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Flashcards in Obs Gyne Deck (198)
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1
Q

Red flags of Breast lumps

A

• Hard lump with fixation +/- skin tethering
• Phx of Breast CA
• Lump getting bigger
• Eczematous skin not responsive to topical tx
• Bloody nipple discharge
• Unilateral discharge
Nipple inversion

2
Q

Explain Screening program of breast CA

A

Women 50-70:
2 view mammography every 3 years

High risk women <50:
• If FHx of breast cancer
• 40-49 - annual 2 view mammography
• Genetic mutation of BRCA1/2 - annual MRI from 30y+

3
Q

Tx of mild/moderate cyclical breast pain

A

• Diet - reduce caffeine and sat fat
• Simple analgesia
Changing/stopping contraceptives

4
Q

Tx of non cyclical breast pain - well localised and generalised

A

• Well localised - consider ill fitting bras, breast abscess, cyst, mastitis, CA
Generalised - consider lung disease, nerve root pain

5
Q

Give epi, S&S, Ix, and Tx of fibroadenoma

A

Epidemiology:
Peak 16-24

S&S:
Discrete, firm, non tender and highly mobile

Ix:
• Mammogram
• USS
FNAC

Tx:
Refer for confirmation

6
Q

Patho of sclerosing adenosis

A

Overproliferation of duct lobules. Results in pain and small firm nodules.

7
Q

S&S, epi, tx, ix of phyllodes tumour

A

Epi:
40-50 peak

S&S:
Lump forms grows large and quickly

Ix:
USS, mamography, FNAC

Tx:
Wide surgical excision

8
Q

hx and S&S of fat necrosis. Ix and tx?

A

S&S:
• Hx of injury and bruising
Scarring results in firm lump in breast

ix - uss, mammography, FNAC
tx - none needed once confirmed

9
Q

Breast cyst Ix and S&S

A

S&S:
Firm round lump not fixed and no skin tethering

1st cyst - urgent referral to exclude CA
hx of cysts - FNAC and referral if blood stained or non resolving

10
Q

Galactocoele patho

A

Patho - obstruction of lactiferous duct results in cyst containing milk

11
Q

S&S and tx of galactocoele

A

S&S:
• Cyst on examination
Occurs whilst or shortly after lactation

Tx:
Aspiration

12
Q

Duct ectasia patho and S&S

A

• Occurs around menopause
• Ducts become blocked and secretions stagnate
Discharge which may be blood stained +/- breast lump +/- nipple retraction +/- breast pain

13
Q

duct ectasia ix and tx

A

Ix:
Urgent referral to exclude CA

Tx:
• Self resolving
Surgery may be needed to confirm diagnosis

14
Q

Breast abscess hx and S&S. tx?

A

Hx:
• Usually occurs in lactating breast following mastitis
Presents as gradual onset pain in one breast segment with hot tender swelling of area.

tx - aspiration

15
Q

RFs of breast CA

A

Age, denser boobs, obesity, alcohol, smoking, FHx, HRT, Genetics

16
Q

S&S of breast ca

A
Presentation:
	• Breast lump - 90%
	• Nipple skin changes - 10%
	• Painful lump - 21%, pain alone 1%
Nipple discharge - 3%
17
Q

Ix and tx of breast cancer. cx of ix?

A

Ix:
• Lymph node biopsy
Can result in lymphoedema

Tx:
• Tamoxifen - if oestrogen receptor +ve
• Aromatase inhibitors eg anastrozole - blocks synthesis of oestrogen for oestrogen +ve
• Herceptin - Monoclonal Ab directed at HER2
Surgical, axillary lymph node clearance

18
Q

Emergency contraception options and when they can be used?

A

Copper IUCD - <5 days
Levonorgestrel - 1.5mg PO. <3days OTC.
Progesterone receptor modulator - <5 days oral

19
Q

Contraindications COCP?

A

Venous disease, arterial disease, liver disease, cancer, drug interactions

20
Q

If missed 1 pill of COCP what do? Missed 2+ pills?

A

Missed doses:
• If 1 pill missed - take ASAP even if 2 in 1 day. Continue
If 2+ pills missed - Take most recent missed pill even if 2 in 1 day. Leave earlier missed pills and use barrier contraceptives for next 7 days.

21
Q

Define antepartum hemorrhage, miscarriage, and PPH

A

APH - Bleeding from uterus after 24th week
Miscarriage - Bleeding <24 wks
PPH - Bleeding after birth of baby

22
Q

Causes of APH

A

• Placenta praevia
• Placental abruption
Local infection

23
Q

S&S of APH

A
• Pain (suggests abruption)
	• Painless (suggests placenta praevia)
	• Failure of fetal head to engage with praevia
	• Signs of fetal distress
Signs of shock if severe bleeding.
24
Q

Ix of APH

A

• Always admit for assessment, even if small bleed
• No VE until praevia ruled out
• USS
• Resus if severe bleed
• Blood tests - FBC (Initial Hb may not reflect sudden blood loss), G&S, X match, clotting studies
• Fetal monitoring
Maternal corticosteroids if at risk of preterm birth

25
Q

Placenta Praevia S&S, RFs, Ix. What must you never do if suspected?

A
S&amp;S:
	• No pain
	• Uterus non tender
	• Lie and presentation may be abnormal
	• Small PV bleeds before large

RFs:
• Multiparity
• Multiple pregnancy
Previous C section

Ix:
• Usually picked up at 20 wk abdo scan
If suspect - TV scan

26
Q

RFs for GBS?

A
RFs for GBS:
	• Premature
	• Prolonged rupture of membranes
	• Previous sibling GBS infection
Maternal pyrexia
27
Q

Define early and late miscarriage

A

Loss of pregnancy <24 wks gestation

Early <12 wks. Late 13-24 wks.

