose of it?
8-10w.
Offer general lifestyle advice.
Comprehensive obstetric history and examination.
Check for HIV, Hep.B, Syphillis, Rubella.
204
Antenatal screening: what diseases are being screened for in the foetal anomaly screening test?
1. Down's (T21).
2. Edward's (T18).
3. Patau's (T13).
205
Antenatal screening: when should a foetal anomaly screening test be done?
A blood sample should be taken by 14+1 weeks.
An anomaly scan is done between 18-20+6 weeks.
206
Antenatal screening: what is the threshold for further testing following a foetal anomaly screening test?
If the risk is >1 in 150 then further testing will be done e.g. chorionic villous sample (CVS) or amniocentesis.
NIPT is available privately.
207
When is the dating scan done?
An early USS is done at 10-14w, this is used for dating the pregnancy, confirming viability and checking for multiple pregnancy.
208
Antenatal screening: what diseases are being screened for in the infectious diseases screening test?
1. HIV - identify and treat mum and reduce the risk of transmission to the baby.
2. Hep B - look if mum is infected.
3. Syphillis - treat mum to prevent congenital syphillis.
209
Describe the inheritance pattern of sickle cell and thalassaemia.
Autosomal recessive.
210
Name 3 neonatal screening programmes.
1. New born blood spot.
2. Hearing test.
3. New born and 6-8w physical examination.
211
Neonatal screening: what is the new born blood spot?
The new born blood spot screens for 9 conditions. A heal prick blood test is done at days 5-8 and looks for CF, congenital hypothyroidism, sickle cell and 6x metabolic diseases e.g. MCADD, phenylketonuria, maple syrup disease etc.
212
Neonatal screening: when is a hearing test done?
Within 4 weeks. You are looking for a response in the cochlea.
213
Neonatal screening: when is a new born physical examination done?
Within 72 hours of birth. It is repeated at 6-8 weeks by a GP.
214
Neonatal screening: give 4 things that a new born physical examination is looking for.
1. Eye problems.
2. Heart defects.
3. Dysplasia of the hips.
4. Undescended testes.
215
What should a doctor tell a patient in order for the patient to give fully informed consent?
1. The nature of the procedure.
2. About any reasonable alternatives.
3. Relevant risks, benefits and uncertainties.
4. The patient's understanding should also be assessed.
216
What 4 questions can be asked to assess mental capacity?
1. Does the patient understand the information?
2. Can the patient retain the information?
3. Can they use the information to weight up options and make a decision?
4. Can they communicate their decision?
217
Until what week can a lady legally have an abortion?
Abortion is legal in the UK up to 24 weeks under the Abortion Act 1967. After that, it is illegal unless there is a substantial risk to the woman's life or foetal abnormalities.
218
Define pre-eclampsia.
Gestational hypertension which affects the kidneys -> proteinuria (>0.3g protein/24h).
219
Define chronic hypertension.
A patient with high BP which is diagnosed prior to pregnancy or before week 20 of pregnancy. Their high BP is not resolved postpartum.
220
Define gestational hypertension.
New high BP after 20w gestation and resolves after giving birth. There is no proteinuria.
221
What is eclampsia?
Pre-eclampsia (gestational hypertension + proteinuria) and generalised tonic clonic seizures.
222
What medication can be given to women with gestational hypertension/pre-eclampsia?
Labetalol or nifedipine.
If no response, delivering the baby will normalise BP.
223
Describe the treatment for eclampsia.
1. Give IV MgSO4 (neuroprotection) - Can cause Resp. Depression (Give Calcium Gluconate)
2. Treat HTN e.g. labetalol.
3. Stabilise mum.
4. Deliver baby.
224
Give 5 risk factors for developing eclampsia.
1. Very young or very old mothers.
2. First pregnancy.
3. Afro-caribbean ladies.
4. Multiple pregnancy e.g. twins.
5. Renal disease.
6. Existing HTN.
225
Briefly describe the pathophysiology behind pre-eclampsia.
Spiral arteries do not remodel -> arteries are tight leading to increased resistance in the placenta -> placental ischaemia -> RAAS activated -> poor renal perfusion, HTN, proteinuria and oedema -> pre-eclampsia.
226
Give 3 signs of pre-eclampsia that are detected at the kidneys.
1. GFR and renal blood flow decrease.
2. Raised uric acid.
3. Proteinuria.
227
Give 5 symptoms of pre-eclampsia.
1. Visual change e.g. blurred vision.
2. Headaches.
3. Epigastric pain.
4. Weight gain.
5. Vomiting.
228
Give 5 signs of pre-eclampsia.
1. Raised BP.
2. Proteinuria.
3. Retinal vasospasm.
4. RUQ tenderness.
5. Ankle clonus and brisk reflexes.
6. Pulmonary oedema.
229
Describe the management of pre-eclampsia.
1. Prevent eclampsia and other complications.
2. Treat raised BP with labetalol or nifedipine.
If there is progressive deterioration in liver or renal function then you should deliver the baby.
230
Define prematurity.
Prematurity or preterm is defined as babies born alive before 37 weeks of pregnancy are completed.
231
What organs are most likely to be affected in babies that are born premature and why?
The lungs and brain are most likely to be affected as these develop in the 3rd trimester.
232
What is pre-term labour?
When there is persistent uterine activity and cervical dilation and/or effacement before 37 weeks.
233
Name 5 things that you can give to a premature baby to improve their survival.
1. Steroids.
2. Surfactant.
3. Ventilation.
4. Antibiotics.
5. Nutrition.
234
Give 5 risk factors for having a premature baby.
1. Previous pre-term birth.
2. Vaginal bleeding.
3. Multiple pregnancy e.g. twins.
4. Ethnic group.
5. Genital infections.
235
Define puerperium.
The period from placental delivery to 6w after birth - the post-natal period.
236
Give 2 endocrine changes that occur during puerperium.
1. Reduced placental hormones.
2. Increas in prolactin for lactation
237
Give 3 physiological changes that occur during puerperium.
1. Involution of the uterus.
2. Decidua sheds as lochia.
3. Lactation.
238
Puerperium: briefly describe the physiology behind involution of the uterus.
There is muscle ischaemia, autolysis and phagocytosis -> involution of the uterus.
239
The decidua sheds as lochia, what are the three stages of this process called?
1. Lochia rubra.
2. Lochia serosa.
3. Lochia alba.
240
What is the name of the breast milk that is produced at birth?
Colostrum.
241
What does colostrum contain?
- Protein rich.
- Vitamin A.
- NaCl.
- GF's.
- Antibodies.
- Lactoferrin.
242
Briefly describe the physiology of lactation.
Baby suckles -> nipples send impulses to brain -> prolactin is released from the ant.pituitary -> milk is produced by lactocytes -> oxytocin is released from the post.pituitary -> myoepithelial contraction -> milk ejection.
243
Name 3 minor things that women are at risk of during puerperium.
1. Infection.
2. Haemorrhage.
3. Fatigue.
4. Anaemia.
5. Back pain.
6. Haemorrhoids.
244
Name 3 major things that women are at risk of during puerperium.
1. Sepsis.
2. Sever haemorrhage.
3. Pre-eclampsia.
4. VTE.
5. Prolapse.
6. Incontinence.
7. Depression.
245
Name 3 members of a post-natal MDT.
1. Midwives.
2. Breastfeeding support workers.
3. Doula.
4. Nurses.
If complex, obstetricians and paediatricians will be involved too.
246
Give 3 risk factors for sepsis in pregnancy.
1. Obesity.
2. Anaemia.
3. Diabetes.
4. Amniocentesis/invasive procedures.
247
What can cause sepsis in pregnancy?
1. Endometritis.
2. Skin infections.
3. Pyelonephritis.
4. Chorioamnionitis.
5. Pneumonia.
248
Define PPH.
Post-partum haemorrhage: >500ml estimated blood loss after birth of baby.
