Female Reproductive System Anatomy, Contraception

Features of chlamydia

- 70% asymptomatic - Cloudy yellow discharge - Cervitis and urethritis in women - Bleeding of the cervix - Post-coital or intermenstrual bleeding - Dyspareunia, dysuria, pelvic pain - In men discharge from penis

ductal carcinoma in situ (DCIS)

- 85% carcinomas - Malignant proliferation of epithelial cells limited to ducts and lobules by the basement membrane - Calcification and fibrosis on mammography - 80% non-palpable - microscopic invasive foci may develop over time - Ix mammography, biopsyradiotherapy - Rx- lumpectomy , tamoxifen , mastectomy or wide local excision,

Investigations for recurrent miscarriage

- APS antibodies (LMWH/ aspirin - karyotype, TFT, pelvic USS, MRI, prolavtin - Pelvic USS - Thrombophilia screen - Parental karyotyping

Treatment for genital herpes

- Aciclovir, ganciclovir, famciclovir, valcyclovir, - Local anaesthetics, analgesia - Saline bathing - IV anti-viral - Year-round therapy for recurrence - Admission if urinanry retention - Counselling and partner notificantion - Prophylaxis if reccurence - C-section if acquired in late pregnancy

Complications of PPH

- Blood loss - Shock - Collapse - DIC - AKI - Liver failure - Death

Protective factors of endometrial cancer

- COCP - Pregnancy - Smoking

Common infective organisms in puerperal sepsis

- GAS which are: - E.coli - S.aureus - S. pneumoniae - MRSA

Ecstasy in pregnancy

- Gastroschisis

Complications of abortion

- Haemorrhage - Infection - Uterine perforation - Cervical trauma - Failure - Psychological sequelae

Complications of syphilis

- Neuro-syphilis - Aortic regurgitation - Many more - Stroke - GN - Cold AIHA

Aetiology of amniotic embolism

- Occurs when the membranes rupture - Multiple pregnancy - Older age of mother - Eclampsia - Polyhydramnios - Placental abruption - Uterine rupture - Induction of labour

Ix in endometrial cancer

- PUSS - Hysteroscopy and endometrial biopsy - surgical staging - Papanicolaou (Pap) test showing endometrial cells in postmenopausal women - FBC- anaemia due to bleeding - Genetic councelling Risk factors for endometrial cancer# - Oestrogen exposure - Obesity, diabetes mellitus - Early menarche - Nulliparity - Late menopause - PCOS - prolonged amenorrhoea and fat cells convert testosterone to oestradiol via aromatase - Unopposed oestrogen HRT - Tamoxifen - causes oestrogen receptor agonism in the uterus, Stimulates oestrogen receptors - Ovarian tumours producing oestrogen

Ix for genital herpes

- Swab and PCR, NAAT, IgG assay

AEX of prolapse 1B

- Vaginal delivery - Pregnancy - Congenital e.g. Ehlers-Danlos syndrome - Menopause - Chronic increased intraabdominal pressure e.g. obesity, cough, constipation, heavy lifting, pelvic mass - Iatrogenic e.g. pelvic surgery, hysterectomy

Post-menopausal PV bleed causes

- atrophy - infection - cancer

Potent progestins with no estrogenic effect and less androgenic effects

- desorgestrel - norgestimate - drosperinone

Progestin deficiency AE

- dysmenorrhea - menorrhagia - late cycle spotting

Menorrhagia and causes

- excessive bleeding from vagina causes -can cause anaemia -hypothyroidism -adenomyosis fibroids -COCP -

HTN pts options for contaception

- low dose estrogen - recommend progestin-only - monitor K with drospirenone (yasmin)

Secondary dysmenorrhoea

- painful menstruation, presence of pelvic pathology inc. fibroids, adenomyosis, endometriosis, PID, ovarian tumours, intrauterine ppolyps, IUD, congenital abnormalities - common in women in 30-40s - may be accompanied by other symptoms inc. irregular bleeding pattern, heavy periods, vaginal discharge, and dyspareunia

TVS

-uterine lining thickness -

lobule of mammary gland

A breast lobule is a gland that makes milk. Enlarge. Anatomy of the female breas

Usual position of the uterus (fig 1)

Anteverted and anteflexed

- Uterine prolapse/vaginal vault prolapse -

Apical compartment prolapse (uterine prolapse, vaginal vault prolapse) - Descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus - The apex can be either the uterus and cervix, cervix alone, or vaginal vault - Descent of the vaginal vault, where the top of the vagina descends or inversion of the vagina after hysterectomy. - Vault prolapse can happen after a n abdominal or a vaginal hysterectomy -

fimbriae

Fingerlike projection of the uterin (fallopian) tubes that drape over the ovary.

UKMEC 1

No limitation on use

-UKMEC 3

Risks likely to outweigh benefits

vestibule

The space bounded by the labia minora is the

Progestin effects on lipids

increase LDL and decrease HDL

Women >35 choice of OC

lowest dose of estrogen

labia majora

other name for outer labia

Pregnancy of unknown location

+ve blood and urine for pregnancy no identifiable pregnancy on USS HCG doubles every 48hrs , doubling time increasing after 48 hrs Most outcome is ectopic If hCG levels fall then failing PUL Causes Ectopic Missed miscarriage Too early ? Management Serial hCG Expectant management <1000iu/l 88% successful Rescan after appropriate interval Surgical investigations- laparoscopy MTX (85-94% success)

Delayed second stage#

(no delivery after 2 hours of full dilatation at 10cm) - due to passenger and passage: - Passenger - macrosomia, cephalo-pelvic disproportion, malpresentation - Passage - vaginal tumour, vaginal septum, cervical resistance, scarring, cervical stenosis - Maternal exhaustion and uterine inertia, anaesthesia or sedatives

ovary

(vertebrates) one of usually two organs that produce ova and secrete estrogen and progesterone

Complications of multiple pregnancy

- - Increased mortality - Risk of handicap - Prematurity - IUGR - Miscarriage with vanishing twin syndrome - Intrauterine demise of one twin - Still birth - Preterm birth - polycythaemia -

Chorioamnionitis

- 1-10% pregnancies - Infection of amniotic fluid - Maternal blood or UTIs, STI in cervix - Associated with sepsis, adult respiratory distress syndrome (ARDS), pulmonary edema, and death. - In foetus sepsis, pneumonia , death - Features: intrapartum fever, mat. Tachy, foetal tachy - Ix amniotic fluid culture

Treatment for PET

- 10mg PO nifedipine every hour until desired response - IV labetalol 20mg bolus, 40 after 10 mins then 80mg bolus every 10 mins - Hydralazine (2nd ) 5-10 mg IV every 10 mins - Methyldopa (2nd) 250-750 mg TDS - Magnesium sulphate for seizures and to prevent seizures - beware respiratory depression, hypotension, hypo-reflexia - Steroids for <34 weeks' gestation - Delivery is curable, 6 weeks after back to normal, deliver at 36 wks vaginally preferred - Complications deliver 32-34 wks C-section - Oxytocin alone in the 3rd stage - CTG, fluid balance

Depo-Provera

- 150mg medroxyprogesterone acetate IM injection every 3 months into the gluteal or deltioid muscle - administer within 5 days of onset of menses - new formulation of Depo-SubQ Provera 104 can be given SQ in abdomen or thigh

Bartholin abscess/cyst

- 2 Glands behind labia minor secrete mucus to lubricate for coitus - Blockage leads to cyst formation and infection to abscess (staph or E. coli) - Can become infected with MRSA - Common in women in 20s, less likely to develop with age

Rx of puerperal sepsis

- 3 in : O2, IV abx, IV fluids - 3 out: cultures, lactate, catheter - Analgesia - Woundcare if needed - ABCDE - IV broadpectrum abx (clindamycin or gentamycin, vancomycin, tazobactam, piperacillin) - Hand washing after toilet, cleaning perineum, change pads - Personal hygiene advice after delivery

Recurrent miscarriage

- 3 or more miscarriages in succession <24 weeks - Antiphospholipid syndrome (15% women) - Thrombophilia (protein C/S deficiencies) - Parental chromosomal anomalies - Congenital Uterine anomalies - Infection e.g. bacterial vaginosis - Thyroid disease - PCOS - Obesity - Smoking - Caffeine - Older maternal age

Aetiology of PPH 1B

- 4 Ts 1. Tone - uterine atony: most common cause of PPH within 24 hrs . avoid by giving oxytocin with delivery of the anterior shoulder or placenta - due to overdistended uterus (polyhydramnios, multiple gestations, macrosomia) - uterine muscle exhaustion (prolonged or rapid labour, grand multiparity, oxytocin use, general anaesthetic) - uterine distortion (fibroids, placenta previa, placental abruption) intra-amniotic infection (fever, prolonged ROM) 2. Tissue - retained placental products (membranes, cotyledon or succenturiate lobe) --> Rx US guided Dilation and curettage - retained blood clots in an atonic uterus - gestational trophoblastic neoplasia - abnormal placentation 3. Trauma - laceration (vagina, cervix, uterus), episiotomy, hematoma (vaginal, vulvar, retroperitoneal), uterine rupture, uterine inversion 4. Thrombin - coagulopathy (pre-existing or acquired)

Management of miscarriage

- ABCDE resuscitation, ERPC, ergometrine, IV ABX, oxygen, fluids, blood, anti-D - Threatened, incomplete and missed - still viable or not bleeding, good health expectant management - wait for 2 weeks - Medical management induce miscarriage - oral misoprostol (or vaginal) - for incomplete and missed ( Softens cervix and causes the wound to contract ) - Preceded by 'priming' with anti-progesterone (mifepristone) 48 hours prior to admission -->Tells body its not pregnant, 2 wk follow up scan - ERPC - for missed, anaesthesia, vacuum aspiration but a blind procedure: Plastic suction curette used to removed tissue from uterus. Risk of perforation to cervix - Counselling

Labour Dystocia (2B)/ Abnormal progression of labour

- Abnormal progression of labour - expected patterns of descent of the presenting part and cervical dilatation fail to occur in the appropriate time frame - can occur in all stages of labour

Amenorrhoea definition

- Absence of menstruation, can be primary or secondary. Rare condition - Primary amenorrhoea: no menstruation by age 15/16 in a patient with appropriate development of secondary sexual characteristics due to abnormalities occurring before puberty or - age 14 girls who have not gone through puberty - Secondary amenorrhoea - previously normal menstruation that stops for 3+ months -have to not be pregnant

Contraception AE

- Acne - Migraines - HTN - Lipid changes (minor) - N/V (take with food QHS)

Treatment for antepartum haemorrhage

- Admission - IV fluids and blood products - Oxygen - Correct clotting - Urine output - Delivery

Eclampsia management

- Admit - Supportive therapy and resuscitation with fluids, oxygen - IV magnesium sulphate (can be reversed with calcium gluconate) - Management in ITU;

Postpartum psychosis

- Affects 0.2% of women - Abrupt onset of psychotic symptoms by the 4th day post-partum - Severe risk to mother and baby - Hallucinations and delusions, mania ( talk too much, too quickly, feel on top of workld). Loss of inhibition, paranoia, restless, agitation, low mood - RX admission to mother and baby unit, tranquilisation, medical emergency

Postnatal depression

- Affects 15% of women within the first month postpartum - Fatigue, guilt, feelings of worthlessness, preoccupations with the baby - Persistent feelings of sadness and low mood , lack of enjoymeny and loss of interest in wider world - RX psychotherapy, antidepressants, admission to mother and baby unit, fluoxetine and sertraline are preferred

