1
Q
Endometrial cancer
A
Classically seen in post menopausal women, but 25% occur before the menopause. Good prognosis due to early detection. Majority are adenocarcinomas
2
Q
Endometrial cancer risk factors
A
- obesity
- nulliparity
- early menarche, late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- Family history of endometrial, ovarian, breast, or colorectal cancer, Lynch syndrome
- hereditary non-polyposis colorectal carcinoma
- COCP and smoking are protective
3
Q
Endometrial cancer features
A
- Postmenopausal bleeding- slight and intermittent before becoming more heavy
- Premenopausal women may have a change in intermenstrual bleeding or Menorrhagia
- Pain is not common and signifies extensive disease
- Vaginal discharge is unusual
- Abdo discomfort or bloating, weight loss, anaemia
- Rarely: bowel and urinary changes
- On bimanual examination: enlarged uterus
4
Q
Endometrial cancer investigations
A
- women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- first-line investigation is trans-vaginal ultrasound - >5mm high risk of cancer
- Staging: CT and MRI
- hysteroscopy with endometrial biopsy
- Bimanual and speculum exam
- Staged using FIGO system
5
Q
Endometrial cancer management
A
- Total abdominal hysterectomy with bilateral salpingo-oophorectomy with lymphadenectomy. Patients with high-risk disease may have postoperative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery
- Rarely if young and wish to preserve fertility: progestin(e.g. low dose megestrol) and intensive monitoring using endometrial sampling every 3-6 months.
6
Q
Endometrial cancer red flags
A
- bleeding in between periods, after sex or after the menopause
- heavier periods
- abnormal vaginal discharge
- Thrombocytosis with visible haematuria or vaginal discharge in 55 or older
7
Q
Endometrial cancer: criteria for referral
A
- 2WW: women >55 with post menopausal bleeding
- Referral for TV US in woman >55: unexplained vaginal discharge, visible haematuria plus raised platelets, anaemia or elevated glucose levels
8
Q
Endometriosis definition and common sites
A
Definition: presence of endometrial like tissue outside the uterus, which induces a chronic inflammatory reaction
About 2-10% of the population and 50% of infertile women.
Common sites: pelvic organs, peritoneum, occasionally other parts of the body like lungs
9
Q
Endometriosis clinical features
A
- Chronic pelvic pain
- Secondary dysmenorrhoea: pain often starts days before bleeding
- Deep dyspareunia
- Subfertility
- Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- Chronic fatigue
- Can be asymptomatic. Little correlation between stage and type/severity of pain symptoms
10
Q
Endometriosis on examination
A
- tender nodularity in the posterior vaginal fornix
- visible vaginal endometriotic lesions.
- Fixed retroverted uterus
- Endometriomas: tender, nodular masses
11
Q
Endometriosis risk factors
A
- Age
- Increased peripheral body fat
- Greater exposure to menstruation
- Family history
- Protective factors-smoking ,cocp , exercise
12
Q
Endometriosis investigations
A
- Laparoscopy is the gold-standard investigation
- Examination: possible lass (endometiomas), fixed retroverted uterus with nodules in the uterosacral ligaments in severe disease
- Transvaginal US: often normal but may identify an ovarian endometrioma
- MRI, trans rectal USS, Ba enema (for bowel symptoms)
13
Q
Endometriosis management- mild
A
- NSAIDs and/or paracetamol for symptomatic relief
- If analgesia doesn’t help then hormonal treatment like the COCP or progesterone i.e. medroxyprogesterone acetate (Depo-provero) should be tried. Can take the COCP back to back
- Refer to secondary care if symptoms don’t improve or if fertility is a priority
14
Q
Endometriosis management- secondary care
A
- GnRH analodues- said to induce a ‘psuedomenopause’ due to low oestrogen levels.