249
Define major PPH.
>1500ml blood loss and continuing to bleed/signs of shock.
250
Give 5 risk factors for VTE in pregnancy.
1. Increasing gestational age.
2. Obesity.
3. Smoking.
4. C-section.
5. Family history.
6. Immobility.
7. Multiple pregnancy e.g. twins.
8. Previous VTE.
251
When is a woman at the greatest risk of VTE?
The risk is greatest just after giving birth, in the post partum period.
252
What medication can be given postnatally to reduce a woman's risk of VTE?
LMWH.
TED stockings.
253
Describe the physiology behind a post dural puncture headache?
Accidental dural puncture -> CSF leakage and decreased pressure in fluid around the brain.
254
Give 3 symptoms of a post dural puncture headache.
1. Headache is worse on sitting/standing.
2. Neck stiffness.
3. Photophobia.
255
How would you treat a post dural puncture headache?
1. Lying flat.
2. Analgesia.
3. IV fluids.
256
Give 3 risk factors for urinary retention postnatally.
1. If the woman had an epidural.
2. Prolonged 2nd stage of labour.
3. Forceps/ventouse delivery.
257
Give 3 red flag signs that a mother may be developing mental health problems postnatally.
1. Recent change in mental state.
2. Thoughts/acts of self harm.
3. Estrangement from the infant.
258
Give 3 symptoms of post-natal depression.
Irritable.
Tired.
Appetite change.
Negative thoughts.
259
Define maternal death.
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to the pregnancy or its management but not accidental causes.
260
What are the 3 most common causes of maternal death?
1. VTE.
2. Haemorrhage.
3. Pre-eclampsia.
261
Define menstruation.
Monthly bleeding from the reproductive tract due to hormonal changes.
262
What hormone is responsible for thickening the endometrium?
Oestrogen.
263
Approximately how much blood is lost in menstruation?
60-80ml.
264
Define menorrhagia.
Heavy menstrual bleeding (subjectively considered heavy by the woman) that interferes with physical, emotional and social QOL.
265
Give 3 causes of menorrhagia.
1. Fibroids/polyps.
2. Coagulation problems.
3. Endometriosis/adenomyosis.
4. Hypothyroidism.
5. Infection.
6. Ovulatory problems.
7. Endometrial dysfunction.
266
Give 5 questions that you should ask when taking a history from a lady who is presenting with menorrhagia.
1. How much blood?
2. How many pads is the lady using? Flooding?
3. Any clots?
4. Duration of bleeding?
5. Any pain?
6. Impact on ADL's and QOL?
7. Any associated symptoms e.g. thyroid? Clotting? Drugs (Warfarin)?
267
What investigations might you do on a lady who is presenting with menorrhagia?
1. FBC, B12/Folate/Iron, TSH, STI screen.
2. Smear if due.
3. Transvaginal USS.
268
Describe the management of menorrhagia.
1. Mirena Coil.
2. Anti-fibrinolytics e.g. tranexamic acid.
3. NSAIDS.
4. Progestogens.
5. COCP.
6. Endometrial ablation.
7. Hysterectomy.
269
Name 3 foetal emergencies.
1. Foetal distress.
2. Cord prolapse.
3. Shoulder dystocia.
270
Name 3 disorders that are specific to pregnancy.
1. Gestational diabetes.
2. Pre-eclampsia/eclampsia.
3. Obstetric cholestasis.
4. Acute fatty liver in pregnancy.
271
Name 3 disorders that are exacerbated by pregnancy.
1. Hypertension.
2. Renal disease.
3. Cardiac disease.
4. Endocrine disease.
272
Define antepartum haemorrhage.
Bleeding from anywhere in the genital tract after 24w gestation.
273
Give 3 causes of antepartum haemorrhage.
1. Placenta praevia/LLP.
2. Placental accreta.
3. Placental abruption.
4. Uterine rupture.
274
Give 3 potential complications of antepartum haemorrhage.
1. Premature labour.
2. Need for a blood transfusion.
3. Tubular necrosis.
4. DIC.
275
When might a LLP be detected?
On the 20w anomaly scan. The placenta must be >25mm from the cervical os.
276
Would a woman with a LLP complain of pain?
No, a LLP is classically painless.
277
How should a LLP be managed?
1. Advise mum on the symptoms to look out for.
2. Seek early advice.
3. If recurrent bleeds, admit until delivery.
4. Elective c-section at 38 weeks.
278
What is vasa praevia and what are its risks?
Vasa praevia is when the foetal vessels lie near the cervical os. There is a risk of damage/rupture to foetal vessels -> foetal distress and haemorrhage.
279
Define placental abruption.
Premature separation of the placenta from the uterine wall.
280
How might the uterus feel on physical examination in a woman with placental abruption?
The woman may have a 'woody-hard' and tense uterus.
281
Give 2 potential consequences of placental abruption.
1. Foetal distress.
2. Maternal shock.
282
Give 5 risk factors for placental abruption.
1. Increasing BMI.
2. Smoking.
3. Previous abruption.
4. Hypertension.
5. Uterine overdistension e.g. multiple pregnancy.
6. Trauma e.g. RTA.
7. Domestic abuse.
283
Define primary PPH.
>500ml blood loss within 24h of delivery.
284
Define secondary PPH.
>500ml blood loss between 24h to 12w post delivery.
285
What can cause Primary PPH?
The 4 T's:
1. Tissue - is the placenta complete?
2. Tone - is the uterus contracted?
3. Trauma - check for tears and repair.
4. Thrombin - check clotting.
286
Give 5 risk factors for PPH.
1. Large babies.
2. Nulliparity.
3. Multiple pregnancy.
4. Prolonged labour.
5. Previous PPH.
287
What is cord prolapse?
When the cord is presenting -> membrane rupture -> vasospasm.
288
Give a potential consequence of cord prolapse.
Hypoxia -> foetal morbidity and mortality.
289
Give 4 risk factors for cord prolapse.
1. Premature rupture of membranes.
2. Polyhydramnios.
3. Long cord.
4. Multiparity.
290
How can cord prolapse be managed?
1. Infuse fluid into the bladder (elevated presenting part of cord).
2. Trendelenburg position.
3. Constant monitoring.
4. Transfer to theatre for delivery.
291
What is shoulder dystocia?
Failure of the anterior shoulder to pass under the pubic symphysis after delivery of the foetal head. It requires specific manoeuvres to facilitate delivery.
292
Risk factors for shoulder dystocia.
1. Macrosomia (Gestational DM, Post-maturity, Obesity).
2. Prolonged labour.
293
How should shoulder dystocia be managed?
HELPERR:
```
H - call for Help.
E - evaluate for Episiotomy.
L - Legs in McRoberts.
P - suprapubic Pressure.
E - Enter pelvis.
R - Rotational manoeuvres.
R - Remove posterior arm.
```
294
Shoulder dystocia: give 3 potential complications that the mother is at risk of.
1. Vaginal tear.
2. PPH.
3. PTSD.
4. Bladder/uterine rupture.
295
Shoulder dystocia: give 3 potential complications that the baby is at risk of.
1. Cerebral palsy.
2. Hypoxia.
3. Brachial plexus injury (Erb's Palsy)
4. Fractured humerus/clavicle.
296
Give 5 causes of infertility.
1. Ovulatory (25%).
2. Tubal (20%).
3. Uterine/peritoneal (10%).
4. Male factors (30%).
5. Unexplained (25%).
297
When would you refer a couple for infertility investigations?
You refer them for investigations after 1 year of trying to conceive.
298
What would make you consider early referral for investigating infertility?
Early referral if the woman is >35, has a menstrual disorder, previous surgery or previous PID/STI and/or if the man has genital pathology, previous STI, systemic illness or an abnormal genital examination.
299
What pre-conception advice would you give to a couple?