Infertility history/causes of infertility in women

- Age o Primordial follicles, maximum number 20. 500,000 eggs after puberty. 500 used . eggs degraded. o By age of 36 10% of eggs, by age of 40 less eggs. 12-14-16 o Quality of eggs is reduced with age. Downs at 40 1 in 80 o Miscarriage at 40 1 in 3 o Older men- erectile dysfunction, no regular intercourse, older couple less likely to conceive. - How long have you been trying longer you try less likely to conceive/ duration of infertility - Sexual hx o Difficulty in ejaculation o Difficulty in penetration o Fertility window: 5 days before ovulation (5% chance with 1 intercourse), super fertile window 36-48 hrs 1 intercourse 35% chance - Menstrual Hx o Regular cycle 99.9% ovulating/ Irregular cycle/ no cycle 99.999 not ovulating o Hypothalamic causes o Stress, poor nutrition, excessive exercise o Pituitary - PCOS, prolactinoma, hypopituirinism - Obstretic hx o Infection o Cervical incompetence o Complication in previous pregnancy o Method of delivery o Teratogenic meds o Conditions o ectopics - Gynae hx o Ovarian: premature ovarian failure, luteal phase defect (prem. Corpus luteum, failed lining of uterus), o Tubal 20-30%: PID, adhesions , ligation/occlusion o Uterine <5%: congenital abnormalities (uterine septae), adhesions (asherman's syndrome) fibroids, infection (endometritis, pelvic TB), fibroids/polyps, endometrial ablation o cervical factors (5%): hostile or acidic cervical mucus, anti-sperm antibodies, structural defects (cone biopsies, laser or cryotherapy) o Other factors:Thrombosis previously, pregnancy increases VTE risk, o Endometriosis 30% Medical Hx - systemic diseases (thyroid, Cushing's syndrome, renal/hepatic failure) , DM Congenital: - (Turner's syndrome, gonadal dysgenesis or gonadotropin deficiency) - FHx - genetic abnormalities

breast cancer risk factors

- Age over 50 -Genes - TSG, familial, white ancestry - Oestrogen exposure - older age, early menarche, late menopause, COCP, combined HRT, late birth, nulliparity - Breast disease hx ( previous ca) - Radiation e.g. radiotherapy for Hodgkin lymphoma - Alcohol - Obesity - BRCA1, BRCA2 mutations

Treatment for cord prolapse

- Alarm and emergency - Oxygen , monitor baby HR - Push the presenting part away to stop cord compression - Bring mother's knees to her chest - 500ml saline into the bladder - Terbutaline to reduce contractions - Warm the cord by placing it back in vagina +/- warm saline soak - Mother onto all fours - Instrumental delivery if dilated or C section

Complete miscarriage

- All foetal tissue has been passed - Bleeding is decreasing - Closed cervical os - Empty uterus

Week 16-19 booking visit

- Amniocentesis diagnostic test offered at 16-18 weeks - 1% risk of miscarriage, aspiration of amniotic fluid containing foetal cells, diagnoses chromosomal abnormalities, TORCH, sickle cell, thalassaemia, cystic fibrosis - Quadruple/alternative test offered at 16 weeks - AFP, oestriol, beta-hCG, inhibin - WK 18: screen for structural abnormalities USS

Trichomoniasis vaginalis

- Anaerobic flagellate protozoan - Transmitted by sponges, sex, pools and vertically - Remains in the cervix - Coinfection with gonorrhea and other sexually transmitted diseases (STDs) is common

Complications of HPV

- Anal cancer, rectal cancer, cervical/vaginal/vulvular Ca

visit 20-25 wks

- Anomaly scan offered at 20 weeks - Week 25- GDM testing : OGTT -GDM fasting >5.6 mmols or 2-hr >7.8 mmols - VTE Hx refer to ANC consultant give LMWH - WK 20+ 6 days: screen for structural abnormalities USS (again, done at 18 wks too)

Aetiology of amenorrhoea

- Anovulatory - Ovulatory - Physiological - pregnancy, menopause, lactation - Premature menopause - PCOS - Hyperprolactinaemia - Hypothalamic anovulation/hypogonaoidism (exercise, eating disorders, stress) - Drugs - progestogens, GnRH agonists (induce menopause), antipsychotics causing hyperprolactinaemia e.g. risperidone - Hypothalamic hypogonadism - exercise, anorexia, tumours leads to low GnRH, FSH and LH - treat with COCP or HRT - Sheehan's syndrome - severe post-partum haemorrhage resulting is ischaemic necrosis of the pituitary gland - Hypothyroidism and hyperthyroidism - Congenital adrenal hyperplasia - Turner's syndrome or gonadal dysgenesis - Outflow tract problems e.g. imperforate hymen, vaginal septum, vaginal atresia results in primary amenorrhoea - Secondary amenorrhoea cervical stenosis, Asherman's syndrome (fibroids of endometrium after dilatation and curettage)

Shoulder dystocia

- Anterior shoulder becomes impacted behind the pubic symphysis leading to obstructed and prolonged labour necessitating additional manoeuvres after downward traction is applied - Leads to delayed delivery, asphyxiation, brain injury and death - Excessive traction can cause Erb's palsy - Associated with 4th degree perineal tears

Prevention of Rh incompatibility

- Anti-D given to RhD negative women to destroy foetal red cells in their circulations so that they don't make their own IgG and prevents recognition by the mother's immune system - At 28 weeks' gestation and within 72 hours of any sensitising event - Foetal anaemia is assessed for with MCA doppler, foetal blood sampling - In extremis, in utero transfusion can be performed At birth: - Neonate's blood group is checked - RhD positive anti-D given to mother within 72 hours - Kleihauer test - assesses number of foetal red cells in the maternal circulation within 2 hours of birth, detects cases where larger doses of anti-D are required

28-40 weeks antenatal care

- Anti-D is given at 28 weeks - FBC: Anaemia screening - Week 36: prep for labour, breastfeeding info, Abnormalities: - Raised beta-hCG and inhibin with Down's - Low AFP, PAPP-A and oestriol

Prevention of Pre-eclampsia

- Aspirin 75mg from early pregnancy - Uterine artery Doppler - SFLT-1 to PIGF ratio - High dose vitamin D and calcium up to 16 weeks' gestation

Aetiology of multiple pregnancy

- Assisted conception e.g. IVF, clomiphene - Genetics - Increased maternal age - Multiparity - Prior multiple pregnancies

Features of pre-eclampsia

- Asymptomatic - CNS - frontal headache, drowsiness, reducing GCS - GIT - nausea, vomiting, epigastric/RUQ pain - Hypertension - Massive, sudden-onset oedema - Proteinuria - Hyper-reflexia - Flashing lights in the vision - Reduced foetal movements and IUGR;

Clinical feature of prolapse 1B

- Asymptomatic - Dragging sensation/sensation of something coming down - Lump sensation - Visible lump - Problems with intercourse - Bleeding due to ulceration - Cystourethrocele - frequency, incomplete voiding, stress incontinence - Rectocele - constipation - Manual reduction to enable urination or defecation - Pelvic pain, retention, sexual dysfunction, lower back pain, visible prolapse - Rectal examination - bulge with a rectocele - Usually a clinical diagnosis but can do urodynamic studies and TVUS

Features of syphilis

- Asymptomatic - Primary chancre - often first appears as chancre that is painless, moist base, ulcerated, indurated papule on lips, anus (3 wks after infection, heals ) - Secondary - flu-like features (headache, chills, fever, athralgia, malaise) , organ damage, condyloma lata (2-6 months later ) - Tertiary - years later 3-7 (rare), aortic regurgitation, dementia, gumma (tender nodule - granulomatous)

Features of leiomyomata 2B

- Asymptomatic in 50%, usually incidental finding - General mass symptoms - discomfort, heaviness, pressure and pain, frequency, urgency - Heavy menstrual bleeding in 30% - due to ulceration of fibroid, increased endometrial surface area, interference with uterine contractility - Intermenstrual bleeding - Dysmenorrhoea - Complications e.g. pain due to torsion, red degeneration - Pressure effects - bladder (frequency, retention), ureters (hydronephrosis), fallopian tubes (subfertility), bowel (constipation)

Features of cervical cancer

- Asymptomatic, may be an occult malignancy detected by LLETZ - Post-coital bleeding late - Offensive cervical discharge - Intermenstrual bleeding - Post-menopausal bleeding in the elderly - Features of spread - ureter (uraemia), bladder (haematuria), rectum (rectal bleeding), nerves (neuropathic pain) and bone pain - Speculum examination may reveal and ulcer or mass at the external os of the cervix

Antenatal advice

- Avoid drugs as much as possible in first trimester, minimise polypharmacy - Folic acid 0.4mg/day until 12 weeks' gestation: To avoid neural tube defects, previous affected pregnancy, malabsorption, coeliac, GDM, sickle cell and BMI >30, - Folic acid 5mg/day for obesity, DM, sickle cell, anti-convulsant use - Vitamin D 10ug/day for all women - Vitamin D 25ug/day for obesity, South Asian, Afro-Caribbean, low sunlight exposure, risk of PET - Aspirin 75mg for woman at risk of PET - NO smoking: No safe levels of smoking and Nicotine replacement therapy - Avoid alcohol: associated with Low birth weight, foetal alcohol spectrum disorders, learning and behavioural difficulties - Avoid listeriosis - non-pasteurised dairy, soft/blue cheese, pate, uncooked food - illicit drugs o marijuana childhood neurodevelopmental effects o cocaine: low birthweight, small head circumference, premature birth, perinatal death o heroin: spontaneous abortion, intrauterine death, low birth weight, premature birth, infant distress to acute drug withdrawal after delivery o blood bourne viruses - Regular exercise - Diet and weight management o 18.5-24.9 o Risks of obesity o 5-10% weight loss improves chances of pregnancy and significant health benefits - Obese women have more complex labours

Treatment T.vaginalis

- Avoid sex, contact tracing - Metronidazole

Complications of puerpal sepsis

- Bacteraemia - Viraemia - Fungaemia - Chorioamnionitis (if still preggers) - Endometritis

Ix dysmenorrhoea

- Bimanual exam: uterine or adnexal tenderness, fixed uterine retroflexion, uterosacral nodularity, pelvic mass, or enlarged irregular uterus (findings are rare in women <20 yr) - U/S - laparoscopy and hysteroscopy may be necessary to establish the diagnosis - Screening for infections (vaginal and cervical cultures) Papanicolaou smear may be required - good history of illness: including -The age at which symptoms began -Their nature and severity -Factors that relieve or worsen symptoms (including the effects of contraceptives) -Degree of disruption of daily life -Effect on sexual activity -presence of pelvic pain unrelated to menses

Complications of macrosomia

- Birth injury - shoulder dystocia, birth asphyxia, neonatal hypoglycaemia, brachial plexus injuries, meconium aspiration, hip dislocation - 3-4th degree perineal tears - Extended vaginal tears to the cervix - Prolonged labour - Instrumentation and trauma - Hypocalcaemia - Jaundice at birth

Long acting progestins MOA

- Block LH surge and prevent ovulation - reduce ovum motility in fallopian tubes - thins endometrium - thickens cervical mucus