28
Q

Classify - threatened, inevitable, incomplete, complete, missed, recurrent miscarriages

A

Classification:
• Threatened miscarriage - Mild bleeding. Closed cervical os
• Inevitable miscarriage - Heavy bleeding and clots. Open cervical os.
• Incomplete miscarriage - POC partially expelled.
• Complete miscarriage - POC completely expelled.
• Missed miscarriage - Fetus is dead but retained.
Recurrent miscarriage - 3+ consecutive miscarriages

29
Q

Common causes of miscarriage

A
• Most iatrogenic - COCP
	• Abnormal fetal development
	• Poorly controlled diabetes
	• Poorly controlled thyroid disease
	• PCOS
	• Antiphospholipid syndrome
Uterine abnormality
30
Q

RFs for miscarriage

A
• Age
	• Smoking
	• Alcohol
	• Low BMI
Drugs
31
Q

S&S and differntials of miscarriage

A

S&S:
Bleeding and vaginal pain worse than period

Differentials:
• Ectopic pregnancy
• Implantation bleed
Cervical polyp

32
Q

Ix and tx of miscarriage

A

Ix:
• TV USS
• Serum hCG

Tx:
• Early miscarriage - conservative with urine hCG in 7-14 days
• Medical - Vaginal misoprostol
• Surgical:
○ Indications- persistent excessive bleeding, infected POC
Vacuum aspiration under local - risk of cervical tears and perforation

33
Q

Define pre-eclampsia

A

HTN + proteinuria seen after 20 weeks gestation

34
Q

What does pre-eclampsia dispose to?

A

• Fetal prematurity and growth retardation
• Eclampsia
• Hemorrhage - placental abruption
Cardiac and multi organ failure

35
Q

RFs of Pre-eclampsia, Ix

A
RFs:
	• >40y
	• Nulliparity
	• BMI >30
	• DM
	• Hx of pre-eclampsia
	• Pre-existing vascular disease eg HTN or renal disease 

Ix:
• Urinalysis
• Frequent monitoring of FBCs, LFTs, U&E
Clotting studies if severe pre-eclampsia

36
Q

S&S of severe pre-eclampsia

A
S&amp;S of severe pre-eclampsia:
	• HTN >170/110
	• Proteinuria ++/+++
	• Headache
	• Visual disturbance
	• Papilloedema
	• RUQ pain
	• Hyperreflexia
HELLP syndrome
37
Q

What is HELLP syndrome?

A

HELLP syndrome - serious pre-eclampsia:
• H - Hemolysis (anemia)
• EL - Elevated LFTs
LP - Low Platelets

38
Q

Tx of pre-eclampsia

A

Tx:
• Oral labetalol
• Delivery of baby is definitive cure
○ Not offered pre 34 weeks unless refractory to tx
Prevention - aspirin and calcium if high risk of pre-eclampsia

39
Q

Tx of eclampsia

A
Eclampsia Tx:
	• A-E assessment
	• Mg sulfate IV
	• IV labetalol to reduce risk of further seizures
Fetal delivery definitive tx
40
Q

RFs of hyperemesis gravidarum?

A

RFs:
• Multiple pregnancies
• Hyperthyroidism
Obesity

41
Q

Tx of hyperemesis gravidarum, when usually occurs?

A

8-12 weeks
Tx:
• Antihistamines - promethazine
IV hydration may be needed

42
Q

S&S of ectopic

A

S&S:
• Usually around 6th week of pregnancy
• Pain on one side of Lower abdomen. Sharp, severe, gets worse over several days
• PV bleeding often. Darker bleed than normal
• Shoulder tip pain referred from diaphragm
Tube ruptures - shock

43
Q

RFs of ectopic and Ix

A
RFs:
	• PID
	• Previous sterilisation
	• Endometriosis
IUCD

Ix:
• Pregnancy test
• TV USS of pelvic organs
HCG blood - lower than normal

44
Q

Tx of ectopic pre and post rupture

A

Tx:
• Ruptured - emergency surgery
• Pre rupture:
○ Salpingectomy or salpingotomy (partial fallopian tube removal)
○ Methotrexate
Wait and see - 50% of ectopics self resolve

45
Q

3 causes of postpartum depression. When they start?

A

3 causes of depression post partum:
• Baby blues - Weepy, irritable starting 3rd day goes by 10th
• Postnatal depression - Starts in first 4 weeks after childbirth. Tx advised
Postnatal psychosis - severe mental illness

46
Q

Diagnostic criteria of depression

A

Core symptoms for atleast 2 weeks.
• Anhedonia
• Low energy
Pervasive Low mood

D - depressed mood
E - energy loss
P - pleasure loss
R - retarded movement
E - eating less or more
S - sleep
S - suicidal ideation
I - i'm a failure (low self confidence)
O - only me to blame (guilt)
N - no concentration

Mild - 4 sx. Moderate - <6 sx. Severe 7+

47
Q

Postpartum psychosis S&S

A
Postpartum psychosis S&amp;S:
	• Mood changes - low or high
	• Trouble sleeping
	• Paranoid thoughts
	• Hallucinations
	• Delusions
	• Loss of social inhibitions
Lack of insight
48
Q

Postpartum psychosis ix and tx

A
PPP Ix:
	• BM - hypoglyc
	• TFTs
	• Vitamin deficiencies
CT head to rule out stroke

Tx - lithium, clozapine

49
Q

S&S of fetal distress. Ix

A

S&S:
• Reduced movement felt by mother
• Slowing of growth of serial symphysis fundal height

Ix:
• Doppler USS of umbilical artery
• CTG
Fetal blood sampling during labour

50
Q

RFs of fetal distress and tx

A
RFs:
	• Hx of stillbirth
	• IUGR
	• HTN
	• Obesity
	• Smoking
	• T2DM
	• Pre-eclampsia
	• Age

Tx:
Monitor for potential induction or C section

51
Q

How do you interpret CTG?

