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246 Cards in this Set
- Front
- Back
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In what week of pregnancy do the 3 primary germ layers form?
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Week 3 |
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What do each of the 3 primary germ layers give rise to?
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Ectoderm: Nervous system, Skin epidermis Endoderm: Epithelial lining of respiratory, digestive and urogenital tract Mesoderm: Everything else |
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How many trimesters of pregnancy are there? Outline time frames |
3 trimesters Trimester 1 = 3 months Trimester 2 = 3 months Trimester 3 = 3.5months |
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What are the female anatomical adaptations to pregnancy
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-Reproductive organs become engorged with blood -Pigmentation of facial skin - known as chloasma -Uterine enlargement -Pelvic ligaments and pubic symphysis relax, widen and become more flexible (due to placental production of relaxin --> causes ligaments to relax) -Weight gain -Breasts engorge with blood and areolae darken as a result of increased estrogen and progesterone |
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What are the Metabolic Maternal adaptations to pregnancy
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Placenta enlarges and secretes hPL (human placental lactogen) which: - Promotes growth of the fetus -Combined with Estrogen and Progesterone, stimulates maturation of breasts for lactation - Exerts glucose sparing effect in mother causing maternal cells to metabolise more fatty acids and less glucose than normal Placental also secretes hCT - increases rate of maternal metabolism |
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What are the maternal physiological adaptations during pregnancy
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GI: Nausea until they adjust to elevated progesterone and estrogen, Heartburn, constipation (decreased GI tract motility during pregnancy) Urog: Increased production & frequencyof urine Resp: Increased TV and RR, decreased RV, Dyspnoea (later on) CV: Total body water increases, increased blood volume (by 20-40% by 32nd week), increased CO, Varicose veins (due to uterus pressing on pelvic blood vessels) |
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What are Braxton Hicks contractions?
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Also known as 'false labor' Sporadic uterine contractions (of the myometrium) that sometimes occurs Begin as early as the second trimester but usually experiences in the third trimester Thought to aid the body in preparation for birth They are infrequent, irregular and involve only mild cramping |
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What serotypes of HPV are implicated in cervical cancer? |
Serotypes 16 & 18 (also small portion ~10% caused by types 31 & 45) |
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What serotypes of HPV are implicated in causing genital warts? |
Serotypes 6 & 11 |
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Describe what CIN I, II and III is |
In terms of cervical histology CIN 1 (LSIL) - mild dysplasia or abnormal growth confined to basal 1/3 of epithelium CIN 2 (HSIL) - moderate dysplasia confised to the basal 2/3 of the epithelium. Koilycytes indicated HPV infection CIN 3 (HSIL) - severe dysplasia that spans more than 2/3 of the epithelium 'in situ'. Koilocytes + dysplasitc cells. Show keratin whorls. |
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Can CIN 2/3 revert back to normal histology? |
Yes - only approximately 20-30% can. Unlikely to do so though. |
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What are the risk factors for developing cervical cancer? |
Smoking Estrogen exposure - Early menarche, late menopause, HRT, OCP Family History Previous abnormal pap smear Nulliparity Multiple sex partners (HPV transmission) Immunosupression Unprotected sex |
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What are the clinical features of cervical cancer? |
Symptoms - Irregular vaginal bleeding - post coital, intermenstrual - Previous abnormal Pap smear (LSIL, HSIL) - Unsuually heavy vaginal discharge - Pelvic pain and dysuria - Can be asymptomatic Signs Gross Lesions: - Excophytive - friable growth Ulcerative - erodes cervix |
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Describe Cervical Cancer Staging. |
Stage 0: Carcinoma in situ. Stage 1: Carcinoma confined to the cervix Stage 2: Carcinoma extending beyond the cervix but not intol pelvic wall. Carcinoma involves vagina but not lower 1/3 of vagina Stage 3: Carcinoma extends into pelvic wall and lower 1/3 of vagina. Rectal examination: no cancer free space between tumour and pelvic wall Stage 4: Carcinoma extended into pelvis or has involves mucosa of bladder or rectum. Metastases. |
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What is the management for cervical neoplasia? |
Early invasive cancers: CONE BIOPSY Most invasive cancers are treated with radical hysterectomy with LN dissection (+/- chemotherapy/radiation) Brachytherapy now used |
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What is the advantage of brachytherapy over chemotherapy? |
Brachytherapy is a highly concentrated radiation source is placed inside your body close to the cancer. This means the radiation will be less likely to affect the surrounding organs. |
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What are some preventative measures for cervical cancer? |
-Using barrier method contraception - i.e. condoms (doesn't prevent against genital warts though) -Regular pap smears every 2 years (from 18 years or 2 years after first sexually active - which ever is later) - Diagnosis and removal or precancerous lesions - Surgical removal of invase cancers +/- chemotherapy/radiation - HPV vaccination |
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Who receives the HPV Vaccine and how is it given? |
Gardasil Girls 11-12 years of age (catch up vaccination aat 13-18 years) Given IM injection with 3 doses at 0,2 & 6 month intervals |
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What are the current guidelines for pap smear screening? |
Done every 2 years for all women 18-70years who have had sex & have an intact cervix Screening begins at 18 years or 2 years after 1st sexual activity (which ever later) Women who have never been sexually active do not need a pap smear Women who are >70yrs who have never had a pap smear or who request one should be screened May stop age 70yrs for women who have had 2 normal pap smears within the last 5 years |
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What is the management pathway for HSIL/LSIL result from pap smear? |
HSIL - refer for colposcopy LSIL >30 yrs and no abnormal smear - offer repeat pap in 6 months or immed. colposcopy <30 years - repeat pap in 12 months (if normal can return to normal 2 yearly screening, if still abnormal refer for colposcopy) |
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Explain the process of colposcopy to a patient. |
Colposcopy is a procedure done by specialist. Use a speculum to visualise the cervix. Under high magnification, Vinegar sprayed onto the cervix and any abnormal area will stain white. Then iodine solution applied - any abnormal areas will not stain dark brown. If any abnormal areas, biopsies will be taken, You may need to have another procedures following results. Follow up: Pap smear + colp @ 6 mnths, Pap smear + HPV test @ 12mnths, Pap smear + HPV test @ 12mnths Risks: Infection & Bleeding |
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Explain LLETZ procedure vs. Cone Biopsy |
LLETZ - Normally done under local anaesthetic. Risks: bleeding, infection, potential cervical incompetence. Safe and effective. CONE BIOPSY- Requires GA. Greater risk of bleeding and cervical incompetence. Large amount of tissue taken. Only indicated when: - Cancer is very likely - Abnormality up the cervical canal and not fully visible - Suspected glandular abnormalities |
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What is the new vaccine for Cervical Cancer? |
Cervarix Not on the PBS Covers HPV 16& 18 plus additional cross immunity for 31+45 Still not protective against genital warts. Approved for females aged 10-44years |
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How does endometrial cancer usually present? |
Post menopausal bleeding. (single or recurrent episodes) |
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What is the main histological type of endometrial cancer? |
Adenocarcinomas |
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What are the risk factors for endometrial carcinoma? |
- Prolonged Estrogen Exposure - early menarche, late menopause, amenorrhoea - Nulliparity - OCP/HRT + Tamoxifen use (unopposed) - Increasing age - Family history - Obesity - PCOS - Diabetes |
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What are the appropriate invesitgations for suspect endometrial carcinoma |
Gold Standard: Endometrial curettage ( via pipelle) - office aspiration usually sufficient Hysteroscopy - identifies other causes of PMB i.e. fibroids ect Sonography - endometrial thickness of >5mm (post menopausal) or 12mm (for premenopausal) increases chances of malignancy |
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What are the main types of endometrial carcinomas? |
Type 1: Usually result of unopposed estrogen therapy. 70% of cases. PTEN mutation. Usually arises in setting of endometrial hyperplasia (atypical) Type 2: Usually occur in women a decade later than type 1. Poorly differentiated (stage 3). 15% of cases. Estrogen is NOT a strong risk factor. Mutation of p53 supressor gene. Often have spread outside uterus at time of diagnosis. Generally poorer prognosis. Usually arises in setting of endometrial atrophy |
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Outline the Grading/Staging for endometrial carcinoma. |
Grade 1: Well differentiated. Easily recognisable glandular pattern. Grade 2: Moderately differentiated. Well formed glands with solid sheets of malignant cells. Grade 3: Poorly differentiated. Mainly solid growth with bare recognisable glands, atypia *risk of cancer highest in atypic hyperplasia |
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What are the clinical features of endometrial carcinoma? |