Ix and Rx for Endometrial hyperplasia with atypia

- Bloods - FBC, U&E, glucose - ECG - TVUS - Pipelle or hysteroscopy with endometrial biopsy - MRI, CXR, CT, PET-CT RX Rprogestogens, hysterectomy, monitoring with endometrial biopsy

stages of puberty

- Boobs, pubes, grow, flow -Thelarche - development of breast buds -Pubarche - growth of pubic and axillary hair -Menarche - beginning of menstrual cycles -Adrenarche: increase in secretion of adrenal androgens; usually precedes gonadarche by 2 yr

Antenatal care/booking visit wk 10

- Booking visit - Examination, BMI, BP, abdominal examination with SFH measurement - Screened for: sickle cell disease and thalassaemia, Blood group and rhesus status - Screened for diabetes: - Offered USS for 11-13 weeks+6 days Combined test (nuchal translucency, b-hCG, PAPP-A) : tests for down's, chromosomal abnormalities , also dating scan - Advice on nutrition and diet, Vit D, pelvic floor exercise, - Chorionic villus sampling diagnostic test offered at 11 weeks - biopsy of trophoblast, 2% risk of miscarriage - Syphilis screen, Rubella immunity and TORCH screen/serology, HIV and hepatitis B screen, Varicella , Zika - Urine dipstick, M, C and S

Treatment for uterine rupture

- C section - Avoid induction of labour - Manage acutely with resuscitation, laparotomy and hysterectomy - Rule out placental abruption

Investigations for ovarian Ca

- CA 125 >35 - TVUS - if ascites or a mass refer for biopsy and histology - AFP, HCG, inhibin, LDH - Risk of malignancy index - US x menopausal status x serum CA125 levels = if >250 then MDT - Biopsy and pathology - CT - Laparotomy Ultrasound - Heterogeneous appearance - Papillary projections - Septations - Poorly-circumscribed mass - Cystic and solid components - Ascites - Calcification - Free fluid

Features of breech presentation

- Can be frank( hip flex , knee extended) , flexed (hip and knees flexed) or footling - Only important from 37 weeks' onwards or at labour - Ballotable head at the uterine fundus - Associated with anomalies, hypoxia, birth trauma, hip dislocation, Klumpke's palsy, vaginal delivery - Manage with ECV at 37 weeks, C section or vaginal breech delivery

Effect of diabetes on foetus

- Cardiac defects- ASD, VSD, coarctation - GIT defects- anorectal & duodenal atresia, treaheooesophageal fistula - Renal defects- hydronephrosis, renal agenesis, PCK - CNS & MSK defects- Neural tube defects, caudal regression syndrome, anencephaly , - Preterm labour - Reduced lung maturity - Macrosomia - Polyhydramnios - Foetal sacral agenesis - Stillbirth - Shoulder dystocia - Birth trauma e.g. hip dislocation - Foetal distress and hypoxia - Foetal IUD

Postnatal care

- Care provided for a mother and her baby after the birth of the baby. - Puerperium : 6 weeks after birth - Women advised of signs and symptoms of life-threatening conditions - Secondary PPH (24 hrs-6 wks after delivery) , infections (mastitis, sepsis), thromboebolsism, postpartum eclampsia (with 7 days of delivery) - Perineal care: pain /stinging? --> paracetamol, NSAIDs, topical cold therapy. Should be advised on perineal hygiene, changing pads, daily bathing and shower to keep clean - Dyspareunia: explore sex anxieties and reasons, assess pernium if dyspareunia. Water based lubricant - Headache: PET? - Retention : must pass urine within 6 hrs other wise consider catheter - Incontinence--> pelvic floor exercise - Faecal incontince - Constipation --> assess diet and fluid intake, laxative - Encourage breastfeeding. Bowel should be open within 3 days - Ask about emotional well-being and family support - MEOWS >3 emergency

Rx for cervical incompetence

- Cervical Cerclage reinforcement of the cervical ring with nonabsorbable suture material at the level of the internal os, usually at the end of the first trimester or in the second trimester and removed in the third trimester

Colposcopy

- Cervix is strained with 5% acetic acid and observed with 10-20x magnification - Acetic acid causes aceto-white changes with CIN - Iodine stains normal cervical epithelium and enhances the contrast of CIN - CIN IIIII RX with large loop excision of transformation zone and histology OR colposcopy with biopsy

Menopause (2B)

- Cessation of menses (amenorrhoea) due to decreased ovarian function low response to GnRH - Results in shorter follicular phase, few ovulations and decreased progesterone - Average age is 52 - physiological or iatrogenic - characterised by hot flushes, night sweats, sleep disruption, and genitourinary syndrome of menopause - changes in menstrual flow, breast tenderness, moodiness, - vaginal: dyspareunia, irritation, itching - bone: reduced bone density (20%) - perimenopause years leading to menopause or a year after are most symptomatic - RX: HRT, SSRIs, SNRIs

Risk factors for ectopic pregnancy

- Chlamydia due to damage to fallopian tube - PID or surgery damaging the fallopian tube - Assisted conception with IVF - Pelvic surgery - Previous ectopic pregnancy - Smoking - Multiple sexual partners - Mirena IUS or copper IUD - Infertility - Age <18 at first intercourse - Aged over 35

Sx endometriosis

- Chronic cyclical pelvic pain and cyclical symptoms - Dysmenorrhoea - Deep dyspareunia - Subfertility - Dyschezia - pain on opening bowels - Acute pain with ruptured endometriotic cysts

Treatment for genital warts

- Clears within 18 months with treatment - Podophyllotoxin TOP (.5%): Cytotoxic , antimitotic leads to apoptosis - Trichloroacetic acid: Protein coagulation cells cannot function cell death not used much burns and can cause scarring - Imiquimod( TOP): Cell-mediated immune response modifier -> Reoccurrence rate is low preferred method o May not work in some patients - Cryotherapy/ chemical ablation o Liquid nitrogen o Good in pregnancy o Everyweek, not convenient for some people - Hyfrecation and cautery - Excision - Contact tracing

- Threatened miscarriage

- Closed cervical os - Bleeding before 24 wks - 25% risk of foetal miscarriage

Bacterial vaginosis in pregnancy

- Common cause of vaginal discharge In pregnancy - associated with preterm delivery in high-risk women

Sub-types: of molar pregancy

- Complete mole - pre-malignant, entirely paternal, 46XX, sperm fertilising an empty oocyte - Partial - triploid, 2 sperm and one oocyte - Invasive mole - malignant characteristics - Choriocarcinoma - malignancy, can spread outside uterus

mammary duct ectasia

- Complication of untreated mastitis - Benign blockage of the lactiferous ducts - Leads to discharge and inflammation - Breast lump with painful erythema and thick white-green discharge - if not treated --> abscess - Manage with excision and histology

Genital warts

- Condylomata acuminate ( cauliflower lesions) due to HPV 6 and 11 infection - Spread by physical and skin-to-skin contact , sex - Common in 16-25 YO - Some oncogenic types which can cause neoplasia - Associated with SCC due to HPV 16 or 18 sub-type -> CIN, VIN

Investigations in PET

- Confirm proteinuria - 24hr urinary collection >0.3g/24hrs, PCR>30ng/nmol, urine dip +++ - FBC - thrombocytopaenia, raised Hb, prolonged APTT and PT - LFTs: raised LFTs , raised LDH - U&Es: high urate, creatinine raised - Foetal wellbeing - foetal USS, umbilical artery Doppler, cardiotocography

Complications of obesity in the infant 2B

- Congenital anomalies - Diabetes mellitus - Perinatal mortality is increased

Treatment of slow progress labour

- Conservative - wait, mobilisation, support - In first stage amniotomy and oxytocin - Second stage delivery via forceps or ventouse - Third stage ergometrine and oxytocin as anterior shoulder is born to reduced time of 3rd stage and reduced incidence of PPH

management of multiple pregnancy

- Consultant-led care - Folic acid - Low-dose aspirin USS - Lambda sign (thick septum) with dichorionic twins - T sign with monochorionic - Perform USS at 28, 32 and 36 weeks' - Elective Delivery at 37 for dichorionic after steroids - Elective Delivery at 36 for monochorionic after steroids - Manage TTTS with laser ablation, amnio-reduction and septostomy - Selective reduction of higher order multiples at 12 weeks - Selective termination of one twin with congenital anomalies e.g. intra-cardiac KCL injection in DCDA or cord occlusion and diathermy in MC twins Delivery - C section if indicated or complications - Induction at 37 weeks for DCDA - Induction at 36 weeks for MCDA/MA - CTG, epidural, oxytocin, EVC, ventouse

HIV after birth

- Continue HAART - Commence neonatal PEP within 4h birth for 4 wks - PCP prophylaxis in HIV neonates from 4 wks

Copper IUD

- Copper ions are toxic to sperm and implantation is prevented - Copper wound around an inert frame which sits inside the uterine cavity - Commonly causes excessive, HMB and are poorly tolerated - Plastic strings protrude through the cervix and are pulled to remove the device

Features of genital candidiasis

- Cottage cheese thick, white discharge without odour, itching, soreness - Vaginitis and vulvanitis (pink )

HIV and pregnancy

- Counselling for HIV positive couple - Risk of transmission through unprotected sex 0,03-1% - If mother +ve self-insemination with sperm - Sperm washing in male +ve - Donor sperm - IVF - Rx: zidovudine plus lamivudine, but tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable alternatives. The 3rd agent in HAART should be nevirapine if CD4 <250 - Should be on HAART by 24 wks - Zidovudine monotherapy in women planning C-section

Mendelson's syndrome

- Cyanosis, bronchospasm and pulmonary oedema due to inhalation of gastric acid during anaesthesia - Prevent with pre-operative ranitidine, NBM, entubation and aspiration of stomach contents

Premenstrual syndrome (PMS) and RX

- Cyclical symptoms including tension, irritability, aggression, depression occurring during the luteal phase (7-10 days before menses) may extend into menses - Resolves when menstruation stops - Other symptoms include bloating, GI upset and breast pain and headaches - Occurs in 50%-80% women - May result from genetics, serotonin deficiency, magnesium or Ca+ deficiciences - RX SSRIs, COCP, HRT, GnRH agonists with add-back therapy - Oil of evening primrose, vitamin B6, CBT

Hep B and C in pregnancy

- DNA virus - Spread through blood, sexual,IV drug use , vertical - Non-specific sympons , mild to moderate viral illness - Effects on pregnancy: miscarriage or preterm labour no congenital defects/ Not teratogenic. - Effect of foetus: transplacental/ delivery transmission, fatal infection to neonate. Increases HCC and cirrhosis risk. Become carrier - Rx screen for hep B at booking, vaccination b4 pregnancy - Infants with Hep B vaccine within 12 hrs

VZV in pregnancy

- DNA virus, droplets, vesicle fluid - Foetus: eye lesions, mental retardation, microcephaly, atrophy

Uterine rupture (emergency)

- De novo tear or old C section scar ruptures and leads to extrusion of the foetus into the abdomen - Causes acute foetal hypoxia - Massive maternal haemorrhage with lower abdominal pain, bleeding, cessation of contractions, collapse and shock

Cord prolapse

- Descend of the cord below or adjacent the presenting part after rupture of membranes - Can be compressed physically or go into vasospasm due to the cold - Leads to foetal hypoxia and distress - Cord is visible at the introitus - Foetal bradycardia and decelerations are evident on CTG

Syndromes associated with endometrial cancer

- Diabetes mellitus - Lynch II (familial non-polyposis colorectal cancer) - FHX of endometrial, ovarian or colon cancer - Cowden syndrome - mutated PTEN leads to loss of TSG - MMR mutations HER2 and neu mutations

Features of shoulder dystocia

- Difficulty delivering the head or chin - Turtle-necking - Failed restitution - Failure of shoulders to descend