A
Interpretation - DR C BRAVADO:
	• DR - Define Risk
	• C - Contractions
	• BRA - Baseline rate
	• V - Variability
	• A - Accelerations
	• D - Deceleration
O - Overall impression
52
Q

Pathology of gest diabetes

A

Patho:
• Any degree of glucose intolerance with its onset during pregnancy
• Pregnancy hormones decrease fasting glucose levels, increase fat deposition and increase appetite.
• Postprandial glucose concentrations increase as insulin resistance increases
This is usually countered by increased insulin. In GDM this is not so.

53
Q

RFs of GDM. Ix

A

RFs:
• Age
• High BMI pre pregnancy
Smoking

Ix:
• Fasting glucose >5.6mmol
2 hour glucose post OGTT >7.8mmol

54
Q

Tx of GDM and Cx

A

Tx:
• Glycaemic control below target levels
• Offer USS for fetal abnormalities at 20 wks
Fasting BM 10 wks after birth to exclude diabetes

Cx of GDM:
	• Increased birth weight
	• Preterm risk
	• Shoulder dystocia
Pre-eclampsia
55
Q

S&S of molar pregnancy . ix

A

S&S:
• Pregnancy sx - large for gestation age
Vaginal bleeding

Ix:
• High levels of hCG
USS

56
Q

S&S of multiple pregnancy

A

S&S:
• Hyperemesis and exaggerated pregnancy sx
• Uterus palpable earlier than 12 weeks of gestation
• Large for dates uterine size
2+ fetal heart rates heard on auscultation

57
Q

Causes of primary PPH

A

Primary Cause - 4 Ts:
• Tone - Uterine atony (most common), distended bladder
• Trauma - Laceration of uterus, cervix, or vagina
• Tissue - Retained placenta (2nd most common) or clots
Thrombin - Coagulopathy

58
Q

Define primary and secondary PPH

A

Primary - Blood loss >500ml within 24 hours of delivery

Secondary - Abnormal bleeding 1 day to 6 wks post delivery

59
Q

Causes of secondary PPH

A

Secondary cause:
• Infection
Retained products of conception (RPOC)

60
Q

Tx of primary PPH

A

Tx:
• Resus
• A-E assessment
• Bloods - X match, G&S, U&E, FBC, Clotting, LFT
• Oxytocin IV
• Surgical - Balloon tamponade, hysterectomy

61
Q

S&S of secondary PPH and ix

A
S&amp;S:
	• Fever
	• Abdo pain
	• Offensive vaginal discharge
	• Bleeding
	• Dysuria
Ix:
	• Blood culture
	• FBC
	• MSU
	• High vaginal swab
	• USS
62
Q

Retained placenta tx

A

Tx:
• IV oxytocin
Manual evacuation of placenta

63
Q

pt wants abortion. What Ix?

A
Ix:
	• Screen for chlamydia
	• Discuss future contraceptive needs
	• Risk of VTE
Is smear due?
64
Q

Tx to abort? Options available.

A

• Abx ppx - Metronidazole + doxy as 10% women develop genital tract infection post abortion
• Medical:
○ Mifepristone
• Surgical:
○ Vacuum aspiration up to 14 weeks
○ Dilatation and evacuation between 14-24 weeks
• Analgesia - NSAID
• Anti-D IgG to all non sensitised RhD -ve women

65
Q

Explain the physiology of normal menstrual cycle. Normal menstrual loss?

A

Days 1-14 - follicular phase - FSH high and stimulates egg. Oestrogen produced by developing follicles

Day 14 - ovulation - egg released

Day 14-28 - luteal phase - Ruptured follicle forms corpus luteum and secretes prog and oestrogen.

Day 28 - menses - Corpus luteum degrades. Loss of oestrogen and prog causes necrosis of endometrium. Normal blood loss 20-60 mls. 80+ menorrhagia

66
Q

hx to quantify menorrhagia

A

Questions to quantify:
• How many pads do you use?
• How many tampons?
• Flooding to clothes or bedding?

67
Q

Causes of menorrhagia

A
Causes:
	1. DUB
	2. Fibroids - benign growths in uterine muscle
	3. Endometriosis
	4. Polyps
	5. Infections
	6. Endometrial carcinoma
	7. PCOS
	8. Hypothyroid
Blood clotting disorders
68
Q

S&S of menorrhagia. Ix. Tx.

A

S&S:
• Signs of anaemia
• Examine abdomen and PV

Ix:
	• FBC
	• TFTs
	• Clotting disorders
	• USS
Tx:
	• Mirena coil
	• Tranexamic acid
	• COCP
	• Hysterectomy
69
Q

Primary and secondary causes of dysmenorrhoea

A

Primary - idiopathic cause. Thought to be due to excess prostaglandin release

Secondary:
	• Endometriosis
	• PID
	• Fibroids
	• Endometrial polyps
	• IUCD
	• Ovarian cysts
70
Q

Ix and tx of primary dysmenorrhoea

A

Ix:
• Vaginal exam
• Pelvic USS
• Hysteroscopy

Tx - primary:
• Warmth - hot water bottle on abdo
• NSAIDs - blocks prostaglandins
• COCP

71
Q

Red flags of dysmenorrhoea that indicate its not primary

A
Red flags - not sx of primary dysmenorrhoea:
	• Fever
	• Vaginal discharge
	• Sudden severe abdo pain
	• Dyspareunia
	• Intermenstrual bleeding
	• Postcoital bleeding
72
Q