Irregular, heavy or post menopausal bleeding Watery vaginal discharge (uncommon) Uterine enlargement, palpable mass (if spread to broad ligament), +/- regional LN involvement Later: metasastes to lung, liver bones & other organs. Bowel and urinary tract obstructions, SE of radiation/chemo, psychological complications (loss of self esteem, fear of pain/dying) |
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Outline the management of Type 1 Endometrial Carcinoma |
1. Surgery - total hysterectomy (cervix and uterus) + Bilateral oophorectomy 2. +/- chemotherapy/radiation therapy 3. +/- Hormone therapy - medroxyprogesterone acetate 4. Hormone Replacement Therapy post surgery |
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If the portion of endometrial cancers is low, why do they account for more deaths? |
Because they are silent growing and are often detected late. Also requires extensive surgery and chemotherapy. |
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What is the 5 year survival rate for ovarian cancer? |
Under 25 %. In more than 70% of cases, growth spread byeond ovaries by time of diagnosis. |
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What are the 2 types of ovarian neoplasms? |
1. Cysts - benign, younger women (20-40 years) - 80% of cases 2. Solid tumours - malignant, older women (>40 years) - 20% of cases |
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What are the risk factors for ovarian cancer? |
- BRCA1 mutation - Family history of breast or ovarian ca. - Nulliparity - Inferility - Early menarche, late menopause *OCP is protective! reduced risk by 50% if >5 years of use *Multiparity is also protective |
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What are the clinical features of ovarian cancer? |
Asymptomatic for long time Consitutional: night sweats, weight loss, loss of appetite Increasing abdominal distension Pressure sx: Constipation or urinary frequency Pelvic mass (hard, fixed) Ascites Enlarged supraclavicular LNs, Pleural effusion Irregular menses if premenopausal |
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What are the appropriate investigations for suspect ovarian cancer? |
- USS, CT or MRI of pelvis - CXR + Full body CT/MRI for mets - Ca-125 blood test (mainly for follow up testing of treatment efficacy) - Pelvic laparotomy +/- biopsy |
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Is there any screening tests available for ovarian cancer? If so, what are they? |
No effective screening mechanism. Screening only in high risk population: - Ca-125 - TVS (trans-vaginal sonogram) - Pelvic examination in post menopausal women |
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What is the appropriate management of ovarian cancer? |
1. Surgery: removal of malignant tissues including omentum - Removal of uterus (total hysterectomy) - Bilateral salpingo-oophorectomy) - Partial/complete removal of omentum - Examination, biopsy or removal of LNs 2. Secondary management: Combination chemotherapy (paclitaxel + carboplatin) -->Alternative chemo = cyclophosphamaide + cisplatinum 3. Follow up - every 3 months for 2 years, then every 6 months (sx, signs, imaging & tumour markers) |
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What are the complications of an ovarian cyst? |
- Ovarian torsion - Cyst rupture - Bacterial infection of the cyst - Chance of malignancy |
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What is the most common type of vulvul/vaginal cancer? |
Squamous Cell Carcinoma |
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What is VIN and how is it managed? |
Vulvular intraepithelial neoplasia Is benign and in some women disappears without treatment Mx: - Best treatment unknown - Can watch expectantly or local resection - Needs follow up as 1/3 of women have recurrent disease |
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What are the risk factors for Vulvular carcinoma? |
Smoking HPV Vulvular dystrophy (lichen sclerosis) Immunodeficiency |
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What is the usual clinical presentation of vulvular carcinoma? |
-Usually occurs in elderly & post menopausal women - Usually SCCs -Starts as a lump or ulcer on one labia minora/majora (hard nodules or ulcer with sloughing base and raised edges) -LN involvement in 50% of cases ! -Vulvular itching for months-years |
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What is the appropriate management of a vulvular carcinoma? |
- Vulvectomy with dissection of Inguinofemoral LN or radical vulvectomy *Overall 5 years survival is 70% |
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What are the complications of a vulvectomy? |
1. Wound necrosis 2. Persistent leg oedema (20%) |
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What is the typical clinical presentation of vaginal cancer? |
-Very rare -Usually post menopausal women -More commonly seen as an extension of cervical cancer - Most are secondary cancers from endomet., colon, rectum, ovaries, vulva - SCCs - Present with abnormal bleeding |
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What is the appropriate treatment of vaginal cancer? |
Upper vaginal: Partial/radical vaginectomy +/- total hysterectomy Lower vaginal: Radiotherapy *5 year survival = 45% |
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What are the risk factors for fallopian tube carcinoma? |
Chronic inflammation/infection of tubes ?Genetics |
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What are the clinical features of fallopian tube carcinoma? What are the appropriate investigations for this type of cancer? |
Clinical Features: -Vaginal bleeding, discharge & pelvic pain -Pelvic mass -Ascits (only in 15% of cases) Ix: -Pelvic USS - Pelvic examination - Exploratory laparoscopy |
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What is the treatment for fallopian tube carcinoma? |
Surgery + chemotherapy - Bilateral salpingo-oophorectomy with total hysterectomy with omentectomy (removal of CT folds) |
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What are the general characteristics of a fallopian tube carcinoma? |
- Acts essentially as ovarian tumour - Mean age 55-60 years - Majority are papillary serous adenocarcinomas - Very uncommon |
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What is a choriocarcinoma? What hormone do they increase? |
High grade malignancy of trophoblastic cells (placenta) in the uterus derived from a previous pregnancy - Beta GCG ( carcinomas include syncytioblasts which produce beta hCG) |
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In what settings do choriocarcinomas usually form after? |
- Hydatidifrom mole (50%) - Previous abortion (25%) - Normal pregnancy (22%) - Ectopic pregnancy (3%) |
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What is the typical characteristic (diagnostic) findings of a choriocarcinoma? |
1.Very very high beta-hCG PLUS 2.Absent fetal heart/other signs of life |
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What are the clinica features (sx) of a choriocarcinoma? |
- Brownish,bloody vaginal discharge + rising beta hCG - Unevenly enlarging uterus - Abdominal/pelvic pain - Widespread metastases (LUNGS, brain, liver, kidney, vagina) |
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What are the appropriate investigations of a suspected choriocarcinoma? |
Bloods- FBC, UCE, LFT, B-hCG USS - Abdo/pelvis, absent fetal heart sounds, vesicular filled structures CT/MRI - mets exploration |
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What is the treatment for choriocarcinoma? |
1. Chemotherapy - ++ sensitive, 90-95% cure/remission rate even with metastatic disease 2. Surgery - hysterectomy (usually offered to >40 years) |
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What are some psychological effects of gynaecological cancer and their subsequent treatment? What are some strategies to reduce psychosexual concerns? |
- Unable to have children post surgery - Decreased/absent sexualy drive, reduced vaginal lubrication - Many women become depressed! - Partner may have difficulty accepting 'mutilated ' partner - May feel like sexual intercourse may cause damage 1. Pre-operative explanation of effects of surgery & radio/chemotherapy 2. Sexual counselling for both partners 3. Use of estrogen vaginal creams |
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What is the most common age group for STIs? What are the most common STI's? What ethnic population has the highest rates of STI's? |
15-30 years age group 1.Genital warts 2. Herpes (HSV) 3. Chlamydia +/- Gonorrhoea, Vaginitis (Bact, Trich, Candidiasis), Hepatitis B, Syphillis, HIV, Donovanosis, Lymphogranuloma venerum The Indigenous population |
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What are the common clinical presentations of STIs and describe what symptoms they usually are accompanied with? |
Urethritis: dysuria, discharge Vaginitis: dyspareunia, irritation, discharge, odour Cervicitis/PID: Pelvic/back pain, mild discharge, mucopurulent discharge, dysuria, dyspareunia Ulcers: HSV, Syphillis, Donovanosis Lumps(warts): Genital warts (condylomata acuminate) or Secondary Syphilis (condylomata lata) Pruritis/Rash Extra-genital STIs - Hepatitis, HIV |
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What are the differential diagnoses for genital warts? |
Skin tag, sebaceous gland/cyst, condylomata late (syphilis), pearly penile papule, molluscum contagiosum, seborrhoeic keratosis, lichen sclerosis/planus |
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What are the differential diagnoses for genital ulcer? |
Infectious: Herpes/Syphilis (primary chancre)/Donovanosis/LGV/chancroid Trauma: mechanical/chemical Allergic: Fixed drug eruptions, generalised rxn Neoplastic: premlaignant/,malignant lesions (SCC) Secondary: Infections, dermatosis, lichen sclerosis Other: Bechet's, pemphigoid, pemphigus, rieter's |
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What are the 5 P's of a sexual history? |
1. Partners - how many in how long 2. Practices - vaginal, oral, anal sex 3. Previous STI's 4. Prevention of STI's 5. Prevention of pregnancy |
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What are the 3 C's of HIV Antibody Testing? |
1. C - Consent 2. C - Confidentiality 3. C - Counselling |
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What is the organism responsible for Chlaymdia? How is it contracted? |