1. Have intercourse 2-3 times a week.
2. Folic acid.
3. Ensure smears are up to date.
4. Smoking cessation and reduce alcohol intake.
5. Manage co-morbidities.
6. Ensure healthy weight.
300
Name 3 reproductive disorders that are associated with obesity.
1. PCOS.
2. Miscarriage.
3. Infertility.
4. Obstetric complications.
301
What 3 things are investigated in initial infertility tests?
1. Ovulation.
2. Semen quality.
3. Tubal patency.
302
Infertility investigations: what initial tests would the GP do?
1. Hormone profile (D2, FSH, D21 progesterone).
2. TFT's.
3. Rubella.
4. Smear.
5. Semen analysis.
303
Infertility investigations: how can you check ovulation?
Measure mid-luteal progesterone.
304
Infertility investigations: what hormone levels are looked at in order to test ovarian reserve?
1. FSH.
2. AMH
AFC (antral follicle count) is also determined through imaging.
305
A sperm count less than what will indicate the need for clinical examination and further tests?
<5m/ml.
Further testing may include endocrine tests and karyotyping e.g. klinefelters.
306
Infertility investigations: how can tubal patency be investigated?
1. HSG (hysterosalpingogram) imaging.
2. HyCoSy (Hysterosalpingo-contrast-sonography).
3. Laparoscopy.
307
How can infertility be managed if there is a mild abnormality?
Intrauterine insemination.
308
How can infertility be managed if there is a moderate abnormality?
IVF.
309
How can infertility be managed if there is a severe abnormality?
Intra-cytoplasmic sperm injection.
310
How can infertility be managed if azoospermia is the cause?
1. Surgical sperm recovery.
| 2. Donor insemination.
311
Infertility: Give 3 risk factors for anovulation.
1. Stress.
2. Low weight.
3. Extreme exercise.
4. Kallmann's + Turner's syndrome.
312
What is the rotterdam diagnostic criteria for PCOS.
1. Anovulation/oligomenorrhoea.
2. Polycystic ovaries seen on imaging.
3. Increased androgens - clinically or biochemically.
2/3 Criteria must be met in order to make the diagnosis.
313
How can PCOS be treated?
1. Encourage weight loss.
2. COCP if not wanting to get pregnant.
3. Symptomatic treatment of acne and hirsutism.
Managing Infertility:
1. Clomifene/tamoxifen.
2 Metformin.
3. Ovarian drilling.
314
How does Clomifene work in the treatment of PCOS?
Clomifene is an anti-oestrogen. It leads to increased production of LH/FSH and so there is more follicle stimulation. It can treat menstrual disturbance and has a good pregnancy rate.
315
Infertility: give 3 causes of tubal disease.
1. Infections.
2. Endometriosis.
3. Iatrogenic e.g. following surgery.
316
Briefly describe the process of IVF.
Ovarian stimulation -> egg collection -> insemination -> fertilisation check -> embryo culture -> embryo transfer -> luteal support.
317
Why is only 1 egg transferred in IVF?
To avoid multiple pregnancy.
318
Give 4 risks associated with IVF.
1. Multiple pregnancy.
2. Miscarriage.
3. Ectopic pregnancy.
4. Foetal abnormality.
319
Give 4 factors that can affect the likelihood of IVF being successful.
1. Increasing age -> reduced egg quality.
2. Successive cycles/longer duration infertility.
3. Obesity.
4. Environmental factors e.g. smoking, alcohol, caffeine.
320
Give 3 examples of uterine abnormalities that can affect fertility.
1. Endometrial polyps.
2. Fibroids e.g. sub-mucous will significantly affect pregnancy rates.
3. Adhesions.
321
How can pregnancy affect anaemia?
- 2-fold increase in iron requirements -> micro-cytic aneamia.
- B12/folate deficiency -> macrocytic anaemia.
322
By what percentage does cardiac output increase in pregnancy?
40%.
323
If a lady with mechanical heart valves was pregnant what drug would you consider prescribing?
You would anti-coagulate the patient with LMWH as this does not cross the placenta.
324
What inheritance pattern is associated with obstetric cholestasis?
Autosomal dominant.
325
What symptoms does obstetric cholestasis often present with?
Itching! Typically on the palms and soles.
326
What might you see on the blood results taken from a patient with obstetric cholestasis?
Raised AST, ALT and bile acid.
327
What is there an increased risk of in women with obstetric choelstasis?
Still birth.
328
What happens in women with gestational diabetes when extra glucose crosses the placenta?
Insulin, GF and GH's are produced -> foetal growth is stimulated and fat and glycogen are deposited.
329
Give 5 things a diabetic lady is at increased risk of if she is pregnant.
1. Shoulder dystocia.
2. Macrosomia.
3. Amniotic excess - polyhydramnios.
4. Stillbirth.
5. Hypoglycaemia.
6. Premature labour.
7. Miscarriage.
8. Foetal abnormalities.
330
How can epilepsy in pregnancy be managed?
- Pre-conception counselling is important.
- Manage triggers and control seizures.
- Medications are often very teratogenic e.g. sodium valporate (Neural Tube Defects).
- Small risk of baby inheriting epilepsy.
331
Define FGM.
Procedures involving damaging or removing external female genitalia for non-medical reasons.
332
What problems can FGM cause?
1. Problems with conception and labour.
2. Increased risk of infections.
3. PTSD.
4. Chronic pain.
5. Women are also at increased risk of needing a c-section, episiotomy and having PPH.
333
Define primary amenorrhoea.
No menses by age 16 in the presence of secondary sexual characteristics or by age 14 with no secondary sexual characteristics.
334
Define secondary amenorrhoea.
Cessation after the onset of menses. Can be due to weight loss, exercise, PCOS, pregnancy etc.
335
Define oligomenorrhoea.
Menses >35 days apart.
336
Define precocious puberty.
The onset of secondary sexual characteristics before 8 years old in females and 9 years old in males
337
What disease must you rule out in girls with delayed puberty and short stature?
Turner's syndrome.
338
What is endometriosis?
A chronic oestrogen dependent disease where there is growth of endometrial tissue outside of the uterus.
339
Why does endometriosis tend to get better after the menopause?
Endometriosis relies on oestrogen and so when oestrogen levels fall after the menopause the symptoms of endometriosis tend to improve.
340
What hormone is responsible for 'growing' the endometrium and what hormone 'shrinks' the endometrium?
Oestrogen grows the endometrium and progesterone shrinks.
341
Describe the epidemiology of endometriosis.
Endometriosis is more common in young, nulliparous women. Most girls present when their periods start.
342
Describe the aetiology behind endometriosis.
The cause of endometriosis is thought to be due to retrograde menstruation and a genetic component. Lymphatic spread may also be responsible.
343
What anatomical areas are most likely to be affected by endometriosis?
The pouch of douglas and the uterosacral ligaments.
344
Give 8 risk factors for developing endometriosis.
1. Early menarche.
2. Late menopause.
3. Delayed childbearing.
4. Short cycles.
5. Obstruction to vaginal flow.
6. Genetic predisposition.
7. Long menstruation
8. Uterine/Fallopian Tube Defects
345
Give 2 factors that are protective against endometriosis.
1. Multiparity.
2. COCP
346
What is the gold standard investigation for diagnosing endometriosis?
Laparoscopy.
347
What grading classification is used in endometriosis?
AFS classification.
348
What investigations might you do in a woman who you suspect has endometriosis?
1. Laparoscopy = gold standard.
2. Digital exam.
3. USS.
349
Give 6 symptoms of endometriosis.
1. Cyclic pain -> dysmenorrhoea and dyspareunia.
2. Menorrhagia
3. Lump.
4. Infertility.
5. Dyschezia.
6. Dysuria
Remember: symptoms are often worse at certain times in a woman's cycle!
350
Give 3 reasons why a woman with endometriosis might be infertile.
1. Oocyte toxicity.
2. Adhesions.
3. Tubal and ovarian dysfunction.
351
What non-specific protein marker might be raised in a woman with endometriosis?