Define DUB

A

Patho:
• Excessive bleeding in absence of pregnancy, infection, trauma or tx
• Diagnosis of exclusion

73
Q

Ix of DUB

A
Ix:
	• FBC to check if anaemic
	• USS to exclude fibroids
	• TFTs - hypothyroidism
	• Clotting studies - von willebrand disease
74
Q

tx of DUB

A
Tx:
	• Mirena coil
	• Tranexamic acid - doesn’t reduce pain
	• COCP
	• Surgical - Uterine artery ablation and hysterectomy
75
Q

Hx to ask of dyspareunia

A
Hx:
	• Superficial or deep?
	• Tightening of muscles - vaginismus
	• Recent or always?
	• Following childbirth?
	• Pain continues after sex?
	• Any hx of sexual abuse or rape?
	• FGM?
	• Menopause sx?
	• UTI sx?
76
Q

Examination for Dyspareunia

A
S&amp;S:
	• External genital exam. Look for:
		○ Skin disease
		○ Vaginal secretions
		○ Infection
		○ Scarring
	• VE - Be very careful and only when pt is ready.
77
Q

Ix of dyspareunia

A

Ix:
• STI swab
• Dipstick urine - UTI
• Laparoscopy if adhesions suspected

78
Q

Intermenstrual bleeding causes

A
Causes:
	• Pregnancy related - inc ectopic pregnancy
	• Vaginal causes:
		○ Vaginitis
		○ Infection
	• Cervical causes:
		○ Cervical Polyps
		○ Cervical ectropion
	• Uterine causes:
		○ Fibroids
		○ Polyps
		○ Cancer
	• Missed OCPs
	• Breakthrough bleeding - Occurs when starting new contraceptive
79
Q

Hx to ask in intermenstrual bleeding

A
Hx:
	• Menorrhagia?
	• LMP?
	• Timing of bleeding in menstrual cycle
	• Associated sx - abdo pain, fever, discharge
	• Pregnancy?
	• Sexual hx
80
Q

Exams for intermenstrual bleeding

A

S&S:
• Tampon in vagina - establish if bleeding is from vagina and nowhere else
• High BMI - RF for endometrial cancer
• PV exam

81
Q

Ix of intermenstrual bleeding

A

Ix:
• Infection screen
• Pregnancy test
• TVUS for structural abnormalities

82
Q

Post coital bleeding causes

A

Cause:

1. Infection
2. Cervical ectropion
3. Polyps
4. Vaginal or cervical cancer
83
Q

Define menopause

A

12 months of secondary amenorrhoea

84
Q

S&S of menopause

A
S&amp;S:
	• Menstrual irregularity
	• Hot flushes and sweats
	• Dyspareunia, vaginal discomfort and dryness
	• Recurrent UTIs
	• Sleep disturbance
	• Mood changes
	• Loss of libido
85
Q

Tx of menopause. Risks and benefits

A

Tx:
• HRT:
○ Used in early menopause
○ Tx of women where risk:benefit ratio is favourable
○ Benefits - reduces menopause sx + osteoporosis risk
○ Risks - VTE, stroke, breast cancer

86
Q

Postmenopausal bleeding causes

A

Causes:

1. Vaginal atrophy
2. HRT
3. Endometrial hyperplasia
4. Endometrial cancer
5. Polyps
6. Cervical cancer
87
Q

Endometrial Ca RFs

A
Endometrial cancer RFs:
	• Oestrogen only HRT
	• Age
	• PCOS
	• Early menarche and late menopause
88
Q

Ix of postmenopausal bleeding

A
Ix:
	• Trans vaginal USS
		○ Endometrial thickness should be thinner than premenopause. If thick, suspect endometrial CA.
	• Endometrial biopsy
	• Hysteroscopy
89
Q

What is meigs syndrome. S&S and tx

A

3 features:
• Ascites
• Benign ovarian tumour
• Pleural Effusion

S&S:
• Affects 40+ women
• Rare

Tx:
• Drain fluid and remove tumour

90
Q

Epi of fibroid

A

Epi:
• Common in 30-50y
• FHx
• Obesity increases risk

91
Q

S&S of fibroids

A

H&E:
• Heavy or painful periods - dysmenorrhoea and menorrhagia
• Swelling in abdomen
• Constipation or urinary urgency due to compression of fibroid
• Dyspareunia - Bleeding during or after sex. If growing in cervix or near vagina

92
Q

Ix and tx of fibroids

A

Ix:
• Abdo USS
• TV exam

Tx:
• Observation
• Medication to reduce bleeding - see DUB tx (COCP, mirena coil)
• Shrink fibroids - GnRH analogue for 6 months. Gives sx similar to going through menopause.
• Surgery - Hysterectomy, myomectomy to retain fertility. GnRH analogue given pre surgery to shrink fibroid

93
Q

Define endometriosis and adenomyosis

A

Endo - endometrial tissue outside of uterus

Adeno - Endometrial tissue in myometrium

94
Q

S&S of endometriosis

A
S&amp;S - related to menstrual cycle:
	• Dysmenorrhoea
	• Menorrhagia
	• Dyspareunia
	• Lower abdo pain
	• Intermenstrual bleeding
	• Reduced fertility
95
Q

Ix of endometrriuosis. What might you see?