Herpes simplex virus

- Direct contact - C-section recommended for genital HSV in labour, in UK women are allowed to deliver

Multiple pregnancy 1B

- Dizygotic - different oocytes fertilised by different sperm dichorionic diamniotic (DCDA) - Monozygotic - single zygote divides into identical twins: - Incomplete division in this manner results in conjoined twins - Chorionicity is determined by ultrasound at 11-14 weeks

Complications of PET in the mother

- Eclampsia and seizures - Stroke - Liver failure - Liver rupture, infarction and haemorrhage - DIC - HELLP syndrome - Renal failure - Pulmonary oedema

Complications of gonorrhoea

- Ectopic pregnancy - Infertility - Blindness and conjunctivitis in neonates - Disseminated infections - Chronic pelvic pain - Fits-Hugh-Curtis syndrome - peri-hepatitis and violin-string adhesions

Treatment for shoulder dystocia

- Elective C section for macrosomia

Diagnosis and treatment for gonorrhoea

- Endocervical or vulvovaginal swab - Send for culture, NAAT, culture, urinalysis (men) PCR ->Gram negative diplococci - HIV test and syphilis

Gynaecomastia

- Enlargement of male breast tissue - Due to increased oestrogen activity - Obesity - pseudo-gynaecomastia - Puberty - Old age - Cirrhosis - Drugs - alcohol, cannabis, heroin, anabolic steroids, cimetidine, spironolactone, digoxin, antipsychotics - Klinefelter's syndrome - Leydig cell tumour - Sertoli cell tumour - Treat with tamoxifen, danazol, surgery

gynacomastia

- Enlargement of male breast tissue - Due to increased oestrogen activity - Obesity - pseudo-gynaecomastia - Puberty - Old age - Cirrhosis - Drugs - alcohol, cannabis, heroin, anabolic steroids, cimetidine, spironolactone, digoxin, antipsychotics - Klinefelter's syndrome - Leydig cell tumour - Sertoli cell tumour - Treat with tamoxifen, danazol, surgery

Amniotic fluid embolism

- Entry of amniotic liquor into the maternal circulation - Leads to anaphylaxis, dyspnoea, hypoxia, hypotension, shock, seizures and cardiac arrest - Also increases the likelihood of DIC, pulmonary oedema and respiratory distress in survivors - Foetal distress and hypoxia

Complications of chlamydia

- Epididymitis - Reactive arthritis - Newborn conjunctivitis - Pneumonia - Ectopic pregnancy - Infertility due to tubal damage (in women) Inflammatory response to dead bacteria -> Results in scarring in the tube, can be fixed surgically - Pelvic inflammatory disease

Tests for PTL

- Examination - contractions, cervical dilatation, rupture of membranes - Predict likelihood of preterm birth with cervical length as seen on TVUS - Foetal fibronectin present - CTG and foetal blood sampling - Infection - vaginal swab, MSU, CRP, WCC Prevention of PTL# - Cervical cerclage - sutures to strengthen cervix at 12-14 weeks - Progesterone - Treat infections - Selective termination of pregnancy to reduce higher order multiples - Amnio-reduction for polyhydramnios - NSAIDs for polyhydramnios - risks premature closure of ductus arteriosus

Ix Bartholin cysts

- Examination palpable painless cysts - Culture of Dx - >40 YO biopsy to exclude cancer

Obesity and pregnancy 2B

- Exercise, diet, weight loss - Folic acid 5mg/day - Vitamin D 10mcg/day - Maintain weight during pregnancy, don't lose weight - Consultant-led care - BMI >40 requires thromboprophylaxis

Ix in maternal sepsis 1B

- FBC, cultures (before giving Abx then give don't wait for results), lactate within 6 hrs (ABG), AXR, U&Es, CR, throat swab, Pelvic USS, genital swab

IX FOR HELLP

- FBC: thrombocytopaenia, low Hb, prolonged PT and APTT - LFT: raised - Bilirubsin: raised - LDH: raised

Signs of leiomyomata 2B

- Features of anaemia - Abdominal mass continuous with uterus - Large uterus

Features of puerperal sepsis

- Fever, rigors - foul smelling profuse bloody dx - Tender bulky uterus on examination - Abdominal pain, diarrhoes, vomiting - Tachy - Rash

breast cancer protective factors

- First child - Exercise - Breastfeeding

Features of bacterial vaginosis

- Fishy smell/malodourous - White-greyish thin dx - Alkaline dx Ix and treatment of bacterial vaginosis# - Can cause PID and preterm labour - IX - swab, raised vaginal pH, positive Whiff test with KOH, clue cells on microscopy - RX - metronidazole, clindamycin

CMV in pregnancy

- Foetal effects later demonstrate deafness, learning disability, and/or delayed psychomotor development.

Missed miscarriage

- Foetus has died in utero <20 wks w/out placenta detachment - Closed cervical os - Foetus is dead but still inside the uterus - Not recognised until USS

Breech presentation

- Foetus presenting butt first - Associated with cord prolapse, preterm labour, birth trauma or maternal morbidity or ROM

other causes of dx

- Foreign bodies - Chemical (drugs) - Stricture

Uterine inversion

- Fundus of the uterus inverts into the uterine cavity - Leads to haemorrhage - Pain - Shock - RX resuscitation, push the fundus back up manually, pump warm saline in to push it back up or surgical correction

Treatment for prolapse 1B don't have to know

- General - reassurance, weight loss, stop smoking, physiotherapy, pelvic floor exercises - Pessary - unfit for surgery, don't want surgery, reduces the prolapse - Ring pessary - can have sex, less effective - Shelf - more effective, cannot have sex, good for no uterus - Change every 6-9 months - Can cause pain, urinary retention, infection, fall out - Oestrogen - topical, HRT for vaginal atrophy, dryness, ulceration, post-menopausal - Mesh repair - Vaginal hysterectomy - Hysteropexy - uterus and cervix attached to sacrum with a mesh - Sarcocolpexy - fixation of vaginal vault to sacrum with mesh - Sacrospinous fixation - vaginal vault to sacrospinous ligament - Urethral prolapse - urethropexy or mid-urethral sling - TVT, TOT and colposuspension for stress incontinence

Treatment for PCOS

- General - weight loss, exercise - Medical - COCP, Mirena IUS if not wanting babies - cyproterone acetate,spironolactone, metformin, orlistat - Conception - clomiphene (anti-oestrogen) add dexamethasone if fails - metformin, aromatase inhibitors e.g. letrozole - Mechanical hair removal - laparoscopic ovarian diathermy or drilling reduce the amount of functional ovarian tissue to reduce androgen production, also reduces inhibin production, allowing FSH to rise and stimulate ovarian aromatase) can restore ovulation and result in pregnancy rates of 25% to 65%. - Gonadotrophins - IVF

Aetiology of PCOS

- Genetics - Raised LH and insulin levels increase ovarian androgen production - Androgens disrupt follicle genesis and lead to excessive numbers and anovulation - Associated with T2DM and obesity

Chlamydia trachomatis 1A

- Genital tract infecntion caused by chlamydia trachomatis -> small bacterium - Most common STI - Transmitted urogenitally, rectally, pharyngeally, vertically

Cancer and HPV

- HPV 16,18 associated with cancer - Acts on genes controlling the cell cycle especially P53 o P53 patrols DNA: repairs, or discards it o Prevents cells from recognising mutations

Risk factors for cervical cancer

- HPV infection - high risk behaviours (risk factors for HPV infection): multiple partners, other STIs (HSV, trichomonas) early age at first intercourse high risk male partner - smoking

History for Amenorrhoea

- Have menses ever occurred - If so were they regular - How long and how heavy - Discomfort with menses - Breat tenderness/mood changes - Systems review inc: - Galactorrhea, headaches, and visual field defects: Pituitary disorders - Fatigue, weight gain, and cold intolerance: Hypothyroidism - Palpitations, nervousness, tremor, and heat intolerance: Hyperthyroidism - Palpitations: Anorexia nervosa with electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) - Acne, hirsutism, and deepening of the voice: Androgen excess - For patients with secondary amenorrhea, hot flushes, vaginal dryness, sleep disturbance, fragility fractures, and decreased libido: Estrogen deficiency - PMH - Functional hypothalamic anovulation, such as stress chronic illness new drugs and a recent change in weight, diet, or exercise intensity - In patients with secondary amenorrhea, Asherman syndrome (eg, D & C, endometrial ablation, endometritis, obstetric injury, uterine surgery - DHx - Drugs that affect dopamine (eg, antihypertensives, antipsychotics, opioids, tricyclic antidepressants) - Cancer chemotherapy drugs (eg, busulfan, chlorambucil, cyclophosphamide) - Sex hormones that can cause virilization (eg, androgens, estrogens, high-dose progestins, OTC anabolic steroids) - Contraceptives, particularly recent use - Systemic corticosteroids - OTC products and supplements, some of which contain bovine hormones or interact with other drugs - FHx: genetic disorders - Examinations: BMI, secondary sexual charasteristics, galactorrhoea,

Process of termination of pregnancy

- Hb, blood group, rhesus status, anti-D, screen for STI, discuss contraception - Suction curettage/manual evacuation/ dilatation + vacuum aspiration ± curettage: - 7-14 weeks, prepare with vaginal misoprostol, prophylactic antibiotics, dilatation and evacuation with suction cannula - Medical - , mifepristone anti-progesterone ( pregnancy cant be maintained, uterus thins/sheds in hrs) then misoprostol after 48 hours - best done before 7-9 weeks but can be done whenever as an alternative to suction - most effective for 14-24 weeks too - If from 22 weeks, foeticide via KCL injection first

- Posterior compartment prolapse (Rectocele and enterocoele)

- Hernia of the posterior vaginal segment often associated with descent of the rectum or small intestine - Rectocele - The anterior wall of the rectum is prolapsed with the lower two third of the posterior vaginal wall - Enterocele - (hernia of the pouch of Douglas) The upper third of the posterior vaginal wall descends lined by the peritoneum of the Douglas pouch and containing loops of the intestine

Type 2 endometrial carcinoma

- High-grade - Endometrioid, clear cell or serous - P53 mutation (10%) - Oestrogen-insensitive

Rubella in pregnancy

- Highly infectious RNA togavirus, pread by droplets (inc 14-21 days) - Symtpns: maculopapular rash, arthralgia, lymphoadenopathy, mild febrile - In foetus: causes vascular damage, sensorineural deafness, PDA, VSD, congenital cataracts, microphthalmia, and glaucoma, microcephaly and mental retardation - Infections >16 weks gestations defects rare - Later causes: DM, thyroid dz, panencephalitis. - Ix rubella IgG abds and IgM - Rx- vaccine before pregnancy, contraindicated 10-12 wks

Ix for ectopic pregnancy

- Hx - Positive pregnancy test - beta-hCG - TVUS - doughnut sign, ring of fire sign, free fluid in the pouch of Douglas, empty uterus - Curettage/biopsy: exclude an ectopic pregnancy by demonstrating histologic evidence of products of conception - Serum hCG - raised, 48 hours later between a decline of 50% and an increase of 63% - Culdocentesis: shows presence of free blood in peritoneal cavity - Laparoscopy

Features of multiple pregnancy

- Hyperemesis gravidarum - Large for dates, large SFH - 2 foetal heart rates on USS over 2 poles - A multiplicity of foetal parts on examination and USS # -