- Chlamydia trachomatis - Spread by vaginal, oral or anal sex + can be passed from mum to baby during childbirth |
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What are the clinical features of chalmydia (in female & males)? |
- ~50% are asymptomatic! - Males: urethritis, epidymitis, prostatitis, whitish/yellow D/C from penis, dysuria, irritation/soreness around urethra - Females: cervicitis, PID, Salphingitis, dysuria, CLEAR WATERY DISCHARGE (mucopurulent), dyspareunia, pelvic pain, intermenstrual spotting - Children - conjunctival chlamydia --> conjunctivitis causing TRACHOMA (scarring of eyelid/cornea - May also cause pneumonia |
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What are the complications of chlamydia if left undx/untreated? |
Females: Infertility, PID, Scarring of Fallopian tubes Males: Infertility, epididymitis, prostatitis May cause Reiter's syndrome |
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What is Reiter's Syndrome? |
Reactive arthritis Triad of: 1. Inflammatory polyarthritis 2. Conjunctivitis 3. Urethritis |
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What are the necessary investigations for chalmydia? |
Urine (first catch) for PCR (male & female) Females: Endocervical & high vaginal swab Males: Anterior urethral swab Throat swab if 'high risk' (from oral sex) Tests: PCR (75-95% sensitive), immunofluorescence, Antigen Detection Test (ELISA, DFA), Chlamydia culture (reticulate bodies in pap smear) |
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What is the Treatment of Chlamydia? What further steps should be taken? |
Azithromycin 1g one dose orally OR Doxycillin 100 mg orally 12 hourly (bd) for 7 days Advise about safe sex & spread of infection PLUS contact tracing |
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What are the clinical features of Gonorrhoea? What is the causative organism? |
Men: acute urethritis with dysuria and purulent (greeny) discharge Women: endocervical infection with increased vaginal secretions, purulent discharge and intermestrual bleeding (PID & inferility if untx) May be asymptomatic in women (major reservoire for disease) May also infect non genital sites: rectum oropharynx & eyes Neisseria gonorrhoea |
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What are some complications of gonorrhoea infection? |
Urethral stricture Spread Urinary retension PID Occular infections Neonatal conjunctivitis |
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Investigations for Gonorrhoea |
Male: Urethral swab Women: Endocervical swab First catch urine PCR GRAM STAIN: show intracellular gram negative, kidney shaped diplo-cocci |
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What is the treatment/management steps for Gonorrhoea? |
Ceftriaxone 250mg IM - Preferred over ciprofloxacin 500mg/Ampicillin/amoxicillin due to pencillin resistance Contact tracing! |
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What is the causative agent in genital herpes? What does the other type usually cause? |
Herpes Simplex Virus type 2 HSV 1 usually causes cold sores however there is increasing incidence of genital lesions caused by type 1 |
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What are the clinical features of Genital Herpes? |
Commonly aysmptomtic Can get closely group vesicles on the genitals surrounded by erythema, itchy Vesicles can burst and cause painful ulcers Clusters of inflamed papular, vesicles and ulcers on outer surface of genitals May have flu-like illness Latent infection if virus invades local sensory nerve endings Recurrence common - same dermatome as previously |
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What are the investigations for Genital Herpes? |
-Viral isolation from vesicle fluid (pop and swab) and send for PCR - Srapings from base of vesicle = tzanck smear - Pap smear |
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What is the treatment/management of genital herpes? |
Valaciclovir 500mg orally 12 hourly (bd) for 5 days (use due to less frequent dosing) Aciclovir 400mg orally tds (8hrly) for 5 days Famiciclovir 250mg orally tds for 5 days |
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How do you treat reactivation/recurrences of genital herpes? |
Episodic Treatment: - Treatment must be initiated within 2 days of lesion onset or during prodrome preceing some outbreaks - Same as acutely: Valacilovir 500mg bd PO for 3 days - Should provide supply of prescription or drug to patient - No evidence that episodic treatment alters symptoms and duration of future episodes Initiate supressive treament - decreases recurrences by 50% |
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What is the supressive treatment use for Genital Herpes? |
Valaciclovir 500mg PO once daily for 6 months (reasses at 6 months) OR aciclovir 400mg orally bd for 6 months (reasses at 6 mnths) |
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What virus and serotypes of this virus are the cause of genital warts? How are genital warts transmitted? |
Human Papilloma Virus Serotypes 6 &11 cause genital warts Transmitter by skin-skin contact and by inanimate objects |
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What are the clinical features of genital warts? |
Incubation periods nearly 3 months Most cases are asymptomatic Clear infection rapidly - but can transmit Painless, fleshy warts, cauliflower-like epithelial growth Women: appear on vulva, vagina, cervix, post coital bleeding, abnormal vaginal discharge Men: appear on penis, pubic area, around the anus, or on the testicles Often accompanied by: itching, burning, tenderness and irritation |
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What are the invesitgations for genital warts? |
Pap smear & Biopsy - presence of koilocytes HPV DNA detection (hybrid capture test) - used as an adjunct to pap smear |
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Outline the management of genital warts. |
Podophyllin (gel/cream) : - Physician applied 10-25%, wash off after 4 hours, use weekly - Patient applied (0.5% condolyine paint, use 3 day cycles) Aldara (Imiquimod) - clears 1/3 men, 2/3 women Cryotherapy Surgery - excision -Counselling - recurrence ect - Refer if warts = excessive, refractory, in the cervix or on rectal mucosa - Prevention - HPV vaccine (3 inj. over 6 months) |
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What is the causative agent of syphilis and how is it transmitted? |
Treponema pallidum. Transmission: - Sexual (esp. homosexual activity) - Transplacentally (congenital syphilis) - Blood contamination - i.e. IVDU - Direct contact with infected lesions |
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Outline clinical features of syphilis |
Primary - primary chancre(firm red pimple --> develops into clean punches out ulcer + LNs (inguinal lymphadenitis). If untreated resolves within 4 weeks Secondary - 2-8 weeks post initial clearance.Maculopapular rash, painless LNs & condylomata lata (painless, broad based moist warty growths in skin folds - very infectious) Latent - months - 2 years, positive serology w/o signs or sx Tertiary: Gumma often occurs in testis, Occurs after 2 years & involves CV and Neuro symptoms |
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What are the invesitgations for syphilis? |
Non-Treponemal tests: - RPR + VDRL but give false +'ve Treponemal tests: - Treponema pallidum hemagglutination assay (TPHA) - Fluorescent teponemal anibody absorption (FTA-ABS) Definitive diagnosis: detection of T pallidum on 1. Dark field microscopy 2. PCR |
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What is the management/treatment for syphilis? |
Benzathine Pencillin 1.8g IM as single dose OR Procaine pencillin single dose IM for 10 days |
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When is it appropriate to test for syphilis in pregnancy? What are the symptoms of congenital syphilis to be wary of and how do you treat it? |
-Test for syphilis at first antenatal visit -Then again at 28 weeks for 'high risk' women - Pregnant women treated with pencillin Congenital Syphilis: - Increased risk of miscarriage,prematurity, still born, infant death - Deformities, developmental delay, seizures - Fever, rash, hepatosplenomegaly, anemia, jaundice - Tx: 50mg/kg IV benzylpencillin 12hrly for 10 days |
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What are the causative agents of vaginitis? |
1. Candida albicans (thrush) 2. Gardnerella vaginalis (bacterial vaginosis) 3. Trichomonas vaginalis (trichomoniasis) |
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What is bacterial vaginosis? What are the clinical features of BV? |
Caused by overgrowth of mixed flora (replaced normal flora) in the vagina: Overgrowth of: Gardnerella vaginalis, bacteroides, mycoplasma hominis Loss of acidity and altered/absent lactobacili CF: Grey/white profuse discharge, pruritis, dyspareunia, dysuria, fishy odour of discharge (amine wiff test) |
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How is BV diagnosed/What are the investigations for BV? |
AMESELs DIAGNOSTIC CRITERIA 1. Alkalinity of secretions (vaginal pH >4.5) 2. >20% clue cells present on microscopy White homogenous discharge 3. Amine whiff test positive - fish odour 4. White homogenous discharge 3/4 need to be present to confirm diagnosis Ix: High vaginal swab M/C/S - wet film microscopy, gram stain shows 'altered flora' and 'clue cells' |
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What is the treatment of BV |
Metronidazole 400mg bd for 5 days - Contraindicated in pregnancy/CNS disease!! - In pregnancy: Clindamycin 300mg PO bd for 7 days Can also use: - Clindamycin 2% vaginal cream 1 applicatorful (PV) @bedtimefor 7 nights (careful in 1st trimester) -Metronidazole 0.75% vaginal gel 1 applicatorful PV at bedtime for 5 nights BV can cause PPROM & Preterm labour** |
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What is the causative organism for Trichomoniasis? What are the clinical features of Trichomoniasis |
Trichomonas vaginalis Sx: Frothy green discharge Pruritis, dyspareunia Pelvic pain Straberry vagina (uncommon) |
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What are the investigations for Trichomoniasis? What is the management for Trichomoniasis? |
Ix: -High vaginal swab for PCR -Gram stain to rule out other cases of vaginitis Mx: -Screen for other STIs (concurrent infections in 1/5) - Metronidazole 2g orally single dose (or Tinidazole 2g stat PO) |