CA125.
Non-specific, anything that irritates the peritoneum -> raised CA125.
352
In what type of cancers is CA125 often raised?
Ovarian cancer (serous cancers).
353
What tumour markers should be looked at in pre-menopausal women?
b-HCG, AFP and HDL.
354
Briefly describe how the treatment for endometriosis works.
The pathology is oestrogen therefore remove the oestrogen or give an antagonist.
Surgery can be offered to improve fertility although the endometrial tissue will almost certainly return.
355
What medications can be given to treat endometriosis?
Abolish cyclicity:
1. OCP.
2. GnRH agonists.
Thin endometrium:
1. POP.
2. Mirena coil.
356
Give 3 advantages of using the OCP to treat endometriosis.
1. Cheap.
2. Effective.
3. Minimal side effects.
4. Predictable and reliable.
Often 3 packs are taken back to back = 'tri-phasing' -> glandular atrophy.
357
Describe how GnRH agonists work in treating endometriosis.
GnRH is normally released in a pulsatile way, GnRH agonists are given continuously in order to stop ovulation and triggers an 'artificial menopause' - this is reversible.
GnRH agonist -> huge release of FSH/LH -> down-regulation of FSH/LH -> no oestrogen release.
358
Give 3 side effects of GnRH agonists being used to treat endometriosis.
1. Osteoporosis.
2. Hot flushes.
3. Mood swings.
359
Endometriosis treatment: how can the side effects of GnRH agonists be prevented?
A small dose of oestrogen should be prescribed - 'add back' e.g. livial (HRT).
360
What drugs can cause endometrium glandular atrophy and so can be used in the treatment of endometriosis?
Progesterones e.g. POP, depot provera, mirena coil.
Coil is good because the progesterone is put directly in the uterus and so this reduces any systemic effects, the endometrium is thinned and also provides good contraception.
361
How would you treat endometriosis in a woman who is wanting to get pregnant?
Surgery e.g. ablation and excision.
362
Give 3 differentials for endometriosis.
Chronic pelvic pain:
1. PID.
2. Uterine fibroids.
3. If older woman, adenomyosis.
4. Ovarian cysts.
363
What is adenomyosis?
The presence of functional endometrial tissue within the myometrium of the uterus.
364
Give 4 risk factors for adenomyosis.
1. Multi-parity.
2. Uterine surgery.
3. Previous caesarean section.
4. Family History
Adenomyosis is thought to occur after uterine damage e.g. Uterine surgery.
365
Describe the epidemiology of adenomyosis and compare it to that of endometriosis.
Adenomyosis: older, multiparous women.
Endometriosis: younger, nulliparous women.
366
Give 3 symptoms of adenomyosis.
1. Menorrhagia.
2. Dysmenorrhoea.
3. Dyspareunia.
Pain is typically cyclical.
367
What investigations might you do to confirm a diagnosis after adenomyosis?
1. Transvaginal USS.
2. MRI.
Adenomyosis is difficult to diagnose with imaging, and histology at hysterectomy is definitive.
368
What is the treatment for adenomyosis?
Only curative treatment is hysterectomy.
Hormone therapy and analgesia can be used as conservative treatments.
369
What are fibroids?
Benign smooth muscle tumours (leiomyomas) of the uterine myometrium.
370
What hormone is thought to stimulate fibroid development?
Oestrogen.
371
How are fibroids classified?
Fibroids are classified according to their position in the uterine wall, for example:
- Intramural.
- Sub-mucosal (Distorts Uterine Cavity)
- Sub-serosal (Into Abdominal Cavity)
372
With regards to position in the uterine wall, what type of fibroids are most common?
Intramural - fibroids confined to the myometrium.
373
Describe the location of sub-mucosal fibroids.
Fibroids growing into the uterine cavity.
374
Describe the location of sub-serosal fibroids.
Fibroids growing outwards from the uterus.
375
Give 5 risk factors for the development of fibroids.
1. Obesity.
2. Early menarche.
3. Family history.
4. Increasing age.
5. Ethnicity (African-American).
376
Give 6 symptoms of fibroids.
1. Pelvic Pain.
2. Infertility/sub-fertility.
3. Menorrhagia.
4. Pressure symptoms e.g. urinary frequency if pressing on the bladder.
5. Abdominal Distention.
6. Can cause iron deficiency anaemia -> lethargy and pallor.
377
What investigations might you do to determine if a patient has fibroids?
1. Pelvic USS.
2. MRI
3. Hysteroscopy
378
Describe the different treatment options for uterine fibroids.
1. Conservative: watch and wait.
2. Medical: hormone therapy e.g. POP. GnRH agonists (Zolidex), Ulipristal (Selective Progesterone Receptor Modulator).
3. Surgical: hysteroscopic resection, myomectomy (uterine saving), hysterectomy, uterine artery embolisation.
4. TXA
379
What is the gold standard treatment for uterine fibroids?
Hysterectomy.
If the patient is young and wants children then a myomectomy can be done.
380
Give 3 differentials for uterine fibroids.
1. Endometrial polyps.
2. Cancer.
3. Endometriosis/adenomyosis.
4. Chronic PID.
381
Describe a first degree vaginal tear.
First degree - tear within vaginal mucosa only.
Does not require repair.
382
Describe a second degree vaginal tear.
Second degree - tear into sub-cutaneous tissue.
Repaired on ward by suitably experienced midwife.
383
Describe a third degree vaginal tear.
Third degree - laceration extends into external anal sphincter.
Requires repair in theatre.
384
Describe a fourth degree vaginal tear.
Fourth degree - laceration extends through external anal sphincter into rectal mucosa.
Requires repair in theatre.
385
Give 3 risk factor's for vaginal tears.
1. Primigravida.
2. Macrosomia and shoulder dystocia.
3. Forceps delivery.
386
Define menopause.
The cessation of menstruation normally around 51 years old. Menopause is diagnosed retrospectively after 12 months of amenorrhoea or 12 months after the onset of symptoms if the patient has had a hysterectomy.
387
Define peri-menopause.
The period leading up to the menopause. It is characterised by irregular periods and symptoms e.g. hot flushes, mood swings and urogenital atrophy.
388
A depletion in what hormone is thought to trigger the symptoms of the menopause?
A reduction in oestrogen.
389
Give 2 vasomotor symptoms of the menopause.
1. Hot flushes.
2. Night sweats.
This can impact on sleep, mood and QOL.
390
Give 2 MSK symptoms of the menopause.
1. Joint pain.
2. Muscle pain.
391
Give 3 local affects of the menopause.
Vaginal atrophy ->
1. Vaginal dryness.
2. Dyspareunia.
3. Recurrent UTI's.
4. PMB.
392
Give 3 potential long term impacts of the menopause.
1. Osteoporosis.
2. CV disease.
3. Dementia.
393
Describe how the menopause can be managed in a symptomatic patient.
1. Holistic approach, lifestyle advice, reduce modifiable RF's.
2. HRT, vaginal oestrogens.
3. Non-hormonal options e.g. clonidine.
4. Non-pharmaceutical e.g. CBT.
394
Give 3 advantages of HRT being used to treat the menopause.
1. Relief of symptoms.
2. BMD protection.
3. Prevents long term morbidity.
395
Give 3 disadvantages of HRT being used to treat the menopause.
1. Increased breast cancer risk.
2. Increased VTE risk with oral HRT.
3. Increased CV disease risk.
396
What hormone should be given to women with a uterus who are prescribed HRT?
Progesterone.
This protects the endometrium from the stimulatory effects of unopposed oestrogen.
397
When might transdermal HRT be indicated?
1. Women with gastric problems e.g. Crohn's.
2. Migraines/epilepsy sufferers.
3. High-risk VTE.
4. Older women.
5. Hypertensive patients.
6. Patient choice.
398
What is premature ovarian failure?