A

Chocolate cysts:
• Large patches of endometriosis form cysts which bleed when you have a period
• Cysts fill with dark blood giving a chocolate appearance

Ix:
• Confirmed via laparascopy

96
Q

Tx of endometriosis

A

Tx:
• Analgesics - paracetemol, NSAIDs, codeine
• COCP
• Mirena coil
• GnRH analogues
• Laparascopic surgery to remove large patches

97
Q

S&S of adenomyosis

A
S&amp;S:
	• Dysmenorrhoea
	• Dyspareunia
	• Menorrhagia
	• Infertility possible
	• Examination - uterus symmetrically enlarged and tender.
98
Q

Ix and Tx of adenomyosis

A

Ix:
• MRI
• Histology

Tx:
• GnRH analogues
• Hysterectomy

99
Q

RFs of endometrial cancer

A
RFs:
	• Increased exposure to oestrogen
	• Obesity
	• Diabetes
	• PCOS
	• COCP lowers risk
100
Q

S&S of endometrial cancer

A
S&amp;S:
	• Post menopause bleeding
	• Postcoital bleeding
	• Intermenstrual bleeding
	• Dyspareunia
	• Lower abdo pain
101
Q

Ix of endometrial cancer. Tx

A
Ix:
	• Vaginal exam
	• Uterine USS
	• Endometrial biopsy
	• Hysteroscopy
	• Staging CT if confirmed cancer

Tx:
• Surgical excision
• Hysterectomy with bilateral oophrectomy
• Radiotherapy

102
Q

S&S of cervical carcinoma

A

S&S:
• Vaginal discharge
• Bleeding - post defecation, micturition or post coital
• Vaginal discomfort
• Late sx - painless haematuria, chronic urinary frequency, Painless fresh rectal bleeding, altered bowel habit
• Bulk in pelvis

103
Q

Ix and tx of cervical carcinoma

A
Ix:
	• STI screen
	• Colposcopy to visualise cervix
	• FBC, LFTs, U&amp;Es
	• CT CAP if mets
Tx:
	• Surgical excision
	• Hysterectomy
	• Radiotherapy
	• Chemotherapy
104
Q

RFs of ovarian carcinoma

A
RFs:
	• Age
	• Smoking
	• Obesity
	• HRT
	• FHx
105
Q

S&S of ovarian carcinoma. Differentials

A

S&S:
• Early is vague - abdo discomfort, distension, bloating
• Pelvic or abdo mass associated with pain
• Ascites

Differentials:
	• Fibroids
	• Benign ovarian tumour
	• Cyst
	• Endometriosis
106
Q

Ix and tx of ovarian carcinoma

A

Ix:
• Abdo pelvis USS
• CT CAP
• CA 125

Tx:
• Surgical
• Chemo + radio

107
Q

S&S of vulval carcinoma and tx

A

Tx:
• Wide local excision +/- lymph node dissection
• Chemoradiotherapy

S&amp;S:
	• Itching
	• Bleeding
	• Vulval lesion
	• Inguinal lymphadenopathy
108
Q

S&S of benign ovarian tumour

A
S&amp;S:
	• Asymptomatic
	• Dull ache in lower abdo or low back
	• Torsion - more likely if tumour
	• Dyspareunia
	• Pressure affects on bladder, or venous system
109
Q

Ix and tx of benign ovarian tumour

A
Ix:
	• Pregnancy test
	• FBC - infection, hemorrhage
	• USS
	• CT if USS not definitive

Tx:
• Small cysts with no sx - watchful waiting
• Medium cysts - yearly USS to monitor
• Larger cysts - surgery

110
Q

PCOS S&S

A
S&amp;S:
	• Infertility
	• Irregular periods or no periods
	• Hirsutism
	• Acne
	• Thinning of scalp hair
	• Weight gain
	• LT - diabetes, HTN, hypercholesterolemia
111
Q

PCOS Ix and Tx

A
Ix:
	• Testosterone bloods
	• LH bloods - higher in PCOS
	• USS of pelvic organs ovaries
	• Impaired glucose tolerance test for diabetes
Tx:
	• Lose weight
	• Acne tx
	• Clomifene to ovulate and increase fertility
	• Metformin not universally recommended
112
Q

PID causative organisms

A

Causative organisms:
• Chlamydia trachomatis - most common
• N gonorrhoea

113
Q

PID S&S

A
S&amp;S:
	• Lower abdo pain
	• Fever
	• Deep dyspareunia
	• Dysuria
Cervical excitation
114
Q

PID Ix and tx

A
Ix:
	• Chlamydia and gonorrhoea screen
	• FBC
	• CRP
	• MSU
	• Blood cultures
	• Pelvic USS

Tx:
• oral ofloxacin + oral metronidazole
• Contact tracing

115
Q

Cx of PID

A

Cx:
• Infertility
• Chronic pelvic pain
• Ectopic pregnancy

116
Q

Define stress and urge incontinence

A

• Overactive bladder/urge incontinence - detrusor overactivity
Stress incontinence - Small leaks when coughing or laughing

117
Q

Ix of urinary incont

A

Ix:
• Bladder diary for minimum 3 days
• Vaginal exam to exclude prolapse
Urine dipstick and culture

118
Q

Tx of stress and urge incont

A

Tx - stress:
• Pelvic floor muscle training
• Surgery - retropubic mid urethral tape

Tx - urge:
• Bladder retraining
• Antimuscarinic eg oxybutynin - not in frail elderly

119
Q

S&S of pelvic prolapse

A

S&S:
• Feeling of something coming down
• Pain in vagina, abdomen or back
• Dyspareunia
• Worse after long periods of standing, better on lying down
• Urethrocystocele - incontinence, urgency, Incomplete emptying, retention
Rectocele or enterocele - Incontinence, urgency, incomplete emptying

120
Q

RFs for pelvic prolapse

A
RFs:
	• Age
	• Difficult or protracted Childbirth
	• Increased pressure in abdomen eg obesity or chronic cough
Gyne surgery
121
Q