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1. What are the clinical features of Donovanosis? 2. What population is this most commonly seen in? 3. What is the causative organism? 4. What are the appropriate investigations? 5. What is the treatment? |
1. Painless, oozing and progressively disfiguring genital ulcers 2. Indigenous populations in the NT and WA (Aust) 3. Klebsiella granulomatis (previously known as Calymmobacterium granulomatis) 4. Swab of ulcer/ microscopy of scrapings (giemsa stain --> shows Donovan bodies), PCR also option but not always available 5. 1gram Azithromycin PO, once weekly for minimum of 4 weeks by DIRECTLY OBSERVED THERAPY) OR.... Doxycycline 100mg PO, 12 hrly for minimum 4 weeks, if lesions haven't healed by 6 weeks->biopsy |
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What are the typical clinical features of HIV/AIDS? What are appropriate investigations? |
- Fever, weight loss, diarrhoea, generalised lymphadenopathy, multiple opportunistic infections, neurological disease, secondary neoplasms (Kaposi's sarcoma) - HIV serology (HIV-Ab by ELISA, usually confirmed by western blot) - repeat at 6 weeks/3 months due to window 1-3 weeks after exposure where antibodies may not have been developed yet (or test HIV RNA or core P24 antigen in plasma). CD4 count - used for staging and guide treatment/monitoring |
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What is the treatment for HIV/AIDS |
Antiretroviral drugs: - Initial: at least 3 drugs - 2 nucleoside/nucleotide reverse transcriptase inhibitors (emtricitabine + tenofivir) PLUS either 1. A non-nucloside reverse transcriptase inhibitor (efavirenz or nevirapine) OR 2. Protease inhibitor (atazanivir + ritonavir OR lopinavir + ritonavir Or fosamprenavir+ritonavir) |
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What is the staging regime for HIV? |
CD4 Count Stage 1: Asymptomatic, CD4 >500 Stage 2: Mild, CD4 350-499 Stage 3: Moderate, CD4 200-349 Stage 4: Severe, CD4 <200 |
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What are the 5 phases of the human sexual response? |
1. Sexual desire 2. Sexual arousal & excitement 3. Plateau phase 4. Orgasm 5. Resolution |
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What are the sexual disorders of the DESIRE phase? |
1. Hypoactive Sexual disorder 2. Sexual aversion disorder |
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What is Hypoactive Sexual Desire Disorder? What is Sexual Aversion Disorder? What is the management of these conditions? |
Hypoactive Sexual Desire Disorder: - Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity Sexual Aversion Disorder: - Strong negative feeling with fear or anxiety at the prospect of sexual interaction with a partner Treatment: Differential one from the other. Sexual history and ideas about sex. Refer to sexologist/psychologist (endocrinologist for hypoactive sexual desire disorder) |
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What are the sexual disorders of the AROUSAL phase? |
1. Female sexual arousal disorder 2. Male erectile disorder |
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What is Female Sexual Arousal Disorder? What is the treatment/management of this disorder? |
Female Sexual Arousal Disorder The persistent or recurrent inability to attain or maintain until completion of sexual activity an adequate lubrication-swelling response of sexual excitement Mx: determine sexual history and time course, sexual stimulation levels. Tx: Use of lubricant/topical estrogen |
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What is Male Erectile Disorder? What is the treatment/management of this disorder? |
Male Erectile Disorder The persistent or recurrent inability to maintain until completion of sexual activity an adequate erection (and is not better accounted for by another axis 1 disorder, not due exclusively to direct physiological effects of a substance or a general medical condition) - most common in overweight men as adiposity produces estrogen Mx: assess meds, sexual history, check medical conditions (diabetes, endocrine status, CV disease) Tx: Injectables, PDE5inhibitors (sildenafil - vigra, tadalafil - cialis), penile prosthesis, vacuum pump, refer to sexologist |
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What are the sexual disorders of the orgasm phase? |
1. Female orgasmic disorders/Anorgasmia 2. Male orgasmic disorder 3. Premature/Rapid ejaculation |
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What is Female orgasmic disorder/anorgasmia? |
Female orgasmic disorder: Persistent or recurrent delay in or the absence of orgasm following a normal excitement phase Tx: Directed masturbation, pelvic floor exercises, use of erotic stimuli |
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What is Male Orgasmic Disorder? |
Male Orgasmic Disorder: Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity Tx: Decrease performance anxiety, refer for help with relationship problems, reduction of anxiety/environmental factors, education |
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What are the sexual pain disorders? |
1. Vaginismus 2. Dyspareunia (painful intercourse) |
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What is Vaginismus? |
Painful spasm of the vagina preventing intercourse which may be transient or permanent Usually psychosomatic- involuntary tightening of muscles that surround the entroitus and lower 1/3 of the vagina Often traced back to: - Sexual assault during childhood - Painful brutal early experience of intercourse --- Traumatic birth Tx: Refer to therapist, series of graded dilators, relaxation techniques |
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What is Dyspareunia? |
Dyspareunia: painful intercourse Recurrent or persistent genital pain associated with sexual intercourse in either male or females Usually has an organic component (e.g. vulovaginal infections, episiotomy scar, endometriosis, PID, ovarian cysts ect) Aggravated when women fails to be aroused sexually and fails to lubricate 3 types: 1) Superficial - pain on penetration/entering, 2) Middle - pain in middle of vagina, 3) Deep - pain on deep penetration |
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What are the differential diagnoses of Dyspareunia? |
Ovarian cysts Vulovaginal infections PID Uterine pathology (adenomyosis, endometriosis, fibroids Psychosomatic (stressful relationship) Abuse Cervical cancer |
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What is the treatment of dyspareunia? |
1. Determine & Treat the underlying cause 2. Use of lubricants & vaginal estrogen 3.Suggestions about techniques to better enjoy (different positions ect) |
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What is Pelvic Inflammatory Disease? |
Infection or inflammation of one or more of the genital organs. Causes: - Sexually acquired - Chlamydia/Gonorrhoea infection - Infection of endometrium (from ectopic pregnancy or childbirth) - ascends up genital tract - Hematogenous spread - from TB or pelvic peritonitis Enometrium infected first --> myometrium --> fallopian tubes --> ovaries/peritoneum |
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What are the clinical features of pelvic inflammatory disease? |
Depends on affected area: 1. Cervical infection - dysuria, discharge, intermenstrual bleeding 2. Endometrial infection - usually asymptomatic, bacterial infections post delivery/miscarriage due to retained products 3. Uterine tube infection - lower abdominal/pelvic tenderness, pain on moving cervix, fever |
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How is PID diagnosed/what are the recommended investigations? |
1) 1 or more physical exam findings of: - Uterine tenderness - Adnexal tenderness - Cervical motion tenderness 2) Test for Chlamydia and gonorrhoea - First catch urine M/C/S or endocervical/urethral swab for PCR) 3)Transvaginal USS - further evaluate upper genital tract and exclude other differentials 4. Laporoscopic confirmation (+/- endometrial biopsy) - usually need due to non specific symptoms |
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What is the treatment of ACUTE mild to moderate sexually- acquired PID? |
1. Ceftriaxone 500mg in 2mL of 1% lignocaine IM/500mg IV as single dose PLUS 2. Aithromycin - 1 gram PO, single dose PLUS 3. Metronidazole - 400mg PO, 12 hrly for 14 days PLUS 4. PLUS Either: - Doxycycline 100mg PO, 12 hrly for 14 days OR - Azithromycin 1g PO single dose, 1 week later |
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What is the treatment of ACUTE severe sexually-transmitted PID? |
1. Ceftriaxone 2g IV, daily PLUS 2. Azithromycin 500mg IV daily PLUS 3. Metronidazole 500mg IV, 12 hourly |
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What is the treatment of ACUTE mild-moderate non sexually-acquired PID? |
1. Amoxicillin + calvulanate 875+125mg PO, 12 hourly for 14 days PLUS 2. Doxycycline 100mg PO, 12 hourly for 14 days If penicillin allergy: Ciprofloxacine 500mg PO 12 hourly for 14 days PLUS Metronidazole 400mg PO, 12 houlry for 14 days |
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What is the treatment for ACUTE severe non-sexually acquired PID? |
1. Amoxy/ampicillin 2g IV, 6 hourly (q.i.d) 2. Gentamicin 4-5mg/kg per 24 hours (max 3 doses) 3. Metronidazole 500mg IV, 12 hourly |
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What are the complications of PID? |
Main complications: - Infertility - Chronic pelvic pain - Ectopic pregnancy risk |
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What is Chronic Pelvic Inflammatory Disease? |
The long term consequence of untreated acute/subacute PID infection - Involves the connective tissues of the pelvic, causing chronic pelvic cellulitis |
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What are the 2 complications that make up Chronic PID? |
1. Pyosalphinx 2. Hydrosalpinx - a progression of pyosalpinx |
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What is a Pyosaplinx? |
Fallopian tube is filled and/or distended with pus. - Usually forms as a result of blocakge of the lumen of the tube. - Ovary may be involved to for a chronic tubo-ovarian abscess. - Commonly caused by acute infection - Sx: May be asymptomatic or have vague pelvic pain (worse in premenstrual phase of cycle) - Dx: hysterosalpingogram (dye injected + cray to see bloackage) + laparoscopy, USS initially - Tx: oophorectomy, salpingectomy |
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What is a hydrosalpinx? |