- Dual therapy does not significantly affect fertility
- Surgery: if not responding to medicine. When trying to conceive use laparoscopic excision or ablation of endometriosis plus adhesiolysis. Ovarian cystectomy is also an option
15
Q
Medication for endometriosis
A
- Treat with - adequate analgesia(NSAID,S)
- Hormonal treatment- COCP
- Progestogens
- Anti progestogens
- GnRH agonists
- For pain from rectovaginal endometriosis refractory to other medical or surgical treatment- Consider Aromatase inhibitors in combination with oral COCP, progestogens, or GnRH analogues
16
Q
Endometriosis surgical treatment in order of severity
A
- At laparoscopy identified-surgically treat (see and treat).
- Consider both ablation and excision of peritoneal endometriosis and removal of adhesions (adhesiolysis)
- SURGICAL INTERRUPTION OF PELVIC NERVEPATHWAY-(LUNA,PSN-)should not be performed.
- OVARIAN ENDOMETRIOMA-perform ovarian cystectomy
- DEEP Endometriosis-perform surgical removal –refer to centre of expertise
- Failure to respond to conservative treatment +family complete-consider HYSTERECTOMY+BSO and removal of all visible lesions
- ADHESION PREVENTION AFTER SURGERY-use oxidised regenerated cellulose
17
Q
Endometriosis pathophysiology
A
metaplasia of coelomic epithelium and implantation of viable endometrial cells. Retrograde menstruation.
18
Q
Endometriosis: pre and post operative hormonal treatment
A
- Do not prescribe pre or post operative hormonal treatment except for pain
- After surgery prescribe a LNG-IUS or a combined hormonal contraception for 18-24 months for secondary prevention of endometriosis associated dysmenorrhoea but not for pain.
19
Q
Complications of endometriosis
A
- Surgery: Infertility, adhesion formation
- Epithelial cell ovarian cancer
20
Q
SUDEP and pregnancy
A
Most deaths are due to SUDEP (Sudden Unexplained Death in Epilepsy), often associated with poorly controlled disease. Nocturnal seizure is a RED flag symptom for SUDEP and should prompt rapid referral
21
Q
Epilepsy and pregnancy: preconception
A
- Optimize anti-epileptic medication (AEM): use lowest dose possible and preferably monotherapy, avoid polytherapy to reduce risk of congenital malformations (most commonly neural tube defects and cardiac anomalies)
- Women with history ofepilepsybut with no high risk of unprovoked seizures can be managed as low risk pregnancies a
- If no fits for 2 years consider stopping all medication
- Carbamazepine and lamotrigine have best safety profile
- Commence 5mg folic acid for 3 months pre-conception
- Don’t use sodium valproate
22
Q
Epilepsy and pregnancy: antenatal
A
- Explain the importance of never stopping or changing AEMs abruptly.
- Inform of risk factors for seizures (sleep deprivation, stress and adherence to AEMs)
- Don’t routinely check serum levels of AEMs, only do so on advice from Neurology
- Vitamin K given from 36 weeks gestation
- If taking AEM they require serial growth scans at 28, 32, 36, 40 weeks to detect small for gestational age (SGA) babies
23
Q
Epilepsy and pregnancy: intrapartum
A
- Epilepsy is not an indication for Induction of labour or C-Section
- Ensure adequate analgesia and hydration as pain, stress and dehydration can precipitate seizures
- Women should continue to take AEMs whilst in labour, and if unable to do so orally, alternate routes should be considered
- If epileptic seizure occurs during labour give Benzodiazepines quickly
- Seizure in first trimester with no previous diagnosis of epilepsy assume eclampsia
24
Q
Epilepsy and pregnancy: postpartum
A
- The risk of seizures here is still low, although relatively higher than during pregnancy (due to worsening of risk factors)
- If AEM dosage was modified in pregnancy, it should be reviewed by a neurologist within 10 days postnatally
- Babies born to mothers who have been taking enzyme inducing AEMs should be offered 1mg of IM Vitamin K to prevent Haemorrhagic Disease of the Newborn.