Tx of pelvic prolapse

A

Tx:
• Watchful waiting
• Lifestyle - lose weight, stop smoking (chronic cough)
• Pelvic floor exercises
• Vaginal pessary
Surgery - hysterectomy, vaginal mesh (chronic pain)

122
Q

Ovarian torsion S&S and ix and tx

A

Ix:
• Pelvic USS

S&S:
• Sudden onset sharp unilateral lower abdo pain
• N&V

tx - laparascopy and fixation of ovary

123
Q

Define primary and secondary amenorrhoea

A

Primary - menses not occurred by age 14 in absence of secondary sexual characteristics or by 16 if secondary characteristics developing

Secondary - Menses stopped after starting for 6 consecutive months

124
Q

Causes of primary amenorrhoea

A

Primary causes:
• Secondary char present:
○ Constitutional delay - no abnormality, just late
○ Genitourinary malformation - malformations of genitals eg absence of uterus or vagina
○ Testicular feminisation - XY but insensitive to androgens
○ Hyperprolactinaemia - hypothyroidism and drugs
○ Pregnancy
• Secondary absent:
○ Ovarian failure eg Turner syndrome
○ Hypothalamic failure due to underweight

125
Q

Causes of secondary amenorrhoea

A
Secondary amenorrhoea causes:
	• Pregnancy
	• Premature ovarian failure 
	• Depot and implant contraception
	• Loss of weight
	• Thyroid disease
	• PCOS
Cushings
126
Q

Ix of amenorrhoea

A
Ix:
	• Examine for signs of excess androgen - hirsutism, balding, acne
	• TFTs
	• Pregnancy test
	• VE
	• Prolactin
	• Total testosterone
	• Pelvic USS - if pt underage avoid VE
	• Karyotyping if suspect turners
127
Q

Pathology of ovarian hyperstimulation syndrome

A

Pathology:
• Ovaries form many follicles following increase in hCG
• Vasoactive mediators released from hyperstimulated ovaries result in capillary permeability
• Fluid shift into 3rd space compartments eg ascites and pleural effusion

128
Q

S&S of OHS

A
S&amp;S:
	• Can be mild to severe
	• Bloating - due to ovarian size or ascites
	• Pleural effusion
	• Hypercoagulability
129
Q

Ix and RFs of OHS

A
Ix:
	• USS of ovaries
	• FBC - haemoconcentration
	• U&amp;E
	• Coagulation screen
	• LFTs
	• CXR

RFs:
• PCOS - use of clomifene
• Age under 30
Low BMI

130
Q

Tx of OHS

A
Tx:
	• Analgesia
	• Anti-emetics
	• Colloid IV if clinically dehydrated
	• Aspiration of 3rd space fluid
131
Q

Commonest cause of vulval swelling

A

bartholins abscess

132
Q

S&S of bartholins abscess tx

A
S&amp;S:
	• Pain
	• Swelling
	• Dyspareunia
	• Unilateral vulval swelling
	• Tender to palpation if abscess

Tx - incision and drainage

133
Q

S&S and tx of atropic vaginitis

A

S&S - vaginal soreness, dyspareunia, vagina looks pale and dry
Tx - topical oestrogens or HRT

134
Q

S&S and Tx of vulval dystrophy. Types

A

S&S - itching and soreness on outside
Hypoplastic (lichen sclerosis):
• 45-60y
• Skin looks atrophic +/- white plaques
Hyperplastic:
• Multiple symmetrical thickened hyperkeratotoic lesions on vulva
Tx - Topical steroids

135
Q

S&S and tx of vaginal intraepithelial neoplasia

A

• S&S - post coital bleeding, abnormal discharge

Tx - local ablation

136
Q

Ix of pelvic pain

A

• Pregnancy teest
• High vaginal swab
• FBCs, CRP
Pelvic USS

137
Q

Gyne acute causes of pelvic pain

A

Ectopic, PID, endometriosis, torsion, dysmenorrhoea, ovarian cyst

138
Q

Gyne chronic causes of pelvic pain

A

Endometriosis, adhesions, fibroids, prolapse, cyst, PID

139
Q

Non gyne causes of acute pelvic pain

A

Appendicitis, colitis, diverticulitis, renal stones

140
Q

Chronic non gyne causes of pelvic pain

A

IBS, nerve entrapment

141
Q

Define endometritis, S&S

A
S&amp;S:
	• Fever
	• Lower abdo pain
	• Uterine tenderness
	• Purulent discharge

Infection of endometrium occurring usually after surgery (IUCD) or childbirth

142
Q

Ix and tx of endometritis

A

Ix:
• High vaginal swabs
• Endocervical swabs

Tx:
• Doxy + metronidazole

143
Q

When is normal labour

A

Between wk 37 to 42

144
Q

Give stages of labour and explain

A

Stage 1 - dilation of cervix up to 10cm. Water break. Lasts 12 hrs

Stage 2 - Passive stage no urge to push. Active stage urge to push. Baby born.

Stage 3 - placenta expelled. circa 15 mins.

145
Q

What tx for delay in stage 1 labour?