Fallopian tube is filled and/or distended with fluid. - May be symptomless or have varied symptoms (i.e. ill health, menstrual disturbance,chronic aching in lower abdomen) - Can occur with some gyn cancers - Dx: Hysterosalpingogram + Laporoscopy, USS initially - Tx: Surgery : 1) neosalpingostomy - incision made to open blocked duct, 2) removal of tube |
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What are the symptoms of chronic pelvic cellulitis? |
Results in thickening and fibrosis of connective tissue of the parametrium -Sx: Deep pelvic ache, often localised to one side or back ache, dyspareunia, tender uterus drawn to one side and fixed in position -Tx: Surgery, short wave diathermy and hysterectomy |
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What are the 2 types of ovarian cysts? |
Benign (80%) and Malignant (20%) |
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What are the 2 types of functional cysts? Describe the features of each |
Follicular cysts -Enlargement of unruptured Graafian follicles that has continued to secrete fluid Usually unitlateral, <5cm, may secrete estrogen causing longer menstrual cycles & menorrhagia Corpus luteum cysts - Occur when, instead of degenrating when the embryo fails to implant, the corpus luteum survives and grows |
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What are the 2 types of Benign Cysts? |
1. Mucinous - Frequently 35-55 years - Multilocular, usually unilateral, rarely malignant - Mucin is secreted into cyst -> tense wall -> increased risk of rupture 1. Serous - Frequently 35-55 years - Secrete thin watery fluid and tension inside cyst is low - 30% are bilateral and malignant changes occur in 1/3 of cases |
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What are the clinical features of ovarian cysts? |
- Can be asymptomatic - Menstrual changes - Pelvic pain (if torsion or rupture) - Palpable mass |
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What are the complications of an ovarian cyst (s)? |
- Torsion - Rupture - Hemorrhage into cyst - Adhesions - Infection/abscess |
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What are the investigations to diagnose ovarian cyst? |
- Abdominal or transvaginal USS NB: If simple mass <30mm (cm) - often follicle just before ovulation |
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What is the management/treatment of ovarian cysts? |
Observe for 2-3 months as many regress <5cm - Conervative therapy, as usually resolves without intervention >5cm - Increased risk of torsion - surgery (ovarian cystectomy in younger women, oophorectomy for older ages) |
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What is the classic triad of PCOS? What is the criteria for diagnosis? |
Rotterdam criteria = 2/3 of these key features 1. Oligo/amenorrhoea 2. Clinical or biochemical evidence of androgen excess 3. Multiple (12+) follicular cysts (polycystic ovaries on TV USS) |
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What are some features of hyperandrogenism? |
Hirsutism Acne Hairloss Breast atrophy Virilization (clitoral hypertrophy, deepened voice) |
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What are the clinical features of PCOS? |
Amenorrhea/Oligomenorrhea Anovulation Infertility Obesity Hirsutism Hypertension Insulin resistance, T2 diabetes |
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What are the complications of PCOS? |
Infertillity Increased time for spontaneous pregnancy Increased risk of miscarriage Glucose intolerance/T2 diabetes/Metabolic syndrome Increased risk of endometrial cancer if anovulation persists for multiple years No increased risk of breast or ovarian cancer |
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What are the appropriate investigations for PCOS? |
Bloods: - Testosterone/DHAS (dihydroepiandrosterone sulphate - precursor for testosterone) - LH & FSH (have reversal of ration with LH >FSH) - normal is FSH>LH - TFTs - Serum prolactin - Transvaginal USS - Oral glucose tolerance test |
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What is the appropriate treatment/management of PCOS? |
1. Lifestyle modification - lose weight and increase exercise to increase metabolic control and fertility 2. OCP - to reduce acne, cyst formation and lower androgens 3. Metformin - to reduce insulin resistance, regular menstrual cycle in overweight women 4. Anti-adrogen therapy - SPIRONOLACTONE (blocks effects of androgens in the body, adrogen receptor antagonist) 5. MDT involvement - dietician, obs&gyn, endocrinologist, GP, exercise physiologist, psychologist |
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What is a Tubo-ovarian abscess? |
Inflammatory mass involving the fallopian tube, ovary and potentially adjacent pelvic organs Causes: - Bowel obstruction - E.coli or bacteroides in peritoneum - Lower genital tract infection (ascends up and into the tubes --> purulent exudate and oedema compromises blood supply --> necrosis) - Complication of PID |
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What are the clinical features of a Tubo-ovarian abscess? |
Pelvic |
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What is the management of a Tubo-ovarian abscess? |
1. Broad spectrum antibiotics & admit as inpatient 2. Surgical drainage IF: |
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What is the definition of an ectopic pregnancy? What is the most common site? |
- Implantation of the fetus in any other site than the endometrial lining of the uterus - Incidence increases with age Most common site is fallopian tubes (90%) |
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What are the risk factors for Ectopic Pregnancy? |
Previous ectopic pregnancy Prior PID Endometriosis Appendicitis, previous surgery - causing peritubular scarring Infertility treatment (ovulation induction & IVF) Intrauterine devices |
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What are the 3 outcomes of an ectopic pregnancy? |
1. Tubal abortion - Repeated small hemorrhages form. Invaded area of tubal wall detaches ovum which dies and is absorbed (completely or incompletely) or forms blood mole. 2. Tubal rupture = Growth of gestational sac distends the fallopian tube causing thinning and rupture --> frequently results in massive intraperitoneal hemorrhage 3. Secondary abdominal pregnancy (rare) - Extruded ovum continues to grow and later trophoblasts attach to abdominal organs |
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What are the clinical features of an ectopic pregnancy? |
Abdominal/pelvic pain - often radiates to shoulder! - Amenorrhoea - typically presents 6 weeks after previously normal period - Abnormal vaginal bleeding - Adnexal mass/tenderness In rupture: - Hemorrhagic shock - syncope, dizziness, orthostatic hypotension, tachycardia - Acute abdomen - rebound, guarding, hypoactive bowel sounds |
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What are the complications of an ectopic pregnancy? |
Abortion Bleeding Chorioamnitis Choriocarcinoma |
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What are the investigations for a suspected ectopic pregnancy? |
- Serum Beta hCG (double every 2-3 days for the first 6-7 weeks of pregnancy - levels that fall/double slowly = abnormal pregnancy) - USS (transvaginal or transabdominal) - fetal heart should be detected once B-hCG reaches 1500 IU - Laparoscopy - Bloods - FBC, Groud and Hold, Rhesus status |
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What is the management of an Ectopic Pregnancy? |
If in shock: resuscitation (fluids/transfusion/morphine) RhoD immunoglobulin (in Rh neg women) Urgent surgery: - (laparotomy/laparoscopy) - excise fallopian tube containing gestation OR open tube & remove ectopic - Salpingectomy/salpingotomy Methotrexate injections - if: tube not ruputred, gestation sac is small and hCG level is not high (25% failure rate) Follow up weekly serum B-hCG measurements post treatment until negative |
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What is menorrhagia? |
Menorrhagia: Excessive uterine bleeding (flow or duration): - Lasting >7 days OR - Needing to change super pad/tampon more than every 2 hours Causes symptomatic anemia or lifestyle disturbance |
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What is the workup for Menorrhagia? |
FBC - anemia, plateletd UCEs - hypertension, renal failure LFTs- suspect liver failure TFTs - hypo/hyperthyroidism USS - uterus Hysteroscopy + endometrial sampling (in >40 years or in those with risk factors for endometrial cancer - i.e. famhx, nulliparity, infertility, >90kg) |
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What is the medical management options for menorrhagia? |
1. Tranexamic acid - prevents dissolution of blood clots, inhibits factor XIII 2. NSAIDs - PGE2 inhibitors, inhibits vasodilation --> vasoconstrictor 3. Progesterone - thins endometrial lining (counteracts estrogen( 4. . Mirena - for heavy regular periods, local progesterone secretion, thins endometrial lining preventing build up 5. GnRH analogue |
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What are the surgical management options for menorrhagia? |
1. Uterine cavity embolisation 2. Endometrial ablation 3. Hysterectomy 4. Emergency D&C if medical therapy not working |
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What is endometriosis? |
Endometriosis: presence of functioning endometrial tissue anywhere outside the uterus - Causes chronic inflammatory reaction - Most commonly found in uterosacral ligament, pouch of douglas and ovary - Can regress, remain unchanged or progress - More common in women with irregular menstrual cycles |
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What is the theoretical etiology of how endometriosis occurs? |
1. Retrograde menstruation - causes: menorrhagia, cervical stenosis, outflow obstruction (endometrial cells that are supposed to be shed, flow black along the fallopian tubes into the pelvis/ovaries where they implant and begin to grow) 2. Metastasis 3. Vascular/lymphatic spread |
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What are the clinical features of endometriosis? |
Asymptomatic Severe dysmenorrhea Chronic pelvic pain Deep dyspareunia Menstrual irregularities Infertility - fluid secreted by endometriosis in peritoneum = toxic to eggs *7-12 yer delay between onset of pain and symptoms and surgical diagnosis - |
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How is endometriosis diagnosed? |