Treatment of gonorrhoea

- IM ceftriaxone+ PO Azithromycin - Spectinomycin - Avoid sex, contact tracing

RX FOR HELLP

- IV Mg sulfate prophylaxis for eclampsia/seizures (6g IV stat , then 2g/hr) - Phenytoin - DELIVERY and IV dexamethasone - Antihypertensives (labetalol, hydralazine, methyldopa) - Anti-D

Treatment for molar pregnancy

- IV fluids and resuscitation with blood products - Anti-emetics - ondansetron - Ranitidine H2 antagonism - Hysterectomy - ERPC - Vacuum aspiration - Serial blood and urine HCG after therapy - Hormonal contraception prevent it happening - Anti-D

Ix and treatment of candidiasis ( genital)

- IX - high vaginal swab (gram stain- blue eggs and worms), culture, microscopy shows hyphae and budding - RX - topical clotrimazole pessary, oral fluconazole, amphotericin and nystatin, imidazole> nyostatin

Primary dysmenorrhoea

- Idiopathic dysmenorrhoea, no pelvic pathology/organic disease - Can also experience nausea, vomiting, diarrhoea, fatigue and headache - common in adolescents

Rx for breech presentation

- If early resolves by 8 weeks - External cephalic version (ECV) : attempted d conversion of breech to vertex by manualmanipulation through maternal abdomen done at 36 wks

Delivery in diabetes

- If well-controlled spontaneous - Induce At 38 wks if on insulin - C-section due to birth trauma/dystocia risk - Insulin and dextrose during labour aim for 3.5-6.5 mmol to reduce hypoglycaemia in baby - Steroids for <34 weeks

Ectopic pregnancy

- Implantation of the embryo outside the endometrial cavity - 95% occur within the fallopian tube, - Occurs in 1 in 100 pregnancies - Other sites - cornu, cervix, ovaries, intra-abdominal - Trophoblastic invasion of the thin fallopian tube leads to bleeding and rupture with intraperitoneal haemorrhage, peritonitis and acute abdominal emergency - Commonly presents as as abdominal pain and bleeding in a pregnant woman before 24 weeks' gestation

Aetiology of preterm labour

- Increased contents multiple pregnancy, polyhydramnios, increased cervical and uterine stretch - Foetal survival response IUGR, pre-eclampsia, infection, abruption - Uterine abnormalities uterine fibroids, congenital anomalies - Cervical incompetence painless cervical dilatation secondary to surgery e.g. LLETZ - Cervical and uterine damage secondary to infection chorioamnionitis, offensive liquor, neonatal sepsis, endometritis, bacterial vaginosis, GBS, trichomoniasis, chlamydia - Others: DM, HTNm smoking , drugs alcohol

Effects of GDM In the motherEffects of GDM In the mother

- Increased insulin requirements by 300% - Ketoacidosis - Hypoglycaemia - UTI, wound and endometritis - PET - Heart disease - C section or instrumental delivery - Nephropathy and retinopathy both deteriorate - Polyhydromnios - Preterm labour - Hypoglycaemia

Complications in the mother

- Infection - Risks of instrumental delivery and C section

Gonorrhoea 1A

- Infection caused by Neisseria gonorrhoea - Alost always through sex but through birth

Acute mastitis

- Infection of brest tissue, common in those lactating - Occurs during the first month of breastfeeding due to local infection of staph A or strep - Lactating mastitis - staph A or strep - Non-lactating mastitis - smoking-related - Symptoms include Erythema, pain, fever and discharge, flu-like symptomns - Nipple dx, lymphoadenopathy and decreased milk outflow Ix- Breast USS, aspiration, cytology, milk culture, biopsy , pregnancy test, mammogram Rx - Oral flucloxacillin for 2 weeks - Analgesia, fluids, expression of milk - Surgical drainage and aspiration

Endometritis (2B)

- Infection of the uterus esp. the endometrium - Common after C-section can also occur with STI, C section, intrauterine procedures, IUD, retained products of conception, cancer - Symptoms include tenderness, fever, pyometra, pelvic/abdominal pain, VG bleeding or Dx - IX- blood cultures, urinalysis, clinical diagnosis - RX ERPC, antibiotics (gentamycin+ clindamycin) - Complications: thrombophlebitis, septic shock, peritonitis

Septic miscarriage

- Infection within the uterus results in death of the foetus - Offensive vaginal loss and bleeding - Tenderness, fever, pain, peritonism

Aex of puerperal sepsis

- Infections in uterus o C/S o PROMs o Chorioamnionitis o Prolonged labour o Multiple pelvic exams o Internal foetal monitoring o Perineal wound infection o UTI - Anaemia - Mastitis - Skin and soft tissue infections: cannula, injection sites, C/S wounds - Thhrombophebitis - RespTI - HX group B strep nfection - Immusupression - Diabetes - Obesity

Syphilis

- Infectious dz caused by Spiral spirochaete - treponema pallidum - Sexual, bloodborne and transplacental transmission - Commonly co-infected with HIV

Management of GDM

- Initially dietary modification if <7mmol then metformin - If >7.0 mmol then INSULIN - Tight glycaemic control- consider switching to Insulin if fasting glucose >5.8 mmol and post prandial >11.1mmol - Stop oral hypoglycaemic except metformin - Optimise glucose control - fasting glucose 4-7mmol/L - Folic acid 5mg OD - Stop statins - Change anti-hypertensives to labetalol, nifedipine and methyldopa - Monitor renal (creatinine clearance) and BP, Monitor HbA1c, glucose, - Aspirin 75mg - Foetal echocardiography and USS at 32 and 36 weeks - Monitor glucose- post natally for 2 wks

Preterm delivery/labour

- Intense and frequent uterine contractions between wk 20-37 which cause effacement and dilation - Delivery between 24-37 weeks' gestation - Delivery before 24 weeks' is termed as a miscarriage - At 24 weeks - 1/3 die, 1/3 survive, 1/3 are handicapped - At 32 weeks - risk of death/handicap is 5%

Features of Intrahepatic cholestasis of pregnancy

- Intense pruritis in 2nd or 3rd trimester - Dark urine - Jaundice

Complications in the baby from PTL

- Intensive care - Perinatal mortality increased - Cerebral palsy risk - Chronic lung disease risk - Blindness - Disability - Cognitive and behavioural problems

Complications of leiomyomata 2B

- Iron deficiency anaemia - Polycythaemia- due to increased erythropoietin production as part of a paraneoplastic syndrome. - Enlargement and mass effects - Torsion of a pedunculated fibroid leads to acute pain - Carneous/red degeneration - inadequate blood supply leads to haemorrhage into the fibroid, pain, tenderness, necrosis, occurs during the 3rd trimester due to most blood being diverted to the foetus - Hyaline/cystic degeneration - liquefaction of the fibroid - Sarcomatous change into a leiomyosarcoma - fibroids GROWING in postmenopausal women, enlarging rapidly or sudden onset of pain (0.1%) - Infection - Abscess - Disturbance of local architecture - Bowel and bladder symptoms - HRT in menopause can cause fibroid growth - Infertility with submucosal intrauterine fibroids

Ix and Rx for Intrahepatic cholestasis of pregnancy

- Ix: fasting total serum bile acid level of > 10 mmol/L, severe >40mmol/L, LFTs, coagulation profile, hepatitis ABC, EBV, CMV, anti smooth muscle and anti-mitochondrial abs, dipstick proteinurea, CTG for foetal well being - Rx admit on same day, Ursodeoxycholic acid (UDCA) 5 mg/kg po bid or tid, antihistamines, menthol cream, vitamin K, foetal surveillance in severe disease. C/S or induction as sudden fetal death can occur, repeat LFTs every 1-2 weeks

Diagnosis and treatment for chlamydia

- Ix: swab (urethral,vaginal) , culture, urine PCR, NAATs and PCR - Rx: Doxycycline (100mg BD for 7 days) , azithromycin (1g single dose PO), Ceftriaxone , contact tracing

Foetal distress

- Lack of oxygen/nutrients to foetus during pregnancy or labour - Signs during pregnancy or birth that the foetus is unwell - Suspect with CTG - Confirm with foetal blood sampling - pH <7.2 is hypoxia, pH <7 leads to neurological damage

Miscarriage

- Loss of foetus before 24 weeks - Delivery of a dead foetus before 24 weeks - Most occur within the 1st trimester - 13 weeks - Threatened, inevitable, complete and incomplete - Any PV bleeding <24 weeks - painless/painful = threatened miscarriage

Post-partum haemorrhage definition PPH (1B)

- Loss of more than 500m Lblood time of vaginal delivery or >1000mL with C/S - early (immediate) - within first 24 h postpartum - late (delayed) - after 24 h but within first 6 wk

Management for ectopic pregnancy

- Low risk - expectant management HCG<200IU/L , no evidence of fetal cardiac activity, and willingness to comply with close surveillance, ectopic mass <3cm - MTX 50mg/m2. HcG <5000, <3.5-4, no embryonic cardiac activity, haemodynamically stable. - MTX side effects (nausea, vomiting, bloating, transient transaminitis) are generally mild. - Acute - admission, IV fluids, anti-D, surgical salpingectomy - Subacute - medical used for lower hCG, single dose of methotrexate, monitor hCG until normal, second dose needed in 15%, surgery needed in 10% - Surgical - used for pain, foetal heart activity, very high hCG salpingostomy (preserves fertility is other tube is also damaged, 10% of repeat surgery needed, increased risk of another ectopic) OR salpingectomy (used for complete family, if other tube is patent)

Features of ectopic pregnancy

- Lower unilateral, iliac fossa abdominal pain, colicky at first as tube extrudes the sac then becomes constant - Syncope - Referred pain to shoulder tip - phrenic nerve/diaphragmatic irritation - Dark vaginal bleeding - Collapse - History of amenorrhoea for 4-10 weeks - Haemodynamic instability: Tachycardia, hypotension, abdominal tenderness, peritonitis - Cervical excitation - Adnexal tenderness or mass - Closed cervical os, small uterus

Aetiology of shoulder dystocia

- Macrosomia - Induction of labour - Maternal diabetes mellitus leading to macrosomia - Obesity - Instrumental delivery

Cocaine in pregnancy

- Mainly placenta abruption or spontaneous abortion. intellectual impairment, limb reduction defects, IUGR, cerebral infarction porencephalic cysts, microcephaly, bowel atresias, necrotizing enterocolitis. Maternal complications Seizures, death.

Intra-partum complications of multiple pregnancy

- Malpresentation - Foetal hypoxia - Cord prolapse - Placental abruption - Post-partum haemorrhage - Vasa praevia - Entanglement

signs and symptoms of breast ca

- Mammography - calcifications without density - Fixed, firm, non-mobile, poorly-circumscribed lump - Painless breast lump - 45% occur in the upper outer quadrant - Hard, irregular, radio-dense mass - Unilateral breast pain - Bloody discharge - Puckering, dimpling, change in size, nipple eversion/inversion, retraction - Paget's disease of the nipple - Invasion of pectoralis causes chest wall fixation - Dermal invasion causes dimpling/puckering - Central portion invasion causes nipple retraction - Axillary adenopathy - internal mammary, supraclavicular, para-sternal - Oedema of the skin with tethering to the breast by the ligaments of Cooper leads to p'eau d'orange - Features of metastasis

Common complaints of the puerperium

- Mastitis/abcess : s.aureus, fever, chills, breast erythema, oedema, tenderness - Nipple thrush (pain while feeding, cracked flaky skin, burning itching, shiny areola ) - Endometritis : fever , uterine tenderness, fooul discharge, increased bleeding. Polymicrobial. Rx broadspectrum Abx - Necritising fasciitis - depression - psychosis

Features of T. vaginalis

- May be asymptomatic - Purulent, offensive, grey-yellow-green discharge, frothy - Vulvovaginitis and cervicitis (strawberry vagina/ cervix) - Urethritis, cystitis

Clinical monitoring of foetal distress

- Meconium staining - Intermittent auscultation of foetal heart rate - Pinard stethoscope, Doppler Sonicaid - CTG - If CTG abnormal FBS hypoxia delivery via forceps, ventouse or C section - ABG - CXR - Foetal scalp blood sampling to measure lactate

Depression in pregnancy

- Medications should be ctnd - Use lowest effective dose , glucose test if on diabetogenic anti-psychotics- atypical i.e quitiapine - Avoiding sedating agents before delivery - Ask about mental health/ wellbeing at each visit - Postpartum depression in 3-15% increased risk if prior depression or post-partum depression - peak onset 2-3 months postpartum may resolve spontaneously 6-12 months - Supportive care, medication if necessary - Post-partum psychosis increased risk if FH of mental illness, prior post-partum risk.