A

Delay in stage 1:
• Can induce labour by rupturing membranes
• Offer oxytocin
• If neither work, consider C section

146
Q

Tx for delay in stage 2 labour

A

Delay in stage 2:
• Oxytocin drip
• If not, C section

147
Q

Tx for delay in stage 3 labour and reduce PPH

A

syntometrine IM

148
Q

Indications to induce labour

A

• IUGR
• Prolonged pregnancy - Post 41 weeks
• HTN and pre-eclampsia
Time of delivery in best interests of baby - eg requires cardiac surgery

149
Q

Contraindications to induction of labour

A

Severe placenta praevia, transverse fetal lie, cervix unripe

150
Q

Methods to induce labour

A

• Membrane sweep
• Prostaglandin gel
Oxytocin with/without artificial rupture of membranes

151
Q

S&S and RFs of PROM

A

S&S:
“Popping” sensation with continuous watery liquid draining

RFs of PPROM:
• Smoking
• Previous preterm delivery
Vaginal bleeding at any time of pregnancy

152
Q

Ix for PROM

A

Ix:
• Seeing amniotic fluid pooling in vagina after 30 mins of lying down
• USS
DON’T EXAMINE VAGINA - increases risk of ascending infection, early signs of which are fetal tachycardia and mild increase in maternal temp

153
Q

Cx of PROM

A

Cx:
• PPROM - Prematurity, sepsis, pulmonary hypoplasia
• Umbilical cord prolapse
Placental abruption

154
Q

Tx of PROM

A
Tx:
	• Hospital admission
	• PPROM - erythromycin
	• Antenatal steroids if preterm
Women shouldn’t exceed 96 hours following ROM as infection risk increases
155
Q

Complications of C section

A
Complications:
	• Post partum hemorrhage
	• Bladder injury
	• Lung aspiration
	• Pulmonary embolus
	• Infection
156
Q

Indications for c section

A
Indications:
	• Malpresentation eg breech
	• Placenta Praevia
	• Cephalopelvic disproportion
	• Pre-eclampsia
	• Fetal distress
	• Failed induction of labour
Maternal request IS NOT an indication
157
Q

Indications for assisted delivery

A
Indications:
	• HTN
	• Tired and need help
	• Fetal distress
	• Premature baby
	• Breech delivery
158
Q

Cx of assisted delivery

A

Cx:
• Episiotomy may be needed
• Injury to anatomical structures
• Shoulder dystocia

159
Q

S&S of placental abruption

A

S&S:
• Painful vaginal bleeding. Placenta praevia is painless
• Hard palpable uterus due to retroplacental blood tracking into myometrium.
• Shock out of keeping with visible loss
• Constant pain
• Tender tense uterus
• Fetal heart absent or distressed
• DO NOT PERFORM VE AS MAY BE PRAEVIA

160
Q

Tx of placental abruption

A

Tx:
• Fluid resuscitation
• Urgent delivery when baby stable

161
Q

S&S of breech position

A

S&S:
• Subcostal tenderness
• Ballotable head in fundus area
Fetal heartbeat loudest above umbilicus

162
Q

Ix for breech and Cx of vaginal delivery

A

Cx of vaginal delivery:
• PROM
• Cord prolapse
Fetal head entrapment

Ix:
USS if breech persisting post 35 wks

163
Q

Tx of Breech position

A
Tx:
	• Pre 32-35 wks - no tx necessary
	• 36 weeks offer - 
		○ External cephalic version - lifting of fetal bottom with one hand and pushing head with other. Contra is abnormal CTG, ruptured membranes.
C Section
164
Q

Non pharm Analgesia in labour

A

Non pharm:
• Massage
• Temperature
Transcutaneous electrical nerve stimulation

165
Q

Pharmaceutical analgesia in labour

A

Oral:
• Pethidine

Nitrous oxide and oxygen:
• Entonox - Gas and air

Epidural analgesia:
• Highly effective

Local analgesia:
• Pudendal nerve block
• Perineal nerve infiltration

166
Q

Side effects of epidural analgesia

A

May cause dizziness, shivering, hypotension, or delay 2nd stage of labour

167
Q

Causes of polyhydramnios

A

Amniotic fluid produced by fetal kidneys and maternal plasma. Absorbed by fetus’ GI system and swallowing. Therefore polyhydramnios can be cause by:
• Fetal swallowing problem - eg atresia of upper GI, fetal hypoxia, neuromuscular abnormalities
• Excess Fetal urination - eg. fetal hyperglycaemia caused by GDM
Lack of Absorption via GI system

168
Q

S&S and ix of polyhydramnios

A

S&S:
• Presents as uterus large for date
• Fetal parts difficult to palpate

Ix:
• USS

169
Q

Oligohydramnios causes

A

Fetal causes:
• Chromosomal abnormalities
• IUGR
• Fetal demise

Placental causes:
• Abruption

Maternal causes:
	• Dehydration
	• HTN
	• Pre-eclampsia
	• Diabetes
170
Q

Ix of oligohydramnidos

A

Ix:
• BP and BM
• Test for SLE
• USS

171
Q

Types of prolapsed cord

A

Overt cord Prolapse:
• If presenting part of fetus doesn’t fit pelvis snugly after membrane rupture, there is a risk that the umbilical cord can slip past fetus and become compressed
This compromises fetal circulation and is an emergency

Occult cord prolapse:
Umbilical cord lies alongside presenting part

172
Q

S&S and RFs of prolapsed cord

A
RFs:
	• Prematurity
	• Breech
	• Oblique, transverse and unstable lie
	• Low lying placenta

S&S:
• VE can see overt cord prolapses
• Abdo exam - ill fitting presenting part alert to possibility of prolapse
• Variable fetal heart rate decelerations
• Fetal Bradycardia if complete compression

173
Q

Tx of prolapsed cord

A
Tx:
	• Overt prolapse:
		○ O2 to woman
		○ Place women in knee chest position and push fetus away from prolapsed cord
		○ Immediate C section
	• Occult prolapse:
		○ Woman in left lateral position
		○ If fetal heart remains abnormal - C section
174
Q

Causes of shoulder dystocia

A

3Ps - Power, passenger, pelvis
• Power (uterus) - Unco-ordinated contractions from primigravid mothers
• Passenger (fetus) - Lie of fetus, Macrosomia
Pelvis - Oval brim