- AEMs are not a contraindication to breastfeed, so women should be supported should they wish to do so.
25
Pregnancy and epilepsy medication
1. aim for monotherapy
2. there is no indication to monitor antiepileptic drug levels
3. sodium valproate: associated with neural tube defects
4. carbamazepine: often considered the least teratogenic of the older antiepileptics
5. phenytoin: associated with cleft palate
6. lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
26
Chronic hypertension and pregnancy
- Hypertension predating pregnancy or presenting at <20 weeks
- May be primary or secondary
- Increased risk of developing gestation hypertension and pre-eclampsia
- No proteinuria or oedemia
- If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review. Can also use methyldopa and nifedipine (if asthmativ)
27
Gestational hypertension and prevention of hypertension
new hypertension in pregnancy presenting at >20 weeks without significant proteinuria
Prevention of hypertension: consider aspirin 150mg at night daily if 1 high or 2 moderate risk factors. Start from 12 weeks and continue through pregnancy
28
Gestational hypertension: high risk factors
- Hypertensive disease during a previous pregnancy
- Chronic kidney disease
- Autoimmune disease such as SLE or APLS
- Type 1 or type 2 diabetes
- Chronic hypertension
29
Gestational hypertension: moderate risk factors
- First pregnancy
- Age ≥40
- Pregnancy interval of more than 10 years
- Booking BMI ≥35
- Family history of pre-eclampsia
- Multiple pregnancy
30
Gestational hypertension; overview
- Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
- No proteinuria, no oedema
- Occurs in around 5-7% of pregnancies
- Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
31
Hypertension in pregnancy is usually defined as
- systolic > 140 mmHg or diastolic > 90 mmHg
- or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
32
FGM definition
any procedure involving partial or total removal of the female external genitalia or other injury to the female genital organs for non therapeutic reasons. Its illegal and a form of child abuse. Must be reported to the police immediately
33
FGM classification
1. Type 1= Clitoridectomy: partial or total excision of the clitoris and/or prepuce
2. Type 2= Excision: partial or total removal of the clitoris and labia minora, with or without excision of the labia majora
3. Type 3= Infibulation: narrowing of the vaginal orifice with the creation of a covering seal by cutting and moving the labia minora and/or labia majora, with or without excision of the clitoris.
4. Type 4= All other harmful procedures to the female genitalia for non-medical purposes (pricking, piercing, incising, scraping, cauterization)
34
FGM: potential complications
- Bleeding, severe pain, infection, including tetanus, hepatitis and HIV.
- Urinary retention, urethral damage and incontinence
- Urinary tract obstruction and recurrent UTI.
- Sub fertility, reduced sexual response, infertility, lower self-esteem and PTSD.
- Difficult gynaecological internal examination, catheterization and cervical smears.
35
FGM and pregnancy
- Consultant booking as increased risks of delivery complications such as obstructed labour, perineal trauma, operative vaginal delivery and LSCS.
- Anterior episiotomy during the second stage of labour with local anaesthetic or regional block
- Deinfibultation
Delivery in a maternity unit with immediate access to emergency obstetric care
36
Fibroids definition
benign smooth muscle tumours of the uterus. Benign tumours of the myometrium. More common in afro-caribbean women and >30, rare before puberty, develop in response to oestrogen
37
Fibroids symptoms
- May be asymptomatic
- Menorrhagia and dysmenorrhoea -may result in iron-deficiency anaemia
- Bulk-related symptoms- lower abdominal pain: cramping pains, often during menstruation, bloating, urinary symptoms, e.g. frequency, may occur with larger fibroids. May have palpable mass
- Subfertility
- Rare features: polycythaemia secondary to autonomous production of erythropoietin
38
Types of fibroids
- Intramural: means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
- Subserosal: means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
- Submucosal: means just below the lining of the uterus (the endometrium).