First line: 1. Transvaginal USS (+/- Ca125) - Ca125 levels only sensitivte in 28%) 2. Gold standard = Diagnostic Laporoscopy +/- biopsy |
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What is the treatment of endometriosis? |
1. NSAIDs - to help with pain 2. Hormonal OCP 3. Depo provera (prostagens) - successful in treating pain 4. GnRH agonist - make pituitary gonadotropins insensitive to stimulation by by endogenous gnRH --> supression of ovarian steroid secretion) 5. Mirena (LNG- IUS) 6. Danazol (synthetic testosterone) 7. Surgery (superior to hormone therapy)- Laser diathermy ablation of ectopic endometrium, adhesion removal, ovarian cystectomy, hysterectomy w/ bilateral oophorectomy (last resort) |
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What is Adenomyosis? What is the etiology? |
Adenomyosis Presence of endometrial tissue in the myometrium of the uterine wall (grows into the myometrium) Etiology: unknown Clinical Features: - Asymptomatic (1/3 of women) - Menstrual irregularities - Pain (increasing in severity) with menstruation - Menometorrhagia - prolonged/excessive bleeding at irregular intervals and more frequently |
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What are the investigations for adenomyosis? |
1. Examination - large tender uterus 2. Transvaginal USS 3. MRI |
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What is the management of Adenomyosis? |
Adapt to stage of life - if nearing menopause, conservative management 1. NSAIDs - pain relief and to lighten periods 2. OCP/Progestin only (Mirena, minipill) 3. Total hysterectomy (only cure) NB: Not very responsive to hormonal treatments |
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What are uterine fibroids? What are the clinical features of fibroids? |
Also known as uterine leiomyomas. - Benign tumours that grow in the muscular wall of the uterus (can be subserosal, submucosal or transmural) Clinical Features: regress after menopause, peak in pregnancy, irregular bleeding, pelvic pain, can be asymptomatic, compression of bladder (frequency), Knobbly uterus on examination |
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Can uterine fibroids turn malignant? What are the complications of uterine fibroids? |
Yes. But it is very rare (can transform to leiomyosarcomas) Infection, bleeding, torsion, infertility, abortions, obstruction - In pregnancy: early pregnancy bleeding, PROM, obstructed labor and PPH |
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What are the appropriate investigations for Uterine fibroids? |
Transvaginal USS Biopsy - to ensure not malignant |
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How are uterine fibroids managed? |
1. Expectant management - if asymptomatic or if fibroids smaller than 14 week pregnancy - just leave 2. Myomectomy - preserves fertility 3. Hysterectomy - treatment normally for older women 4. GnRH analogue (not suitable long term) - injections given at intervals, supresses estrogen secretion --> atrophy of fibroids (for 3 months). Can be used to decrease tumour size in preparation for surgery. |
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What is Endometrial Hyperplasia? What is its etiology? What are endometrial polyps? What is the relationship between endometrial hyperplasia and endometrial polyps? |
Endometrial Hyperplasia - the proliferation of endometrial glands relative to stroma Due to hyperestrogenemia --> induces hyperplasia Endometrial polyps: exophytic masses (of variable sizes) that project into the endometrial cavity) Relationship: Endometrial hyperplasia gives rise to polyps through proliferation of tissue |
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What are the risk factors for endometrial hyperplasia/endometrial polyps? |
Prolonged estrogen exposure: - Early menarche - Late menopause - OCP use - HRT use - Obesity - Functional ovarian tumour |
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What are the clinical features of endometrial hyperplasia/polyps |
- Can be asymptomatic - Abnormal uterine bleeding (increase duration, frequency, irregular, heavy) - Infertility |
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What are the appropriate investigations for endometrial hyperplasia/endometrial polyps? |
1. Transvaginal USS - evaluate enodmetrial thickness (<5cm normal, >5cm increase risk of endomtrial cancerinoma) 2. Hysteroscopy + D&C (with endometrial sampling) |
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What are the treatment options for endometrial hyperplasia/polyps? |
1. Use of progesterone - Mirena, minipill 2. Endometrial ablation 3. Removal of polyp with forceps 4 D&C 5. Hysterectomy (total) |
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What are the differentials for dysfunctional uterine bleeding? |
1. Uterine fibroids 2. Endometrial hyperplasia 3. Endometrial polyps 4. Endometrial carcinoma 5. Endometritis 6. Adenomyosis 7. Anticoagulants/Coagulation disorder 8. Liver/Renal failure 9. Hyperthyroidism |
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What is cervicitis? What causes cervicitis? What is the physical appearance of the cervix in cervicitis? |
- Inflammation of the cervix - Occurs secondary to vaginal infections - candida, gonorrhea, trichomonas, chlamydia (cause irritation of the cervix) - Swollen, red cervix (inflammatory cells present in smear) |
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What are the clinical features of cervicitis? What are the investigations for cervicitis? |
- Asymptomatic - Vaginal discharge ++ (green, yellow, brown) - Dysuria & Dyspareunia - Post coital bleeding Ix: - Pap smear - Endocervical swab/Urethral swab for PCR - gonorrhea/chalmydia - First catch urine for MCS- chlamydia - High vaginal swabs - bacterial vaginoses |
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What is the treatment of cervicitis? |
1. ANTIBIOTICS - Non gonococcal infection = Azithromycin 1g stat dose + doxycycline 100mg PO, 12 hourly for 7 days - Gonococcal infections = Ceftriaxone 500mg in 2mL of 1% lignocaine IM OR 500mg IV state dose PLUS Azithromycin 1g state dose 2. Contact tracing for STIs |
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1. What is a cervical polyp? 2. What is the clinical presentation of a cervical polyp(s) |
1. Localised hyperplasia of epithelium and stroma Columnar epithelium covering polyp can undergo squamous metaplasia or ulcerate 2. Clinical Presentation: - Many are asymptomatic - Intermittent Post coital bleeding |
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What are the appropriate investigations for cervical polyps? What is the management/treatment for cervical polyps? |
Ix: - Speculum examination - Remove polyp by Twisting pedicle and send for histopathology Tx: removal. |
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What is vulvovaginitis? What causes it? |
- Inflammation or infection of the vulva and vagina Causes 1) Contact dermatitis - soaps, creams, deodorants, urine, common in children 2) Infections: Gonococcal, chlamydia, strep, HPV, HSV 1 & 2, Candida, Bacterial vaginitis, Trichomonas 3) Other factors: sexual abuse in children, lack of estrogen in PM women --> vaginal dryness and thinning --> itching and burning |
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What are the symptoms and signs of vulvovaginitis? |
Symptoms: Genital itching, irritation Dysuria Discharge - foul smelling, cheesy Signs: Inflammation of genitals - redness, swelling, irritation Discharge |
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What investigations are appropriate for vulvovaginitis? |
Depends on cause: - Vaginal pH - Wetmount test: samples of vaginal lesions/scraping for MCS - High and low vaginal swabs for MCS - Endocervical/Urethral swabs for chlamydia/gonorrhoea if suspected |
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What is the treatment for vulvovaginitis? |
Depends on cause: STIs - treat accordingly (antibiotics, antifunfals) Atrophic vaginitis - estrogen creams Dermatitis - topical steroid cream, antihistamine |
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What is a Bartholin Cyst? |
Infection of the Bartholin gland (located on either side of the vagina) due to obstruction of the duct by an inflammatory process Aetiology -Infection usually due to E.coli or Staphylococci (also N.Gonorrhea or Clostridium trachomatis) - If gland becomes chronically enlarged following inflammation --> Bartholin's cyst |
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What are the clinical features of a Bartholin cyst? |
Pain in the area Erythema Tender swelling beneath posterior part of labia majoris |
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What is the management/treatment for a Bartholin cyst? |
1. Sitz baths - socking in warm water baths few times daily - helps small cysts to drain on their own 2.Test for any STIs (as cause) 3. Pain relief - analgesia 4.road spectrum antibiotics 5. Local excision and drainage with marsupialisation |
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What is Lichen Sclerosis? Where does it normally occur? What is thought to be the cause? |
A chronic inflammatory dermatoses that results in white plaques with epidermal atrophy and scarring in patches Can occur anywhere but commonly vulva, head of penis and anus Thought to result from autoimmune reaction |
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What are the clinical features of lichen sclerosis? What are the Ix? What can it predispose to? |
Atrophic, shiny white plaques Skin may be red or normal If whole vulva is affected, labia becomes atrophic and stiffened Chronic purities, pain and dyspareunia (if ulceration or fissures) Ix - Skin biopsy - horny layer unchanged with thinning of epidermis (exclude malignancy) Predisposes to SCC development |
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What is the management/treatment of Lichen Sclerosis? |
1. Topical corticosteroids - Betamethasone dipropionate 0.5% ointment , every night for 4 weeks, then every second night for 4-8 weeks 2. Encourage use of soap substitutes 3. Follow up every 6 months or so for carcinoma evaluation |
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What is Lichen Simplex Chronicus? What is the cause? |
Non neoplastic epithelial disorder characterised by thickening of the skin caused by rubbing or scratching of the skin to relieve pruritis Thickened skin itches --> more scratching --> more thickening and itching Increased predisposition to cancer Causes: Dermatitis, clothing rubbing/irritating ect |