175
Q

Cx of shoulder dystocia

A
Cx:
	• Brachial plexus injuries
	• Pneumothorax
	• PPH
	• Cervical tears
176
Q

RFs and Tx of shoulder dystocia

A
RFs:
	• GDM
	• Fetal macrosomia
	• Maternal obesity
	• Prolonged labour
	• Previous shoulder dystocia

Tx:
• Prevention:
○ Offer C section if GDM and fetal macrosomia
• Stop mother pushing. McRoberts maneuver. Episiotomy

177
Q

Patho of foetal hydrops

A

Patho:
• Abnormal fluid accumulation in 2+ fetal compartments
• Eg ascites, pleural effusion, pericardial effusion, skin oedema
Either immune (rhesus blood related) or non immune. Immune 90% of cases

178
Q

Causes of foetal hydrops

A

Causes:
• Haem - haem disease of newborn, Alpha thalassaemia, fetal hemorrhage
• Cardiac - Aortic stenosis, coarctation of aorta
Infective - TORCH syndrome

179
Q

Ix for foetal hydrops and tx

A
Ix:
	• Indirect Coombs test
	• USS of fetus + placenta
	• Echo for fetal arrhythmia
	• Fetal karyotyping

Tx:
• Inform parents to help decide if pregnancy should be continued
• Complicated tx..

180
Q

Ix for small for age babies

A

Ix:
• Symphysis fundal height charts - serial measurements reveal little to no growth week on week.
• Refer for USS

181
Q

1st appt for prengnacy - when, what discuss, what do?

A

1st appt - Topics:
• Discuss lifestyle choices ie smoking, alcohol etc.
• Measurement of BP, weight, BMI, proteinuria
• Screen for:
○ Anaemia
○ Red cell allo-antibodies
○ Hep B, HIV, syphillis, Rubella, chlamydia
○ Sickle cell and thalassaemia
○ Gestational diabetes if RFs
• Screen neonate for:
○ Downs, edwards, and pataus done via nuchal translucency measurement
○ USS at 18 weeks for abnormalities

182
Q

Causes of abnormal vaginal discharge

A
Causes of abnormal discharge:
	• Excess normal secretions
	• Bacterial vaginosis
	• Candida albicans
	• Cervicitis - chlamydial, herpetic, gonococcal
	• Trichomatis vaginalis
183
Q

Qs to ask vaginal discharge

A

Hx:
• Sx - itchy, offensive, colour, duration, vulval soreness, abdo pain, menorrhagia, fever, bleeding
• Sexual hx - recent new partner, multiple partners, protection
• Medical hx - pregnancy, diabetes, abx

184
Q

Ix of vaginal discharge

A

Ix:
• Check pH on pH paper - >4.5 BV or TV likely. <4.5 candida or physiological
• High vaginal swab for BV, TV, or candida
• Endocervical swab for gonorrhoea and chlamydia
• Viral swab for herpes

185
Q

S&S and tx of bacteria vaginosis

A

S&S:
• Thin, fishy smelling, offensive discharge with no soreness
• pH secretions >4.5

Tx:
• Metronidazole

186
Q

S&S, ix and tx of candidiasis

A

S&S:
• Superficial dyspareunia
• Pruritic vulvae
• Thick creamy discharge, non offensive

Ix:
• High vaginal swab

Tx:
• Oral flucanazole

187
Q

S&S of chlamydia, tx and ix

A

Ix men:
• Urine testing for chlamydia

* Male - none, sometimes discharge, dysuria
* Female - usually none, lower abdo pain, intermenstrual bleeding

Tx:
• Doxycycline

Ix female:
• Endocervical swab

188
Q

S&S gonorrhoea

A
S&amp;S - women:
	• Vaginal discharge
	• Lower abdo pain
	• PID
Abscess of bartholins gland

S&S - men:
• Urethral discharge, dysuria, prostatitis
Rectal infection - anal discharge, discomfort

189
Q

Tx of gonorrhoea

A

Tx:
• Ceftriaxone
• Contact tracing

190
Q

Trichomonas vaginalis S&S`

A
Women - S&amp;S:
	• Vaginal discharge - frothy, smelly, mucopurulent
	• Abdo pain
	• Dysuria
	• Vulvovaginal soreness/itching

Men - S&S:
• Dysuria
• Urethral discharge

191
Q

Ix of trichomonas vaginalis

A

Ix: women
• pH >4.5
• High vaginal swab

Ix: men
• Urethral swab
• First void urine for culture

192
Q

Tx of TV

A

Tx:
• Contact tracing
• Metronidazole

193
Q

S&S of hep b and c

A
HBV and HCV - S&amp;S:
	• Fever
	• Malaise
	• Dark urine
	• Pale stools
	• jaundice
194
Q

Ix of hep b and C, and tx

A

Ix:
• LFTs
• Hepatitis serology

Tx of both:
	• Avoid alcohol
	• Acute illness - supportive
	• Chronic - interferon and lamivudine
	• Immunise (no vaccine for hep c)
195
Q

Patho of chorioamnionitis

A

Patho:
• Acute inflammation of foetal amnion and chorion membranes
• Due to ascending infection

196
Q

S&S and tx of chorioamnionitis

A

S&S:
• Uterine tenderness
• ROM with foul odour (can occur with intact membranes)
• Maternal signs of infection - tachycardic, pyrexia

Tx:
• Prompt delivery via C section
• IV abx

197
Q

Obstetric cholestasis S&S and tx

A

S&S:
• Pruritis worse on palms, soles, and abdomen

Tx:
• Ursodeoxycholic acid
• Vit K supplement

198
Q

How much folic acid do normal pregancies need? Epilepsy?

A

Take Folic acid 5mg in epileptic, normally 400 mcg