Primary ovarian insufficiency before the age of 40 with associated menopausal symptoms such as night sweats.
399
What would hormone profile tests show in women with premature ovarian failure.
Low oestrogen and high FSH.
400
What can cause premature ovarian failure?
1. Idiopathic.
2. Chromosomal abnormalities.
3. Enzyme deficiencies.
4. Autoimmune.
5. Iatrogenic e.g. following surgery, chemotherapy, radiotherapy.
401
What is the diagnostic criteria for premature ovarian failure?
1. FSH >25IU/I – 2 samples 4 weeks apart.
2. 4 months of amenorrhoea.
402
Describe the treatment for premature ovarian failure.
Oestrogen replacement e.g. HRT or COCP. Donor eggs for fertility.
403
If a woman goes through the menopause <50 for how many years is she still fertile for?
2 years.
404
If a woman goes through the menopause >50 for how many years is she still fertile for?
1 year.
405
Define small for gestational age (SGA).
An infant born with an EBW <10th centile as plotted on a customised growth chart.
406
Define large for gestational age (LGA).
An infant born with an EBW >90th centile as plotted on a customised growth chart.
Increased risk of Shoulder Dystocia and requiring a C-Section.
407
Define foetal macrosomia.
An infant with a birth weight >4000g.
408
Define low birth weight.
An infant with a birth weight <2500g.
409
Define foetal growth restriction.
Infant/Foetus with a weight <3rd Centile for its gestational age.
410
Give 5 potential causes of FGR.
1. Poor weight gain during pregnancy.
2. Poor nutrition and diet.
3. Alcohol, drug use, smoking.
4. Gestational diabetes.
5. HTN and pre-eclampsia.
6. Placental insufficiency.
411
What investigation might you do if you are concerned about foetal growth restriction?
Clinical examination.
USS - HC, AC and FL.
412
Define chronic pelvic pain.
Lower abdominal pain for >6m that does not occur exclusively with menstruation, intercourse or pregnancy.
413
Define acute pelvic pain.
Sudden and unexpected pain for <6m.
414
Give 3 pregnancy related causes of acute pelvic pain.
1. Ectopic pregnancy.
2. Miscarriage.
3. Ovarian cyst rupture/haemorrhage/torsion.
415
Give 3 gynaecological causes of acute pelvic pain.
1. PID.
2. Abscess.
3. Ovarian cyst rupture/haemorrhage/torsion.
416
Give 3 gastrointestinal causes of acute pelvic pain.
1. Appendicitis.
2. Constipation.
3. Bowel obstruction.
417
Give 3 genito-urinary causes of acute pelvic pain.
1. UTI.
2. Renal stones.
3. Urinary retention.
418
Give 2 MSK causes of acute pelvic pain.
1. Disc prolapse.
2. Nerve entrapment.
419
Give 5 gynaecological causes of chronic pelvic pain.
1. Endometriosis/adenomyosis.
2. Fibroids.
3. Adhesions.
4. PID.
5. Ovarian cysts.
420
Give 3 gastrointestinal causes of chronic pelvic pain.
1. IBS.
2. Constipation.
3. Inflammatory bowel.
421
Give a genito-urinary cause of chronic pelvic pain.
Interstitial cystitis.
422
Give 2 MSK causes of chronic pelvic pain.
1. Nerve entrapment.
2. Referred MSK pain.
423
What investigations might you do on a patient who is presenting with pelvic pain?
1. Pelvic USS -> fibroids, ovarian cysts, endometriosis.
2. Laparoscopy -> endometriosis, adhesions.
3. Hysteroscopy -> fibroids.
4. MRI -> adhesions, adenomyosis, fibroids.
5. STI screen.
424
What can cause PID?
Infection e.g. gonorrhoea/chlamydia that ascends from the endocervix.
425
Give 3 symptoms of PID.
1. Lower abdominal pain.
2. Dyspareunia.
3. Abnormal vaginal bleeding e.g. post-coital, IMB, menorrhagia, abnormal discharge.
426
Describe the treatment for PID.
IM ceftriaxone 500mg followed by PO doxycycline 100mg BD and PO metronidazole 400mg BD for 14 days.
427
What layer of the tri-laminar disc forms the male and female genitalia?
Intermediate mesoderm.
428
What does the mullerian duct form?
1. Fallopian tubes.
2. Uterus.
3. Cervix.
4. Proximal 1/3 of vagina.
429
What does the cloaca divide into?
1. Anorectal canal.
2. Urogenital sinus.
430
From what artery are the ovarian arteries a branch of?
The abdominal aorta.
431
Where do the L and R ovarian veins drain?
L ovarian vein -> L renal vein.
R ovarian vein -> IVC.
432
Describe the hypothalamic gonadal axis.
Hypothalamus -> GnRH -> anterior pituitary -> FSH/LH -> Granulosa and Theca cells -> Androgens and Oestrogen.
433
Amenorrhoea aetiology: give 2 hypothalamic causes.
Functional disorders e.g. eating disorders.
Kallmann syndrome.
434
Amenorrhoea aetiology: give 3 pituitary causes.
1. Prolactinomas.
2. Other pituitary tumours e.g. acromegaly and cushing's.
3. Sheehan's syndrome (infarction of pituitary often due to PPH).
435
Amenorrhoea aetiology: give 3 ovarian causes.
1. PCOS.
2. Turner's (45X)
3. Premature ovarian failure.
436
Amenorrhoea aetiology: give 2 uterine causes.
1. Imperforate hymen.
2. Mullerian Agenesis
437
What is androgen insensitivity syndrome?
When a person is genetically male but phenotypically female. They have intra-abdominal gonads and their cells don't respond to male hormones e.g. androgens.
438
Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if FSH/LH levels came back abnormal?
This could indicate a pituitary problem.
439
Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if GnRH levels came back abnormal?
This could indicate a hypothalamic problem.
440
Give 2 signs of polyhydramnios.
1. Increased abdominal size that is out of proportion for weight and gestation.
2. AFI >25 on USS.
3. Maternal dyspnoea and faint foetal heart sounds.
441
Give 3 causes of polyhydramnios.
1. Maternal diabetes.
2. Foetal anomalies e.g. duodenal atresia.
3. Multiple gestation.
442
Give 3 potential consequences of polyhydramnios.
1. Corp prolapse.
2. PPH.
3. Preterm labour.
4. IUGR.
443
Describe the management of obstetric cholestasis.
1. Obstetrician lead care.
2. Symptomatic relief for itch e.g. emollients, anti-histamines, cool showers.
3. Ursodeoxycholic acid.
444
What are the potential consequences of failing to treat pre-eclampsia?
1. Eclampsia.
2. HELLP syndrome.
3. Renal/Liver failure.
4. Premature labour.
5. IUGR.
445
Give 6 differentials for a breast lump.
1. Breast carcinoma.
2. Fibroadenoma.
3. Breast abscess.
4. Breast cyst.
5. Fat Necrosis
6. Lipoma
446
Give 4 investigations you might do in someone who you suspect has cervical cancer.
1. Vaginal examination.
2. Colposcopy.
3. Biopsy.
4. HPV Testing.
447
Rhesus disease: name 3 events during pregnancy when sensitisation may occur.
1. Miscarriage.
2. Abortion.
3. Amniocentesis.
4. Placental abruption.
5. During delivery.
448
Name 3 factors that are protective against cervical cancer.
Breast feeding.
HPV Vaccination
Not Smoking
449
Antenatal screening: What is the combined test?
```
The combined test is done to check for congenital anomalies. It is made up of:
- PAPP-A
- bHCG
- Nuchal Translucency
- Mothers age
(Done at 11-14w).
```
450
Antenatal screening: What is the quadruple test?
The quadruple test is useful for women presenting in the 2nd trimester. It looks for congenital anomalies. It is made up of:
- bHCG
- AFP
- Inhibin A
- Unconjugated oestradiol
451
What chromosomal abnormality is found in Edward's disease. Give 3 physical signs of this condition.