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What are the clinical features of Lichen Simplex Chronicus? What are the Ix? What is the management/treatment? |
Clinical Features? Pruritis Areas of leukoplasia, scratch marks, lichenification, redness, scaling ect Ix: Usually non necessary - clinical dx Skin biopsy may be needed to confirm dx Mx: Topical steroid cream Antihistamine Avoid tight clothing/reduce predposing factors ect |
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What is Lichen Planus? What are the Vulval clinical features? |
Idiopathic inflammatory condition affecting the skin, hair, nails and oral + genital mucosae - Ocassionally can be triggered by drug ingestions or Hep C infection - Autoimmune cause Vulvula fx: Painless white streaks, painful ulcers or erosions, scarring, painful desquamative vaginitis (preventing sex) |
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What is the treatment of Lichen Planus? |
1. Potent topical corticosteroid ointment, twice daily 2. If this not effective - prednisolone 25-50mg PO, once daily for 4-6 weeks (then reduce graduall over 1-2 weeks) 3. Phototherapy |
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Risk factors for chorioamnionitis |
1. Nulliparity 2. Early rupture of membranes 3. Prolonged labour 4. Race/ethnicity |
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What are the organisms that make up TORCH? |
T - Toxoplasmosis O - Other - syphilis R - Rubella C - CMV H - HSV |
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What are the clinical features of chorioamnionitis? |
CLINICAL CRITERIA FOR DIAGNOSIS 2. Significant Maternal tachycardia - >120bpm 3. Fetal tachycardia - 160-180bpm 4. Purulent/foul smelling amniotic fluid or vaginal discharge 5. Uterine tenderness (in presence of confirmed premature ROM) 6. Maternal leukocytosis * Risk of neonatal sepsis is increased when at least 2 of the above are present |
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What are the investigations for Chorioamnionitis? |
Diagnosis based on clinical crtieria - Urine MCS - to exclude UTI - USS - fetal distress |
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What is a molar pregnancy? What are the 2 types of molar pregnancies? |
Also known as a hydatidiform mole Benign tumour that develops in the uterus as a result of overproduction of (abnormal growth) placental tissue 2 types: 1. Partial molar pregnancy - presence of abnormal placenta AND fetal development 2. Complete molar pregnancy - presence of abnormal placenta with NO fetud |
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What are the differences between a partial and complete molar pregnancy? |
Partial: - Triploid (XXY) when a normal egg is fertilised by 2 sperm - Morphology: few blood vessels, few fetal parts, focal hyperplasia of trophoblasts - Relatively lower B-hCG Complete: -Diploid - when a egg that has lots it chromosomes by 2 sperm -Morphology: no blood vessels, no fetal parts, diffuse hyperplasia or trophoblasts - Very high B-hCG |
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What type of molar pregnancy is a choriocarcinoma more likely to develop from? |
Complete molar pregnancy (2% of cases) Rare in partial |
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What are the clinical features of a molar pregnancy? |
- Abnormal bleeding - Abnormally enlarging uterus - No fetal heart detected - USS shows - storm (+++ placental tissues with no fetal heart) - Extremely high B-hCG - Nausea & Vomiting - hyperemesis - Hyperthyroidism - bHCH imitated TSH (features of toxic) - Pre-eclampsia in 1st or 2nd trimester !!(HTN+Oedema) |
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What are the investigations for molar pregnancy? |
- B-hCG - Transvaginal USS - Pelvic examination - Bloods: FBC, clotting and B-hCG - CXR +/- CT/MRI of abdomen for mets |
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What is the medical and surgical management of a molar pregnancy? |
- Methotrexate - targets rapidly dividing cells - D&C - Hysterectomy ** Monitor B-hCG levels every week after to ensure they are going down (until they are 0) - Commence reliable contraception for 6-12 months after (due to risk of second mole) Outcome: sometimes can develop into invasive mole & choriocarcinoma |
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What is the definition of Primary Amenorrhoea? |
1. No periods by age 14 with absent secondary sexual characteristics 2. No periods by 16 regardless of secondary sexual characteristics |
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What are the causes of Primary Amenorrhea? |
Anatomical: absent uterus/vagina, imperforate hymen, horizontal vaginal septum, mulleran agenesis Low body weight - anorexia, extreme exercise Genetic defect - Gonadal dysgenesis Endocrine - Hypothyroidism, Cushing's, Congenital adrenal hyperplasia, PCOS, GnRH deficiency, Pituiary failure/Hypopituiarism, Pituitary adenoma, Hyperprolactinemia, Turner's Syndrome, Hyperprolactinemia Sometimes idiopathic |
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What are the Ix for primary amenorrhea? |
Bloods: FBC, B-hCG, UCEs, LFTs, TFTs, FSH & LH, Estrogen and Progesterone, +/-Testosterone level, GnRH level, 24 free urinary cortisol/dexamethasone suppression test, prolactin level, Bone age Imaging: Pelvic USS, CT/MRI of head for tumours |
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What is the management/treatment of primary amenorrhea? |
Depends on the cause - Adenoma - surgery/chemotherapy - Low body weight - put on weight/decrease extreme exercise - Hormone deficiency - replace hormones - Systemic disease - treat the disease - If it can't be corrected, pseudomenstruation can make girl feel normal |
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What is the definition of secondary amenorrhoea? |
Menstruation does not occur for 3 months (in the absence of pregnancy) in a woman who previously was menstruating |
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What are the causes of secondary amenorrhoea? |
SOAP - mnemonic S - stress O - OCP use, Ovarian failure(Primary) A - Anorexia/extreme exercise/Weight loss P - Pregnancy, PCOS, Prolactin (hyerprolactinemia) |
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What are the Ix for secondary amenorrhea? |
Bloods: B-hCG, Prolactin level, FSH, LH, Estradiol +/- testosterone if hyperandrogenism, progesterone simulation test Imaging: MRI/CT if prolactin level raised (exclude tumour) |
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What is levels of FSH and LH checked twice? |
Because it also has a mid cycle rise |
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What are the common genetic conditions tested for in primary/secondary amenorrhea? |
- Fragile X Syndrome - Turner's syndrome - 46XY |
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What are the 3 common causes of early pregnancy bleeding? |
1. Miscarriage 2. Ectopic pregnancy 3. Molar pregnancy |
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What are the 6 different types of miscarriage? |
1. Threatened miscarriage 2. Missed miscarriage 3. Incomplete miscarriage 4. Inevitable miscarriage 5. Complete miscarriage 6. Septic miscarriage |
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What is a missed miscarriage? What is the findings on examination/history? What are the investigations? What is the treatment/management? |
1) When death of the fetus occurs however, all products of conception are not expelled from the uterus 2) Cervical Os: Closed, Small amount of Bleeding + pain 3)Ix - Pelvic examination and speculum, Pelvic USS, B-hCG 4) Tx: If hemodynamically stable, 1) expectant management, 2) Medical management - Misoprostol 3) Surgery - suction curettage or D&C; |
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What is a threatened miscarriage? What are the examination findings/history? What are the investigations? What is the treatment/Management? |
1) When there is bleeding +/-uterine contractions with a closed internal os. 2) Spec = closed os, pain, bleeding 3) Ix = Spec and examination, Ultrasound (for fetal heart), B-hCG (positive) 4) Resuscitate if shocked, Reassurance and commonly pregnancy will continue, close monitoring (as increased risk of spontaneous miscarriage 50%) |
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What is an Incomplete miscarriage? What are the examination/history findings? What are the investigations? What id the treatment/management? |
1) Where the fetus has deceased and products of conception have only partially been expelled. 2) Spec - os may be open or closed, +/- contractions, ongoing persistent bleeding and pain, +/- shock 3)Ix: Speculum and examination, pelvic USS 4) Admit to hospital, resuscitate if hemodynamic instability, if unstable need to be taken for D&C, if stable, 3 options: 1) expectant management, 2)Misoprostol 400ug 4 hrly for 3 doses, 3) Surgery - Suction curettage/ D&C. Give anti-D if Rh- mother, psychological counselling |
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What is an inevitable miscarriage? What are the examination/history findings?What are the investigations?What id the treatment/management? |
1) Uterine bleeding + strong uterine contractions that cause dilatation of the cervix - a 'miscarriage in process' 2) Bleeding, severe colicky uterine pains + contractions 3) Speculum exam = os is open (part of conception sag bulging through) + pelvic US (no fetal heart) 4) Admit to hospital, group and hold, Anti-D, Psychological support (further management depends on whether progression to complete or incomplete miscarriage) |
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What is a complete miscarriage? What are the examination/history findings?What are the investigations?What id the treatment/management? |
1) Bleeding with Complete expulsion of all products of conception 2) Cervical os closed, bleeding and abdominal pain that decreases over 10 days 3) Ix: speculum, pelvic USS = empty uterus, endometrial thickness <15mm 4) Psychological support, Anti D if Rh- mum and after 12 weeks, follow up to see if bleeding has ceased/kept going |
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What is a Septic Miscarriage? |
1) A miscarriage that is complicated by infection 2) Maternal fever, tachycardia, most likely organisms = strep/staph/e.coli, PINK vaginal discharge, tender abdomen and tender uterus 3) High vaginal swab/cervical swab for M/C/S, Blood cultures (if temp over 38.4), Pelvic US 4) Admit, commence broad spectrum antibiotics |