- Pedunculated means on a stalk: grow into the uterine cavity
39
Diagnosis and management of fibroids
Diagnosis: transvaginal ultrasound. Hysteroscopy can also be done. MRI considered before surgery
Management of asymptomatic fibroids: no treatment is needed other than periodic review to monitor size and growth
40
Management of menorrhagia secondary to fibroids
- Levonorgestrel intrauterine system (LNG-IUS): useful if the woman also requires contraception, cannot be used if there is distortion of the uterine cavity
- NSAIDs e.g. mefenamic acid
- Tranexamic acid
- Combined oral contraceptive pill
- Oral progestogen
- Injectable progestogen
- Non surgical management for fibroids causing abnormal bleeding and under 3cm in size with no uterine distorsion
41
Treatment to shrink/remove fibroids
- Medical: GnRH agonists (Gaserelin) may reduce the size of the fibroid but are used for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
- Surgical: myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically. hysteroscopic endometrial ablation. Hysterectomy. uterine artery embolization
- Surgical management for fibroids causing symptoms due to their mass effect
42
Fibroids: choosing between medical and surgical management
- Fibroids <3cm medical management is the same as heavy menstrual bleeding
- Fibroids >3cm refer to gynaecology for investigation and management. Can be either medical or surgical
43
Fibroids: prognosis and complications
- Fibroids generally regress after the menopause
- Torsion: usually affecting pedunculated
- Delivery: breech, bleeding
- Complications: subfertility and iron deficient anaemia
- Red degeneration: ischaemia of the fibroid, commonly occurs during pregnancy. Causes severe abdo pain, low grade fever and tachycardia
44
Gonorrhoea; risk factors
- Age <25
- Non-barrier contraception
- Co-infection with another sexually transmitted infection
- Causes by Neisseria Gonorrhoeae (gram negative)
45
Presentation of gonorrhoea
- Gonorrhoea presents quite similarly to chlamydia with mucopurulent discharge (green/yellow), dysuria, lower abdominal pelvic pain and anogenital symptoms in both men and women
- Thick yellow/green discharge, pain/bleeding during sex
- In women: bleeding between periods, pelvic inflammatory disease
- Extragenital: Pharyngitis, rectal pain and discharge
- In men: urethritis, dysuria, often asymptomatic, discharge
46
Gonorrhoea pregnant and disseminated gonorrhoea
Gonorrhoea pregnant: children can develop conjunctivitis <48 hours after delivery and need to be treated effectively and urgently to reduce risk of lasting optical complications
Disseminated gonorrhoea: systemic symptoms such as fever, malaise, joint pain, swelling and rash
47
Gonorrhoea investigations
- First catch urine test or endocervical swab/ vulvovaginal swab (better to do swab)
- NAAT is the most sensitive method
- Culture and antibiotic sensitivities
48
Gonorrhoea management
- Antimicrobial susceptibility known: Ciprofloxacin 500mg PO single dose. Dont give if pregnant
- Antimicrobial susceptibility not know: Ceftriaxone 1g IM single dose
- NAAT should be repeated 2 weeks later or cultures >72 hours after antibiotics given to test for adequate treatment of infection
- Abstain from sex for 7 days of treatment
- Contact tracing
49
Gonorrhoea complications
- Infertility in women: due to PID
- Infertility in men: due to epididymitis
- Fitz-Hugh-Curtiz syndrome, Septic arthritis, endocarditis
Year 5
flashcards
Decks in class (24)
# Cards
-
Paediatrics 150
-
Paediatrics 250
-
Paediatrics 350
-
Paediatrics 450
-
Paediatrics 551
-
Paediatrics 659
-
Paediatrics 751
-
Paediatrics 850
-
Paediatrics 950
-
Paediatrics 1038
-
Repro 150
-
Repro 249
-
Repro 349
-
Repro 452
-
Repro 552
-
Repro 649
-
Repro 750
-
repro 850
-
Repro 952
-
Psych 150
-
Psych 250
-
Psych 350
-
Psych 450
-
Psych 545