Dysmenorrhoea definition

- Menstrual pain before or during period, charcatrised by LAB pain and cramping - Pain may radiate to back or lower thigh - High endometrial prostaglandin levels lead to contraction and ischaemia of the endometrium and thus pain - Can be Primary or secondary

Features of trophoblastic disease

- Missed menstrual periods due to technical pregnancy - Vaginal bleeding--> common - Severe nausea and vomiting, hyperemesis gravidarum due to raised beta-hCG levels - Anaemia - Hyperthyroidism due to hCG homology to TSH - Large uterus for gestational age/abdominal mass

Uterine fibroids (leiomyomata) 2B

- Monoclonal benign tumours of the myometrium caused by oestrogen stimulation of muscle proliferation and progesterone stimulates production of proteins that inhibit apoptosis - Can be single, multiple and range in site and size - Smooth muscle and fibrous tissue, histologically give a whorled appearance - Intramural, sub-serosal (can be pedunculated), submucosal etc. - Common in pre-menopausal women >35 (40-50%) - Common in blacks, larger and develop earlier - Can become malignant 1:1000 - Regress after menopause usually - Occurs in many sites inc. oesophagus, small bowel, skin . Uterus most common

Type 1 endometrial carcinoma

- Most cases - Low-grade - Common in younger women - Oestrogen-sensitive - Obesity-associated - Adenocarcinoma

Bacterial vaginosis

- Most common cause of vaginal discharge in women - Due to lack of lactobacilli infection by G. vaginalis, paptostreprocci, mycoplasma, fusobacteria, streptococci - Associated with oral sex, changing partners, black ethnicity, smoking, IUD

Endometrial cancer (carcinoma) 1B

- Most common gynaecological cancer - Usually adenocarcinoma - Seen in elderly women over 60 years of age with postmenopausal bleeding - Oestrogen causes mitosis via over-activation of cyclin D - Mutations then result in carcinogenesis - loss of PTEN, KRAS, P53 and HER2 mutations

Carcinoma of the breast

- Most common malignancy in women - 1/8 of women that live to 80 get breast cancer - >40 YO - Mostly adenocarcinoma,mostly involves glandular breast cells in ducts or lobules - Can be: -ER-positive/Her2-negative, --> 80%, oestrogen drven growth, respond to tamxifen (ER blocker), mets to bone after 6 yrs -Her2-positive ( human epidermal growth factor-2) make too many receptors --> uncontrolled growth of breast tissue --> fast and aggressive -ER-negative, HER2-negative, PR-negative

birth injuries

- Moulding - natural phenomenon, leave alone - Cephalhaematoma - sub-periosteal swelling, bleeding limited by suture lines, fluctuant, can cause jaundice - Caput - scalp oedema, above the periosteum, not limited by suture lines, occurs due to ventouse (chignon - large caput), disappears within days - Erb's and Klumpke's palsies - Skull fractures - Facial fractures

Features of gonorrhoea

- Muco-purulent cervicitis with a milky-white thick discharge - Women: often asymptomatic but may have Urethritis, pelvic infection, dyspareunia, intermenstrual bleeding and post-coital bleeding, - Men: urethral dx

Emergency contraception AE

- N/V (take antiemetic one hour prior) - contact healthcare professional if vomit one hour within taking dose - abdominal pain, HA, menstrual changes - pregnancy test if no menses within 3 weeks - back up method for 7 days - alter cycle by 1 week ahead or delayed - no max doses per month

Estrogen excess AE

- Nausea - breast tenderness - HA - weight gain from fluid retention - dysmenorrhea - menorrhagia - uterine fibroid growth

Anovulatory amenorrhoea

- No release of any eggs ever - Malfunction in hypothalamic-pituitary-ovarian axis - Can be dysfunction in ovaries, hypothalamus or pituitary - Endocrine disorders that cause androgen excess (particularly polycystic ovary syndrome) - Hypothalamic dysfunction congenital gonadotropin-releasing hormone deficiency, GnRH receptor gene mutations that result in low FSH and estradiol levels and a high LH level, Prader-Willi syndrome. Brain injury, tumours in hypothal, infiltrative dieorders (TB, sarcoidosis, lymphoma), excessive exercise, drugs, chronic disorders - Pituitary dysfunction aneurysms, hyperprolactinaemia , Idiopathic hypogonadotropic hypogonadism or Kallmann syndrome (secondary), pituitary necrosis (sheehan syndrome), brain injury, Pit tumours - Ovarian dysfunction Autoimmune disorders (Autoimmune oophoritis as may occur in myasthenia gravis, thyroiditis, or vitiligo, chemo, metabolic disorders ( addisons, DM, galactosema), mumps

Ix for PCOS

- Normal FSH - Raised AMH, LH, testosterone - Raised LH to FSH ratio - Low SHBG - TFTs, prolactin, TVUS, OGTT, fasting glucose, lipids - Ultrasound - >12 peripheral follicles, hyperechoiec stroma, increased ovarian size >10ml, string of pearls appearance, 2-8mm size follicles

Features of PCOS

- Obesity and OSAS - Acanthosis nigricans - Acne - Hair thinning - Hirsutism - Amenorrhoea - may lead to endometrial hyperplasia - Irregular menses or amenorrhoea - Subfertility - Miscarriage - Alopecia - Psychological - mood swings, depression, anxiety, low self-esteem

Complications of placenta praevia

- Obstruction of engagement of the head - Transverse lie - Breech presentation - Prolonged or obstructed labour - Ante-partum haemorrhage - PROM - Placenta accreta or percreta (implant in a scar/uterine wall) (implant and invade through the uterine wall) - Increta - halfway through uterine wall - Vasa praevia

Normal Labour 1B

- Occurs between 38-42 weeks - 3 stages - Regular painful contractions become frequent and stronger as labour progesses - In pregnancy progesterone inhibits uterine contractions - End of pregnancy --> increased oestrogen --> increases oxytocin receptors - Stimulates prostaglandins release from placenta -> enzymes --> digest collagen and soften cervix

Oestrogen in breast cancer

- Oestrogen promotes DNA replication and cell division promotes growth - Accumulation of genetic damage on this background can then cause carcinogenesis - ER-positive BRCA2 pathway - HER2-positive amplification of HER2 - ER-negative BRCA1 pathway, loss of P53 - On this background carcinoma in situ occurs then invasion cancer when basement membrane is destroyed, increased proliferation, escape from growth inhibition, angiogenesis and stromal invasion

Rx for lack of arousal in female lack of arousal

- Oestrogens (HRT) - Testosterone - Bupropion - selected cases - Psycho-sexual counselling

Aex leiomyomata 2B

- Older age - Black and Asian ethnicity - Obesity - Early menarche - FMH - Parity, COC, progestogens - all protective

Risk factors for miscarriage

- Older maternal age - Bacterial vaginosis - Thrombophilia - Previous miscarriage - Chromosomal defects - CNS malformations - Maternal illness - Cervical incompetence - Viral or bacterial infections - APS - Infections : coxsackie, listeria - Genetic : trisomy, monosomy, triploidy - Uterine abnormalities- cervical weakness - Multiple pregnancy - Obesity - Alcohol, smoking - <19 or >45 - Trauma

Inevitable miscarriage

- Open cervical os - Heavy bleeding - cramping - Miscarriage is about to occur - Foetus may still be alive

Incomplete miscarriage

- Open cervical os - Some foetal tissue has been passed - bleeding - Some tissue remains

AEx of cholestasis pregancy

- Oral contraceptives - Genetic - familial intrahepatic cholestasis - familial cholelithiasis

contraception Options for acne

- Ortho-tri-cyclen - Estrostep - YAZ

induction of labour

- PGE2 gel or PGE2 pessary into posterior fornix - Initiates labour and ripens cervix - Misoprostol can also be used Amniotomy and oxytocin - Fore-waters are ruptured with an amnihook - Oxytocin infusion is started Membrane sweep - Passage of finger through the cervix - Strips membranes and lower segment of uterus from eachother - Releases prostaglandins

Complications of bac vaginosis

- PID - Post-abortion and postpartum endo - Chorioamnionitis - PROM - Preterm labour - Preter birth

Risk factors of PET

- PMH of hypertension during pregnancy - Chronic kidney disease - Autoimmune disease - Diabetes mellitus - Chronic hypertension - Nulliparity - Age >35, <17 maternal age - No pregnancy for 10 years or more - BMI >35 - FH of PET - Multiple pregnancy - Foetal hydrops - Molar pregnancy

Risk factors for pre-term delivery

- PMH of preterm labour - Low socioeconomic status - Extremes of maternal age - Short inter-pregnancy interval - Maternal disease - Pre-eclampsia - IUGR - Male foetus - Raised haemoglobin - STIs - Bacterial vaginosis - Cervical surgery - Multiple pregnancy - Uterine fibroids - UTI - Poor dental health - Polyhydramnios - Congenital foetal anomalies - Ante-partum haemorrhage

PROM/PPROM

- PROM is rupture of membranes before labour >37weeks - PPROM is rupture of membranes <37 weeks gestation - Leads to preterm delivery - Can lead to infection mainly by group B strep and E.coli (chorioamnionitis, neonate sepsis), cord prolapse, absence of liquor - Characterised by gush of clear fluid or leaking - Risk factors for PROM: ascending STI (i.e bacterial vaginosis ) weaken membrane , smoking, Prior prom , polyhydramnios. - Ix include USS and CTG, bloods - Rx: Admission steroids and IV ABX, deliver if >34 weeks - <24 week termination;

Complications of miscarriage

- Painful - Heavy vaginal bleeding - Septic shock and infection - Asherman's syndrome (fibrosis of endometrium)

Aetiology of antepartum haemorrhage

- Placental abruption - Placenta praevia - Genital pathology - cervical ectropion, cervicitis, polyps - Uterine rupture - Vasa praevia

Maternal recommendations epilepsy 2B

- Preconception counselling w/ neurologist - High dose folic acid pre-pregnancy - Always shower with door open/ sleep with someone

Tests for miscarriage

- Pregnancy test - USS to confirm - hCG is raised but declines >50% over 48 hours - FBC, Rhesus group and RhD status due to sensitising event Ultrasound: - Empty uterine sac - Mean sac diameter >25mm - CRL>7mm - No foetal heartbeat - Empty uterine cavity in complete - Visible dead foetus in missed without heartbeat