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What is a recurrent miscarriage? What are the examination/history findings?What are the investigations?What id the treatment/management? |
1) A woman who has had 3 or more successive miscarriages (chances of successful pregnancy are high if had a previous live born) 2) Symptoms of miscarriage 3) Refer for investigation of cause - genetic abnormalities of parents, fetal genetic abnormalities, uterine abnormalities |
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What is the definition of APH? |
Bleeding in pregnancy that occurs after 20 weeks. |
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What are the causes of APH? |
Placenta praevia Vasa praevia Placental abruption Uterine abruption Bloody show Hemorrhoids/Hematuria Cervicitis/ Vaginal infections Trauma Coagulation disorder |
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Wha is the general management of APH? |
1. Asssess hemodynamic status - if unstable, resuscitate with IV fluids, Oxygen, IV access (BP needs to be over 100mmHg systolic) 2. Hx and Examination (no bimanual!!) 3. Blood group and hold 4. Clotting screen 5. Catheterise - keep over 30mL/hr 6. TV Ultraousnd - to locate placenta 7. CTG monitoring of fetus 8. Anti D in Rh- women |
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What is placenta praevia? What are the risk factors? |
When the placenta is implanted in the lower uterine segment and lies below the fetal presenting part/leading pole of the fetus Risk factors: Previous placenta praevia, multiparity, previous Cesarean, smoking, advanced maternal age, multiple pregnancy, Uterine abnormalities (e.g. fibroids) |
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What are the grades of placenta praevia and which grades require mandatory Cesarean section? |
Grade 1 - Low lying: <2cms from internal os Grade 2 - Marginal: Reaches the internal os Grade 3 - Partial: Partially covering os Grade 4 - Total: Covering the os (placental praevia major) Minor = Stage 1 & 2 Major = Stage 3 & 4 Grade 3 & 4 require cesarean section |
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What are the clinical features of placenta praevia? |
- Unprovoked, painless vaginal bleeding (usually begins light --> heavy, bright red) - Bleeding after sexual intercourse - Pain 10% have coexisting abruption/uterine contractions - Fetal heart sounds usually normally - Can even be asymptomatic - picked up on USS - Uterus soft, non tenders - Fetal malpresentation |
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What are the maternal and fetal risks of placenta praevia? |
Maternal - APH/ PPH -Placenta acrete - Cesarean section - Hysterectomy Fetal - Preterm birth - IUGR - Congenital - malformations |
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What are the appropriate investigations for placenta praevia? |
1. Transvaginal USS preferred (Transabdominal easiest and safest though) - looks at placental position, volume of liquor, fetal anatomy, biophysical profile of placental 2. Speculum - BIMANUAL CONTRAINDICATED due to risk of rupture of placenta 3. CTG - fetal monitoring |
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What is the management/treatment for placenta praevia? |
1. Hospital admission 2. IV access - 2 large bore IV cannulas, saline, group and hold, antibody screen 3. Localise placenta via USS 4. If severe (massive blood loss/fetal distress) - immediate delivery by cesarean section may be necessary 5. Need cesarean section for delivery - 37-38 weeks 6. Anti D - if mother Rh- 7. Give steroids if <34 weeks (accelerates fetal lung maturity) 8. If over 3cm from os, can attempt vaginal birth |
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What are the following conditions? 1. Placenta accreta 2. Placenta increta 3. Placenta percreta |
1. When the placenta (chorionic villi) attach to the myometrium (instead of just endometrium) 2. When chorionic villi invade into the myometrium 3. When the chorionic villi invade through the myometrium |
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What is placental abruption? What are the 2 types? |
1. Separation of a normally situated placenta from the lining of the uterine wall 2. Concealed and Revealed 3. Risk factors: previous placental abruptuion, hypertension, pre-eclampsia, multifetal gestation, choriomanionitis, smoking, cocaine/amphetamines, external trauma, increasing age/parity 3.Features: Large PV bleeding (70-80%) leading to hypovolemic shock, constant abdominal/pelvic pain and contractions (hallmark feature is PAIN), premature onset of labour, 'woody hard' uterus (painful, tender, tense), fetal distress on CTG |
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What are the Ix for placental abruption? What is the management? |
- CLINICAL DIAGNOSIS - Ultrasound is NOT a method for diagnosis (negative USS does not exclude) Mx: -Admit to hospital, IV access, Cross match/group and hold, DIC screen - IV fluids/resuscitation - CTG - Anti-D (if negative mother) - +/- emergency Cesarean section (if already in established labour - can go ahead but have low threshold for Cesarean) - Anticipate PPH!! - have blood ready for transfusion |
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What is uterine rupture? What are the risk factors? What are the clinical features? |
1) Separation of an old uterine incision with rupture of the fetal membranes resulting in communication between the uterine cavity and peritoneal cavity 2) RF: Hx of trauma, previous cesarean section, previous uterine surgery, grand multiparity, forceps/shoulder dystocia 3 ) Features: vaginal Bleeding, abdominal/pelvic pain and tenderness disappearance of uterine contractions, absence/deterioration in fetal heart rate, easily palpable fetal parts, sudden fetal distress during labour |
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What are the investigations for Uterine Rupture? What is the appropriate management for uterine rupture? |
1. Ultrasound 2. Mx: Emergent laparotomy +/- hysterectomy (based on extent of rupture) |
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What is vasa previa? What is the management? |
Where the fetal vessels from the placenta cross over the entrance to the birth canal (vessels can tear during labour) Ix: TV USS Mx: Elective cesarean section (if detected before labour) |
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What are the differential dx for hypertension in pregnancy? What is the definition of hypertension in pregnancy? |
Chronic hypertension (if present <20 weeks gestation( Pre-eclampsia Eclampsia Gestational Hypertension Chronic hypertension with superimposed pre-eclampsia Hypertension in pregnancy: Greater or equal to 140/90mmHg on at least 2 readings a few hours apart |
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What is chronic hypertension in pregnancy? |
Hypertension that persists and is present before pregnancy or within the first 20 weeks gestation Twice the risk of developing pre-eclampsia High risk pregnancy |
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What is the management of chronic hypertension in pregnancy? |
1) Antihypertensives : - Use methyldopa or beta blocks (atenolol) or Ca channel blockers (nifedipine) - AVOID ACE inhibitors (teratogenic!!) - Avoid diuretics - decrease placenta volume/placental blood flow 2) Increased antenatal visits - to monitor for significant rise in BP or proteinuria --> pre-eclampsia 3) If fetus fails to grow or maternal hypertension deteriorates = DELIVER |
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What is gestational hypertension? |
1) Hypertension that arises after 20 weeks gestation (usually 36-37weeks) and do not have any other features of pre-eclampsia (no proteinuria ect) At risk of developing pre-eclampsia If it occurs before 30 weeks, likely to progress to pre-eclampsia Usually resolved by 3 months post partum |
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What is the management of gestational hypertension? |
1) Careful surveillance 2) Ambulatory BP monitoring at home 3) If exceeds 140/90 --> commence hypertensive therapy (Methyldopa 250-1000mg bd) 4)If BP >160/110mmHg admit to hospital 5) Prophylactic aspirin therapy if 'high risk' of developing pre-eclampsia |
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What is the threshold for commencing anti-hypertensive therapy in pregnancy ? |
BP of 140/90mmHg |
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What is pre-eclampsia? |
Multisystem disorder in pregnancy characterised by Hypertension - greater/equal to 140/90 onset after 20 weeks plus 1 or more of the following: Proteinuria Oedema Renal insufficiency/involvement Liver dysfunction - raised transaminases, RUQ pain Neurological problems - severe headaches ect Hematological disturbances - Thrombocytopenia ect Fetal growth restriction Pulmonary oedema Placental abruption |
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What is HELP Syndrome? |
Complication/variant of Pre-eclampsia Often develops in a woman with hypertension in pregnancy H - Hemolysis EL - Elevated liver enzymes LP - Low platelet count |
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What is eclapmsia? |
Pre-eclampsia complicated by generalised tonic clonic convulsions/seizures *Mainly occurs antepartum and in labour but 45% can occur post-partum usually up to 48 hours after but can also rarely even be after 1 week |
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What are the complications of eclampsia? |
Placental abruption Neurological deficits Aspiration pneumonia Pulmonary oedema Cardio-pulmonary arrest Acute renal failure Maternal death |
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What are the clinical features of eclampsia? |
Convulsions Coma Often preceded by disorientation stage Can occur antepartum, intrapartum and post partum |
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What is the management of eclampsia? |
Goals of management are to: - Control fits by relieveing vascular spasm, Reduce BP to prevent cerebral hemorrhage, Delivery of fetus - ABC, - Control convulsions with magnesium sulphate (4g IV infusion) - monitor RR (stop if RR<14) and plasma magnesium (stop if >3.5) - Delivery after control - >34 weeks can have normal, <34wks give steroids and cesarean section - Treat complications May need HDU/ICU admittance - Give antihypertensives - Hydralizine IV |