Edward's = T18.
Signs: LBW, small head, small mouth/jaw, low set ears, cleft palate, exomphalos, Rocker bottom feet.
452
What chromosomal abnormality is found in Patau's disease. Give 3 physical signs of this condition.
Patau's = T13.
Signs: cleft lip/palate, small eyes, microcephaly, ear malformations, rocker-bottom feet.
453
A rhesus negative mum is having an amniocentesis. What must you give her prior to this procedure?
Anti-D!
There is a risk of sensitisation.
454
Give 4 risks associated with amniocentesis.
1. Miscarriage.
2. Infection.
3. Trauma.
4. Bleeding.
5. Sensitisation reaction.
6. Pre-term labour.
455
Give 3 indications for induction of labour.
1. Post maturity.
2. Pre-eclampsia.
3. Diabetes.
4. Growth restriction.
5. Reduced foetal movements.
456
What is Sheehan's syndrome?
Pituitary infarction/necrosis following PPH. Can lead to reduced TSH, ACH, FSH/LH and so hypothyroidism and genital atrophy.
457
What is Lichen Simplex
Chronic Vulval Dermatitis - chronic inflammation of the Vulva leading to pruritus and changes to skin pigmentation. Treat with emollient.
458
What is Lichen Planus?
A common disease which can affect the Vulva. It presents with Flat, Papular, and Purplish lesions which are painful.
Managed with High Potency Steroid Creams
459
What is Lichen Sclerosis?
Thinning of vulval epithelium.
It is most common in post-menopausal women and leads to severe itching, superficial dyspareunia, and pink-white papules which coalesce to form parchment-like skin.
It can lead to Vulval Carcinoma so a biopsy must be taken.
Treated with Ultra-potent topical steroids.
460
What are the Bartholin's Glands?
Two glands which lie behind the labia minora and secrete lubricating mucus in preparation for coitus.
461
What is the difference between a Bartholin's Gland cyst and an abscess?
A cyst forms due to a blockage of the gland, if this gets infected with E.Coli or Staph then an abscess can form which requires incision + drainage or marsupialization (sutured open).
462
What is VIN?
Vulval Intraepithelial Neoplasia - The presence of atypical cells in the vulval epithelium it is divided into two types:
- Usual Type -- associated with HPV.
- Differentiated Type -- Rare and associated with lichen sclerosis.
463
What is Vaginal Adenosis?
Columnar epithelium found in the vagina due to in-utero exposure to diethylstilbestrol or secondary to trauma. It can become malignant.
464
What is Cervical Ectropion?
Eversion of the endocervix, exposing columnar (secretory) epithelium.
465
What causes Cervical Ectropion?
High levels of oestrogen.
466
Differentials for Cervical Ectropion
Cervical Ca, CIN, Cervicitis, Pregnancy.
467
Investigations for Ectropion
Pregnancy Test, Triple Swabs, Cervical Smear.
Stop all oestrogen containing medications.
468
Cervical Cancer Pathophysiology
Over many years, squamous Cell Carcinoma has arisen from Cervical Intraepithelial Neoplasia (CIN) defined by Dyskaryosis in the transformation zone.
It is most commonly caused by HPV (Strains 16 & 18).
469
Investigations for Cervical Cancer
Colposcopy and Biopsy
The cervix is visualised by acetic acid (protein aggregation), and abnormal areas with more nuclei turn white.
Abnormal cells can be identified using Iodine as squamous cells contain glycogen whereas columnar cells do not.
470
Cervical Screening Program (UK)
The first invite is for women aged 25.
Return every 5 years until 64
The smear is tested for HPV, cytology is only performed on HPV + smears.
471
What is PCOS?
Polycystic Ovary Syndrome
Common Endocrine disorder characterised by excess androgen production and the presence of multiple immature follicles ("Cysts") within the Ovaries.
472
What causes PCOS?
Excess LH and insulin resistance (Suppresses hepatic production of sex hormone binding globulin)
473
Management of PCOS
Amenorrhoea - It is important to induce a few bleeds each year with COCP.
Infertility - Climifene and Metformine help to induce ovulation.
Hirsutism - Can be treated cosmetically or with anti-androgen medication such as cyproterone.
474
What are Ovarian Cysts?
An Ovarian Cyst is a fluid filled Sac within the ovary.
475
Classification of Ovarian Cysts
Non-Neoplastic (No malignant potential)
- Functional (Follicular, Corpus Luteum)
- Pathological (Endometrioma (chocolate cyst), PCOS, Theca lutein (Raised hCG)).
Neoplastic (Ability to Turn Malignant)
- Benign Neoplastic
- Malignant Neoplastic
476
What is RMI?
Risk of Malignancy Index - It is used to stratify the risk of patients with suspected ovarian cancer.
477
Types of Ovarian Cancer
Serous Cystadenocarcinoma (Characterised by Psammoma Bodies).
Mucinous Cystadenocarcinoma (Characterised by Mucin Vacuoles).
478
What is Post-Coital Bleeding and what are it's causes?
Bleeding After Sexual Intercourse
- Ectropion
- Cervical Ca
- CIN
- Polyp
479
What are the causes of Heavy Menstrual Bleeding?
480
Risk Factors for Vaginal Prolapse
NVD, Increasing Age, Menopause, Hysterectomy, Obesity, Chronic Cough, Heavy Lifting and Connective Tissue disorders.
481
Types of Vaginal Prolapse
Anterior Vaginal Wall - Cystocele (Bladder), Urethrocele, Cystourethrocele.
Posterior Vaginal Wall - Rectocele, Enterocele (Small Intestine)
Apical Vaginal Wall - Uterine prolapse, Vaginal Vault prolapse.
482
What is Ectopic Pregnancy?
Implantation of a Fertilised Egg outside the Uterus, most commonly in the Fallopian Tube.
483
Risk factors for Ectopic Pregnancy
Previous Ectopic
PID
History of IVF
Smoker
Age >35
Use of IUD/IUS/POP
484
Symptoms of an Ectopic Pregnancy
PV Bleeding
Abdominal Pain
Shoulder tip Pain
Dizziness
Remember : A woman of childbearing age with abdo pain has an Ecoptic pregnancy until proven otherwise.
485
Management of Ectopic Pregnancy
Conservative - Stable, Pain-Free with a tubal ectopic <35mm bHCG <1000.
Medical - Painless, Well and unruptured ectopic <35mm. bHCG <1500.
Surgical
486
What is the Conservative Management of an Ectopic Pregnancy?
Measure Serum hCG on day 2, 4 and 7 and repeat once weekly until <20 iu/L.
487
What is the Medical Management of Ectopic pregnancy? (hCG 1000-5000)
Give systemic Methotrexate, monitor bhCG on days 4 and 7 then weekly until it is negative.
Patients should be informed to not get pregnant for 3 months following.
488
What is the Surgical Management of Ectopic Pregnancy?
Laparoscopic salpingectomy unless the patient has other risk factors for infertility then salpingotomy can be offered.
Monitor HCG on day 7 then weekly until negative.
489
Types of Miscarriage
Complete - PV bleeding and empty uterus on USS.
Incomplete - PV bleeding, retained products.
- >35 mm surgical management or Mifepristone and Misoprostol.
- <35 mm can offer expectant management.
Delayed/Inevitable Miscarriage - CRL >7mm with no foetal heart activity.
- <9 weeks - expectant, medical or surgical.
- <12 weeks - medical or surgical.
490
What are the three types of Cyst Accidents and how does their presentation differ?
Rupture, Haemorrhage, Torsion.
Haemorrhage tends to have a gradual onset of symptoms.
491
What is PID?
Pelvic Inflammatory disease - it is the presence of infection in the female reproductive system. It can present with deep dyspareunia and fever and is usually caused by Chlamydia, Gonorrhea or Mycoplasma.