Endometrial hyperplasia with atypia

- Premalignant disease of the endometrium - 30-50% of cases progress to cancer ( good prognosis ) - Unopposed oestrogen results in hyperplasia - Further stimulation then causes atypia - increased gland-to-stroma ratio - Can result in bleeding, post-menopausal bleeding, abnormal uterine bleeding -

Effects of leiomyomata on pregnancy

- Premature labour - Miscarriage - Malpresentation - Transverse or oblique lie - Obstructed labour, prolonged labour - Postpartum haemorrhage

Aetiology of breech presentation

- Prematurity - Twin pregnancy - Placenta praevia - Pelvic tumours and deformity - Idiopathic - Polyhydramnios - Foetal anomalies

Adenomyosis

- Presence of endometrial tissue within the myometrium - endometriosis interna - Leads to endometrial enlargement, oestrogen-dependent symptoms and heavy bleeding - Dysmenorrhoea (not as common as in endometriosis) - Enlarged and tender uterus on examination - IX : TVUS, MRI, ultrasound - myometrial cysts and bulkiness - RX :Mirena IUS, COCP, NSAIDs, tranexamic acid, hysterectomy for severe

Aetiology of cord prolapse

- Preterm delivery - Breech presentation - Polyhydramnios - Abnormal lie - Multiple pregnancy - Induction of labour and amniotomy

Complications of T. vaginalis

- Preterm labour - Low birthweight - Other STIs

Features of genital herpes

- Primary infection causes a flu-like illness - Then vesicles occur within 2 days and burst, crust over and heal on a background of erythema - Adenopathy (inguinal ) - Dysuria - Vaginal/ urethral discharge - Resolve by themselves in 17-20 days - Recurrences of 4-6 per year

Pelvic organ prolapse 1B

- Prolapse - descent of the uterus or vaginal walls beyond normal anatomical confines - Herniation of bladder, urethra, rectum or small bowel behind the vaginal wall - Elderly women with history of childbirth - Poor pelvic floor support - cardinal and uterosacral ligaments, endo-pelvic fascia and the levator ani/perineal body

Lobular carcinoma in situ

- Proliferation in lobules that grows discohesive - Loss of TSG E-cadherin due to CDH1 mutations - Leads to loss of attachment to adjacent cells due to lack of E-cadherin - no palpable mass, no mammographic findings, usually incidental finding on breast biopsy for another indication - LCIS is a risk factor for invasive carcinoma (approximately 1%/yr) - RX excisional biopsy, surveillance, tamoxifen

Aetiology of foetal distress

- Prolonged labour and contractions compressing the cord - Placental abruption - Hypertonic uterine action - Oxytocin - Cord prolapse - Maternal hypotension, eclampsia/preeclampsia - polyhydroamnios CTG indications of foetal distress# - Prolonged labour - Meconium-stained liquor - Epidural analgesia use - Oxytocin - Pre-eclampsia - IUGR - Decreased foetal movements - Doppler of umbilical artery

Slow progress and prolonged labour

- Prolonged labour is more than 12 hours time elapse after the latent phase - Defined as <0.5cm/hr after the latent phase - More common in nulliparous women - First stage - latent phase - irregular contractions, up to 4cm - First stage - active phase - regular, painful contractions, dilatation from 4-10cm - Second stage - passive phase - 10cm until head reaches pelvic floor causing desire to push - Second stage - active phase - pushing until delivery of the foetus - Third stage - delivery of the placenta

Signs of puerpal sepsis

- Pyrexia - Hypothermia - Tachy - hypotTSN - CONFUSION/ ALTERED CONSCIOUS LEVELS - raised MEOWs score

Vaccinations HPV

- Quadrivalent GARDASIL - 6, 11, 16, 18 - Cervarix BIVALENT - 16, 18 - 12-13 year old girls at school

Measles in pregnancy

- RNA paramyxovirus , spread by droplets - Features: fever, macpap erythematous rash, kolpik spots, cough, coryza - fetal loss and preterm delivery, no congenital infection or damage would be anticipated in a surviving fetus.

Tests for molar pregnancy

- Raised hCG - FBC - Ultrasound: Complete mole - enlarged uterus, mass with cystic spaces, snow-storm/bunch of grapes appearance Partial mole - enlarged placenta, cystic spaces, empty sac - Hysteroscopy with biopsy to confirm - FBC - TSH

Bowenoid papulosis

- Rare STI - Pigmented warts , dark, velvety on vagina, on the clitoris, groin folds, labia major, labia minor and/or anus. Males may be affected on the glans, shaft and/or foreskin of the penis as well as the anus. - can be cancerous - Caused by oncogenic type HPV 16 & 18 Rx - Cryotherapy - Excision Molluscum contagiosum and Rx # - skin condition characterized by clusters of pink, dome-shaped, smooth, waxy, or pearly and umbilicated papules - not pruritic or painful - Caused by Pox virus infection - Usually sexually transmitted but also skin-skin contact, common in children Rx - can go away on their own - Topical irritants (eg, trichloroacetic acid, cantharidin, tretinoin, tazarotene, podophyllotoxin)

Rubella in pregnancy

- Rare in England - Risk of congenital rubella syndrome

Vulval cancer/carcinoma

- Rarest gynaecological cancer - Most common after age 60 - Increasing incidence due to HPV - 90% are SCC, rest are BCC, adenocarcinoma etc. - Develops as palpable lesion, asymptomatic , watery dx or bleeding. Ix: biopsy Rx: excision, lymph node dissection

Complications of throphoblastic disease

- Recurrence - Choriocarcinoma - suspect if persistently raised hCG levels or raised postmenopausal - RX with methotrexate and folic acid - Thyrotoxicosis - Hyperemesis gravidarum and sequelae

lack of arousal in females

- Relationship problems - Depression - Previous mental or physical trauma - Physical problems - fatigue, cardiovascular disease, neurological disease, chronic pain - Hormone disorders - lack of androgens, oestrogen, thyroid disorders, Diabetes closely linked, PCOS ) - Excessive alcohol and drug use ( alcohol blunts sexually responsiveness) - Certain medications - tamoxifen, anti-convulsants, cimetidine, anti-cholinergics - Worries of pregnancy - Body image issues - Correlates with age - Pregnancy - Post-partum

Treatment of amniotic embolism

- Resuscitation and ABCDE approach - Massive obstetric haemorrhage protocol - Delivery baby by emergency C section - Autopsy - amniotic squames or lanugo hair within the lungs

Aetiology of uterine rupture

- Scarred uterus - Obstructed labour - Congenital anomalies - Hyperstimulation with pxytocin - Grand multiparity

Complications of genital herps

- Secondary infection - Aseptic meningitis - Autonomic neuropathy causing urinary retention - Sacral radiculopathy - Cervicitis, pharyngitis, adhesions - Neonatal encephalitis

Condyloma lata

- Secondary syphilis - Popular lesions of sympylic rash become confluent - Treated with abx

Epilepsy and pregnancy 2B

- Seizure control can deteriorate - In pregnancy, haemodilution and altered protein binding can affect drug levels leading to increased seizure frequency. - Status epilepticus and seizures can occur intrapartum - Continued AED use but fewest drugs, lowest possible doses, AVOID VALPROATE (neural tube defects 1:4), use lamotrigine - Folic acid 5mg/day and vitamin K 10mg from 36 weeks if on enzyme inducer - carbamazepine, phenytoin, phenobarbital - Consultant-led care - Effects of epilepsy on mother# hyperemesis gravidarum, preterm delivery, pre-eclampsia, cesarean section delivery, placental abruption, and perinatal mortality. Most women are fine; - Effects of epilepsy on foetus: neural tube defers, congenital heart disease, orofacial clefts, foetal anticonvulsant syndrome --> due to drugs - Foetal hydantoin syndrome: craniofacial abnormalities (cleft lip, epicanthic folds, hypertelorism), cardiac anomalies, limb defects (hypoplasia of distal phalanges, nail hypoplasia), or intrauterine - growth restriction (IUGR);

Puerperal sepsis

- Sepsis after pregnancy, fever , chills, temp hypotension

Features of genital warts

- Sessile, pigmented, fleshy, verrucous, papillomatous lesions that coalesce into plaque - On the vulva, perianal skin, cervix and vagina - Can cause bleeding, haematuria and an altered urinary stream - Can be soft (non-keratinised) or hard ( keratinsed found on dry hairy skin) - Can be pigmented

Premenstrual dysphoric disorder (PMDD) and RX

- Severe PMS symptoms which interfere w/ routine daily activities - Mood is markedly depressed, and anxiety, irritability, and emotional lability are pronounced. Suicidal thoughts may be present. Interest in daily activities is greatly decreased. - Classified as a mental illness in DSM-5 which requires at least 5 of 11 cognitive-affective, behavioural, and physical symptoms during the final week of the luteal phase that resolve with or near the onset of menses. - RX same as PM - RX SSRIs, COCP, HRT, GnRH agonists with add-back therapy - Oil of evening primrose, vitamin B6, CBT

HELLP syndrome

- Severe form of pre-eclampsia - Characterised by haemolysis(H), elevated liver enzymes (EL), Low platelets (LP) - Signs and symptoms: of HELLP# - Severe epigastric/ RUQ pain due to liver infarction and failure - Dark urine due to haemolysis - Bleeding due to thrombocytopenia - Nausea and vomiting probs due to pain

Alcohol in pregnancy

- Should be avoided - foetal alcohol syndrome (small stature, microcephaly, facial anomalies, growth restriction, small brain, developmental delay) - abnormal palmar creases, cardiac defects, and joint contractures may also be evident. - Renal and cardiac defects may occur - Intellectual disability

Tests for cervical cancer

- Speculum examination: friable, raised, reddened, or ulcerated area visible on cervix - Colposcopy with biopsy and HPV testing - abnormal vascularity, white change with acetic acid, Lugol change, exophytic lesions - Staging - vaginal/rectal examination, surgical examination, cystoscopy, MRI, PET, CT - Dx- figo classification

Treatment for PTL

- Steroids given from 23-34 weeks if planning to deliver <34 weeks' gestation - betamethasone or dexamethasone to increase synthesis of surfactant, also close patent ducts and protect against periventricular leukomalacia and reduce risk of cerebral palsy - Steroids take 24 hours to take effect so tocolytics to prevent labour - nifedipine, atosiban (oxytocin antagonist) - Treat infection - Magnesium sulphate IV for neuro-protection and seizure prevention - Neonatal ITU - C section if indicated - If born at <28 weeks - keep at 26C, plastic bag, heat, delay cord cutting for 3 minutes - IV benzylpenicillin for GBS

Complications of PET in the foetus

- Stillbirth - Preterm birth - IUGR - Placental abruption - Foetal hypoxia and distress

Tests fot T.vaginalis

- Swab and send for NAAT/PCR - Wet prep microscopy - shows motile protozoan, WCCs, epithelial cells - Fineberg-Whittington culture - Culture of urine or urethral swabs from men

Criteria for admission in pre-eclampsia

- Symptomatic - Proteinuria - HTN >160/110 - IUGR - Abnormal UMBA or CTG - Abnormal SFLT-1 to PIGF ratio/assay

Diagnosis syphilis

- Syphilis serology, dark ground microscopy - VDRL and TPPA titres - Raised serum rapid plasma regain Treatment for syphilis# - Early - IM benzylpenicillin - Late - 3 injections of IM benzylpenicillin - If allergic then doxycycline - Treat partner, no sex, contact tracing

Complications of PCOS

- T2DM - Gestational DM - Endometrial hyperplasia and cancer due to unopposed oestrogen during prolonged amenorrhoea