492
What is Fitz-Hugh Curtis Syndrome?
It is a complication of PID where the infection spreads into the RUQ of the abdomen leading to adhesions and RUQ pain.
493
What is the Booking Visit and what investigations comprise it?
It is a visit to the obstetrics dept. to screen for complications that may arise in pregnancy, labour and puerperium.
Investigations: Urine MCS, Urinalysis, FBC, Antibody Screen, HIV, HepB, USS, Screening for Chromosome Abnormalities, Hb Electrophoresis for "at risk" groups.
494
What Supplements should all women take during the Antenatal Period?
Folic Acid - 0.4mg/day until 12 weeks. 5mg/day for women with BMI>30, Diabetes, Sickle cell disease, Malabsorption or taking anti-epileptics.
Vitamin D - 10ug/day for all women. 25ug/day in those with a BMI>30, South Asian or Afro-Caribbean origin.
495
Which women should take Aspirin in pregnancy?
Those at risk of Pre-eclampsia (150mg)
496
According to the Abortion Act 1967, what are the categories to request a Termination of Pregnancy?
1. Pregnancy must not have exceeded Week 24 and the continuation of pregnancy would involve risk (greater than if the pregnancy were terminated) of injury to the physical or mental health of the mother.
2. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman.
3. There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
497
How is a Termination of Pregnancy performed?
Medical - Mifepristone (Progesterone Antagonist) + Misoprostol (Prostaglandin analogue) end the pregnancy and lead to it being expelled, respectively.
Surgical - Suction termination or dilatation and curettage.
498
What is Fetalis Hydrops?
Occurs when extra fluid accumulates in two or more areas in the foetus. It has a high rate of mortality. It can occur due to autoimmune haemolysis or due to chromosomal, structural or cardiac anomalies as well as in twin-to-twin transfusion syndrome.
499
What is Gestational Diabetes and why does it develop?
Any degree of glucose intolerance with onset or first recognition during pregnancy. In pregnancy, there is progressive insulin resistance which means that a higher volume of insulin is needed in response to a normal level of blood glucose.
500
What are the risk factors for Gestational Diabetes?
Obesity, Asian Ethnicity, Previous Gestational Diabetes, 1st Degree Relative with Diabetes, PCOS, Previous Macrosomia.
501
What are the Foetal Complications associated with Gestational Diabetes?
Macrosomia, Organomegaly, Erythropoeisis, Polyhydramnios and Increased risk of Pre-term delivery.
502
How is Gestational Diabetes Diagnosed?
Oral Glucose Tolerance Test - Fasting plasma glucose is taken then a 75g glucose drink is given.
2 hours later the Glucose is remeasured: (GDM is diagnosed if):
- Fasting >5.6mmol/L
- 2 hrs post >7.9 mmol/L
503
How is Gestational Diabetes managed?
Lifestyle advice, Metformin/Glibenclamide, Insulin (Fasting>7mmol/L).
All anti-diabetic medication should be stopped after delivery.
Existing T2DM should stop all medication upon becoming pregnant except insulin and take insulin.
504
What is Acute Fatty Liver Disease?
A severe, rare liver disease related to pregnancy, can result in hepatic failure and necessitates immediate medical and obstetric intervention (Stablilisation and Delivery).
LCHAD mutation leads to the accumulation of fatty acid metabolites in the placenta, which are then shunted into the maternal circulation and subsequently accumulate in the maternal liver.
505
Cytomegalovirus in Pregnancy
CMV is a Herpes virus which can transmit vertically in 40% of cases leading to childhood handicap and deafness. IUGR is a common feature. It is diagnosed by the presence of CMV IgM and IgG and amniocentesis can confirm vertical transmission.
506
Herpes Simplex in Pregnancy
TIIDNA virus which can cause genital herpes. It rarely spreads to the neonate but has a high mortality when it does. To prevent this C-Section delivery is indicated with acyclovir given to any exposed neonates.
507
Rubella in Pregnancy
During pregnancy, rubella causes multiple foetal abnormalities including deafness, cardiac disease, eye problems and mental impairment.
Termination is offered before 16 weeks.
508
Parvovirus in Pregnancy
Affects approximately 0.25% of pregnancies. It leads to anaemia due to the suppression of erythropoiesis. (Fetalis Hydrops)
509
HepB and C in Pregnancy
Hep B, when contracted at birth, can lead to becoming a lifelong carrier.
510
HIV in Pregnancy
Highly active retroviral therapy is given and an elective C-section is offered if the viral load is >50 copies/ml.
511
How is Group B Strep. Managed?
Streptococcus Agalacticae - Commensal in 25% of women. The foetus can be infected during labour. High-dose penicillin is given intrapartum and to those with prolonged ROM (>18 hours).
512
What sequelae can early infection with Toxoplasmosis cause?
Mental Handicap, Convulsions, Spasticity, Visual Impairment.
513
What is Listeriosis and why is it relevant to Pregnancy?
Infection with Listeria Monocytogenes (Gram-Positive Bacilli) due to consumption of pates, soft cheeses and pre-packed meals.
It causes a non-specific febrile illness however in pregnancy it can lead to in utero death.
514
What impact do STIs have on Pregnancy?
Increased risk of Pre-term labour and neonatal conjunctivitis.
515
Bacterial Vaginosis in Pregnancy
Overgrowth of commensal bacteria such as Gardnerlla vaginalis and Mycoplasma hominis are associated with preterm labour and late miscarriage.
516
What is a Missed Miscarriage?
Asymptomatic, Os Closed, No foetal Heart activity.
517
How should women with Anti-Phospholipid Syndrome be managed in pregnancy?
LMWH + Low Dose Aspirin
518
When is Labour Classed as Preterm?
24-37 Weeks
519
Complications of Preterm Labour
Perinatal Mortality, Cerebral Palsy, Lung Disease, Blindness, Minor Disability, Mental Handicap.
520
Risk Factors for Preterm Labour
Previous History, Lower Socioeconomic Status, Extremes of Maternal Age, Maternal Disease, IUGR, Pre-Eclampsia, STI, BV, LLETZ, Uterine Abnormalities, Infections, Polyhydramnios.
521
What leads to Preterm Labour?
"Defenders (Fetus) in a Castle (Uterus)"
- Multiple Pregnancy (Too many defenders)
- Fetal Compromise (Defenders give up)
- Uterine Abnormalities (Poor Castle)
- Cervical Incompetence (Weak Wall)
- Infection (Enemy knocks down the wall)
- UTI (Enemy get round the wall)
522
How can Preterm Labour be prevented?
At-risk groups are identified via History and USS can identify the cervical length:
- Cervical Cerclage (Insertion of a Suture)
- Progesterone (Suppository)
- Infection treatment
- Fetal Reduction
- Therapeutic Amniocentesis
523
What is Labour Characterised by?
Cervical Effacement & Onset of regular uterine contractions
524
Stages of Labour: 1st Stage
This stage is divided into two stages:
- Latent Phase: The period taken for the cervix to completely efface (softens, thins, and shortens) and dilate up to 3-4cm.
- Active Phase: From 4cm to full dilatation (10cm).
525
Stages of Labour: 2nd Stage
- Passive 2nd Stage – full dilatation with no active/involuntary pushing.
- Active 2nd Stage – full dilatation with active/involuntary pushing (forced expiration with a closed glottis) or a visible head.
526
Stages of Labour: 3rd Stage
The duration from the delivery of the baby to the delivery of the placenta and membranes.
- Physiological Management – The cord is allowed to stop pulsating before it is clamped, and the placenta is delivered by maternal effort alone.
- Active Management – Uterotonics are given to stimulate uterine contraction, the cord is clamped early, and controlled traction is applied to the cord.
527
What influences Progress in Labour?
3P's:
Power - Uterine contractions (Oxytocin)
Passenger - Size, Attitude, Lie, Presentation.
Passage - Shape and Size of Pelvis.
(Psyche is a potential fourth P).
528
Management of Failure to Progress: 1st Stage
- Latent Phase - Manage conservatively.
- Active Phase - Less than 2cm of dilatation in 4 hours. Amniotomy, consider Oxytocin.
529
Classification of Failure to Progress: 2nd Stage
Failure to progress in the 2nd stage is when the Active Second stage takes longer than 2 hours in nulliparous or 1 hour in multiparous.
Consider C-Section
530
Classification of Failure to Progress: 3rd Stage
More than 30 minutes in active management and more than 60 minutes in physiological management
531
Consequences of Failure to Progress in the 2nd Stage of Labor.
Hemorrhage, Infection, Tears, Foetal Distress/Hypoxia
532
Causes of Intrapartum Haemorrhage
Vasa Praevia, Placental abruption, Placenta praevia.
533
What is Cord Compromise?
During delivery, the cord is present first (before the baby). This occurs after a membrane rupture; exposure of the cord leads to vasospasm which is a significant risk of fetal morbidity and mortality due to hypoxia.
534
Genital Candidiasis - Presentation & Management
Presentation - Gential itch, "cottage cheese" like discharge, dyspareunia.
Diagnosis - Microscopy and Culture
Treatment - -azoles via pessary or Fluconazole PO.
535
Chlamydia - Presentation & Management
Presentation - Dyspareunia, post-coital bleeding, increased discharge.
Diagnosis - Nucleic Acid Amplification Test
Management - Azithromycin 1g PO (Single Dose) or 100mg Doxycycline BD (7 Days).
536
Trichomonas Vaginalis - Presentation and Management
Presentation - Vaginal discharge.
Diagnosis - Culture Microscopy
Treatment - Metronidazole 2g PO (Single Dose)
537
Neisseria Gonorrhoea: Presentation & Management
Presentation - Urethral/Vaginal Discharge, Dysuria, 50% of patients are asymptomatic.
Diagnosis - NAAT on either a Vaginal Swab (Female) or First Pass Urine (Male). Culture the samples for sensitivities.
Treatment - Ceftriaxone 500mg IM + Azithromycin 1g PO. Add Doxycycline +/- Metronidazole for complicated disease.
Complications - Increasing antibiotic resistance means that bacteria are now less responsive to treatment. Can lead to Pelvic inflammatory syndrome, infertility, Epididymitis and disseminated gonococcal infection.
538
Syphilis: Presentation and Management
Presentation
- 1 (Primary) - <90d after inoculation Painless ulcer called a Chancre develops which has a central slough and a defined rolled edge.
- 2 (Secondary) – Disseminated infection occurs 4-10 weeks after infection and leads to a maculopapular rash, fever, headaches, lymphadenopathy, and hepatitis.
- 3 (Tertiary) – 20-40yr after infection. Neurosyphilis, Gummatous Syphilis (Destructive granuloma in the skin) and Cardiovascular presentations such as aortitis.
Diagnosis - PCR
Treatment - Parenteral Benzylpenicillin boosted with probenecid in CSF disease.
539
Which HPV Strains Cause Genital Warts?
HPV 6 & 11
540
Anti-HIV Medication
PEP (Post Exposure Prophylaxis)
- This is when antiretroviral medication is given following exposure to HIV to prevent infection.
- It must be commenced within 72 hours of exposure.
- Consists of combination therapy with 3 antiretroviral drugs and is continued for a total of 28 days.
PREP (Pre-Exposure Prophylaxis)
- Two antiretrovirals combined into one tablet that can be taken daily or PRN but must be taken within 24 hours of a sexual encounter.
- It is offered to those identified as being at high risk of acquiring HIV (MSM).
- A double dose is taken PRN.
541
SSRIs in Pregnancy
Not associated with fetal malformation, there is some evidence to suggest a risk of cardiac malformation. The fetus is able to adapt to the dose do it should be tapered.
542
What is the safest SSRI in Breastfeeding
Sertraline is secreted into breast milk in the lowest concentration.
543
Foetal effects of Benzodiazepines
It is associated with cleft palate, neonatal withdrawal and floppy baby syndrome. They should be used in very short-term durations.
544
What impact does Lithium have on Fetuses?
Causes Cardiac malformations (Ebstein's Anomaly) - low-lying tricuspid valve which may occur alongside an atrial septal defect.
Use Lamotrigine instead to stabilise mood.
545
What is used to stratify the risk of Obstetric PE?
TRAF
546
What is monitored on the 12-week scan?
Heartbeat to assess Viability
CRL to date
Number of Fetuses
Nuchal Translucency
547
What is imaged on the 20-week scan?
Detects abnormalities with the fetus or the placenta.
548
Missed Pill Rules (COCP)
1 Missed Pill - Take Yesterdays & Todays
2 Missed Pills - Take two, continue the pack and take extra precautions for the next 7 days.
Week 1 Missed Pills - Consider emergency contraception
Week 3 Missed Pulls - Finish the current pack and start a new one the next day.
549
What is the most effective form of emergency contraception?
Intrauterine Device (Within 5 Days of UPSI)
550
What are the two main hormonal emergency contraceptives and when do they need to be taken?
Levonorgesterl (<72 Hrs)
Urlipristal (<120Hrs) - Caution in severe asthma.
551
What is Ovarian Torsion?
Occurs when the ovary and sometimes the fallopian tube twists on its vascular and ligamentous supports. This leads to a presentation of severe abdominal pain and nausea. An enlarged ovary displaying the whirlpool sign may be noted on USS.
552
What drug is given for the pharmacological management of Stress incontinence?
Duloxetine
553
What is the pharmacological management of Urge Incontinence?
Anticholinergics (Oxybutynin)
554
What is the appropriate management step if Glucose is >7 on an OGTT in pregnancy?
Commence Insulin
555
Cervical Cancer Screening
(Interpretation of Results - Positive hrHPV)
Sample examined Histologically:
Abnormal - Colposcopy
Normal - Repeat Smear in 12 months
---> IF abnormal in 12 months - Repeat Again
---> IF abnormal again - Colposcopy
556
Cervical Cancer Screening
(Interpretation of Results - Inadequate Sample)
Repeat the Smear in 3 months - If this sample returns as inadequate then refer for Colposcopy
557
Duration of Hormonal Contraception for Postmenopausal women
< 50 Y/O - 2 Years
> 50 Y/O - 1 Year
558
Which Contraceptives can women w/ Breast Cancer use?
Copper Coil ONLY
559
Post-partum Contraception
Required After day 21:
POP - Anytime
COCP - MEC2 6w - 6m
IUD/S - Within 48 Hrs or after 4 weeks
Lactational Amenorrhoea - Exclusive breast feeding, no periods & amenorrhoeic.
560
Until when can At-home terminations of pregnancy be considered?
10 Weeks
MBChB Finals
flashcards
Decks in class (24)
# Cards
-
Internal Medicine: Cardiology95
-
Internal Medicine: Endocrinology66
-
Internal Medicine: Gastroenterology85
-
Dermatology88
-
TheKnowledgeBuster143
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GP, Public Health, Ethics & Law320
-
ObsGyn560
-
Child Health510
-
Psychiatry170
-
Internal Medicine: Metabolic Medicine29
-
Internal Medicine: Neurology126
-
Internal Medicine: Geriatrics32
-
Ophthalmology51
-
Ear Nose & Throat64
-
Internal Medicine: Haematology103
-
Internal Medicine: Respiratory67
-
Internal Medicine: Urology & Nephrology161
-
Musculoskeletal (Ortho & Rheum)168
-
Internal Medicine: Infectious Diseases138
-
Internal Medicine: Oncology/Palliative Care37
-
Statistics37
-
Knowledge Buster 242
-
Night Before (SAQ)45
-
Night Before/Knowledge Buster (SAQ)32