Ix in endometriosis

- TVUS - Laparoscopy with biopsy - MRI Ultrasound: - Homogeneous endometrioma - May show deep disease - Uterosacral ligament - hypoechoic linear thickening Laparoscopy: - Endometrioma - Nodules - Tissue outside uterine cavity - Active red lesions - White, blue or brown less active lesions - Chocolate cysts - endometriomas

Third day blues

- Temporary emotional lability from days 2-4 postpartum - Lasts around a week - Tearfulness - Insomnia - Confusion - Obsession with the baby - Seen in 50% of women - Manage with support and reassurance

Diagnosis for PCOS

- The diagnosis requires at least 2 of the following 3 criteria: - Ovulatory dysfunction causing menstrual irregularit - Clinical or biochemical evidence of hyperandrogenism - > 10 follicles per ovary (detected by pelvic ultrasonography), usually occurring in the periphery and resembling a string of pearls

Cervical cancer

- The most common cancer in women under 35 - Typically young women with post-coital bleeding - Most cases in those 25-49 years of age - A secondary peak during the 8th decade of life - 90% are SCC - 10% are adenocarcinoma with a worse prognosis - Caused by HPV infection (6,11 (lowrisk),16,18) - multiple sexual partners, early onset of sexual activity, HIV, immune suppression - COCP and smoking

Polycystic ovarian syndrome (PCOS)

- The most common cause of anovulation - 80% of infertility - Most common pelvic disoerder 5-10% - Ultrasound shows >12 2-8mm peripheral follicles in an enlarged >10ml ovary Rotterdam criteria: 2 out of 3: - Polycystic ovaries on ultrasound - Irregular periods >35 days apart - Biochemical or clinical hirsutism/hyper-androgenism - acne, hair, raised testosterone levels

Lichen sclerosus on vulva

- Thin vulval epithelium, loss of collagen, severe pruritus and worse at night - WHITE SCARRED VULVA, thin skin, - Discomfort, pain, dyspareunia, parchment-like skin with fissuring - Labial fusion due to adhesions and narrowed introitus - Risk of vulval cancer in 5% - IX biopsy - RX dermovate -

Complications of obesity in the mother 2B

- Thromboembolism risk - Increased risk of pre-eclampsia - Diabetes mellitus - C section or difficult birth - Postpartum haemorrhage - Infections

Eclampsia

- Tonic-clonic seizures on a background of pre-eclampsia in absence of neurological conditions - Can be antenatal, intrapartum and postnatal - Due to cerebral vasospasm - Can cause hypoxia, organ failure and cerebral haemorrhage

Treatment for leiomyomata 2B

- Tranexamic and mefenamic acid - Oral progestogens - COCP - Mirena IUS - GnRH agonists (leuprorelin, gonadorelin) - induce menopause, shrink fibroids, cause amenorrhoea, menopausal side effects and osteoporosis - give add-back HRT to prevent osteoporosis and side effects - Ulipristal acetate - SPRM - amenorrhoea, shrink fibroids, used before surgery, can cause liver failure - Surgery

Ix breast ca

- Triple assessment - examination, mammography/USS and FNAC/biopsy - Bilateral mammography for >35 - Bilateral USS for <35 (more radio-dense tissue in younger women) - US-guided core needle biopsy, open biopsy, FNAC or excisional biopsy - Sentinel lymph node biopsy - Immunohistochemistry and FISH for ER, PR, HER2 - CT, bone scan, PET-CT -USS/ XRAY, CT, PET for mets

Gestational trophoblastic disease/molar pregnancy/hydatidiform mole

- Tumours arising from abnormalities at time of fertilisation - Aggressive and invasive proliferation of tumour from trophoblastic (foetal) tissue leading to excessive hCG secretion and hyperemesis gravidarum - Mole pregnancy - GTD as a mass of swollen chorionic villi - Due to excessive paternal chromosomes/DNA within cells - More common with extremes of maternal age and in Asian women

Cyst torsion/ovarian torsion

- Twisting of the ovary or cyst on ligamentous support - Results in ischaemia, necrosis and haemorrhage - Causes peritonitis, infection and is a surgical emergency - Acute pelvic or lower abdominal pain that is intermittent and fluctuates - Radiation of pain to back, loin, thigh - Associated with nausea, vomiting, adnexal tenderness - IX TVUS, doppler, FBC, CRP, CT, MRI, pregnancy test - RX cystectomy, oophorectomy, bilateral salpingo-oophorectomy, de-torsion - Oophorexy - shortening of utero-ovarian ligament and fixing ovary in place

Genital herpes

- Ulcerative STI by HSV1 or HSV2 - HSV-1 - cold sores around the mouth, Can be passed on through oral sex - HSV-2 - genital lesions on anus, genitals, can also be in the mouth - Recurrent common in with type 2 - After initial infection, HSV remains dormant in nerve ganglia, from which it can periodically emerge

emergency contraception

- Use, screen for STI, arrange contraception, advice pregnancy test if next period is late - COPPER IUD can be used as emergency contraception within 5 days and is the most effective type

Ovulatory amenorrhoea

- Usually secondary Congenital abnormalities: - Cervical stenosis (rare) - Imperforate hymen - Pseudohermaphroditism - Transverse vaginal septum - Vaginal or uterine aplasia (eg, Müllerian agenesis) Acquired - Asherman syndrome - Endometrial TB - Obstructive fibroids and polyps

Antepartum haemorrhage

- Vaginal bleeding after 24 weeks' gestation - Risk of shock, foetal hypoxia, intrauterine death or cerebral palsy

Clinical features of miscarriage

- Vaginal bleeding and cramp-like pain in the suprapubic region (due to contractions) - Before 24 weeks' gestation - USS confirms or is incidental finding with missed miscarriage - Open cervix on speculum

Delivery in HIV

- Vaginal if on HAART and CD4 count >350 - If on Zidovudine then C-section - ROM > delivery by 34 weeks - Intrapartum IV zidovudine (ZDV) infusion in untreated women and viral load >10000

Breast cancer screening

- Women aged 47-73 are invited to 3-yearly screening - Mammography is used as less radio-dense tissue is present in older women - Woman aged >30 with unexplained lump or pain = 2-week wait - Woman aged >50 with 1 nipple symptom = 2-week wait - Consider 2-week wait in woman >30 with axillary lump and suggestive skin changes - Non-urgent referral for <30 and unexplained lump

Candidiasis (genital)

- Yeast-like fungus candida albicans (95%) and (5%) glabrata - Associated with pregnancy, diabetes, antibiotic use, immune suppression, COCP, hypothyroidism, IDA - Can be sexually transmitted but not necessarily

Termination of pregnancy (abortion)

- active termination of a pregnancy before fetal viability - Legal limit for UK is 24 weeks for clauses C and D - Abortion after 24 weeks is allowed if there is grave risk to the life of the woman, severe foetal abnormality, or risk of grave physical and mental injury to the woman

dypareunia in female sexual dysfunction

- deep (no pain on penetration but on intercourse -pelvic pathology: endometriosis, cysts ,fibroids, malignancies, pelvic floor dysfunction, IBS, IBD, UTI -superficial (vulva, vestibule), pain on penetration

stage 3 of labour

- delivery of baby until delivery of placenta - can last 30 mins before intervention push by mum - uterus continuous to contract after delivery to small size shearing between placenta and uterus - characterised by gush of fresh blood (<500mls), umbilical cord lengthening, uterine fundus changing shape rising upwards - start oxytocin IV drip, 10 IU IM or 5mg IV reduced PPH - partogram record dilation of cervic, frequency and contraction, HR, BP of mum and foetal HR - Oxytocin and ergometrine - Traction for placental delivery - Suture any perineal tears - Count swabs, needles, record any blood loss and clean the mother - Encourage breastfeeding ASAP

Ferguson reflex

- describes labour - descent of head cervix stretches msg to hypothalamus rlease of oxytocin from Ant. Pit - oxytocin acts on uterine receptors increased contraction push foetus down and stretch stronger contractions - pain signals act on spinal cord cause contraction of abdominal muscles - contraction from fundus to cervix weaker as it goes down - uterus contracts and retracts

describe ejaculation and orgasm

- ejaculation is controlled by the SNS --> causes contractions of the epididymis, vas deferens, seminal vesicles, and prostate that transport semen to the posterior urethra--> rhythmic contractions of the pelvic floor muscles result in pulsatile ejaculation of the accumulated seminal fluid. -orgasm is a pleasurable sensation that occurs in the brain simultaneously with ejaculation

factors affecting arousal/erection in men

- erectile dysfunction

BZD, barbituates, anxiolytics in pregnancy

- facial clefts, neonatal hypotonia, withdrawal syndrome in neonate

Complications of Intrahepatic cholestasis of pregnancy

- fetal morbidity as liver cant remove bile salts vasoconstrictive effect on human placental chorionic veins. - Prematurity - Stillbirth - Resp. distress syndrome - Foetal distress

Vasa praevia

- foetal vessels in front of presenting part, leads to bleeding when membranes rupture, painless, moderate and foetal hypoxia emergency C section

Depo-Provera advantages

- good for breastfeeding (Can be used after 6 weeks postpartum during breastfeeding safely) - good for intolerance to estrogen - good for women experiencing premenstrual weight gain, nausea, acne, HTN, dyslipidemia, VTE, SLE - may prevent PID with mucus thickening - pregnancy rates similar to sterilization - can be used in pts with seizures

Progestin excess AE

- increased appetite, weight gain, bloating - constipation - acne/oily skin - hirsutism - depression - fatigue - irritability

classifications fro sexual dysfunction

- lack of desire (70% women) -lack of arousal -anorgasmia (primary (never) or secondary ( di dbefore but not anymore) -dyspareunia *vaginismus *vaginal atrophy *vulvular vestibulitis *PID

factors affecting lack libido/ desire in men

- lack of sexual interest , sexual thoughts, decrease in frequency - can be result of: depression, hypogonadism, CKD, diabetes

IUS/Mirena Coil

- levonorgestrel (Mirena) and Kyleena replaced every 5 years - Liletta and Skyla replaced every 3 years -Banded 10 years , Non banded (5 years) -Less systemic side effects but irregular light spotting - Rapid return to fertility after removal - Prevents implantation and thickens cervical mucus - Safe, effective, reversible, Mirena is good for menorrhagia or dysmenorrhoea - Check for strings after each period

oligohydramnios

- little aminotic fluid - Indomethacin, ARBs, ACEI -Renal pathology - agenesis, dysplasia, posterior urethral valves, polycystic kidney disease, multi-cystic dysplastic kidneys, urethral atresia - IUGR - Premature rupture of membranes - Post-dates - Chromosomal - trisomy 18 and 13 - Placental abruption - Twin-to-twin transfusion syndrome

Dyslipidemia contraceptive options

- low dose COC have no significant impact - possible exception is monophasic levonorgestrel (0.15 mg) - monitor lipid profiles for first few months

risks of ovarian cancer

- low parity -FH ovarian and breast Ca -nulliparity -BRCA 1 & 2 genes Protective factors: multiparity, breastfeeding, and chronic anovulation, oral contraception

Smoking in pregnancy

- miscarriage, preterm birth, IUGR, abruption, SIDS, stillbirth

Delayed first stage of labour

- occurs due to powers: - Inefficient uterine action - Epidural anaesthesia

- Oligomenorrhoea

- periods every 35 days to 6 months

S&S for endometrial ca+

- postmenopausal bleeding - premenopausal recurrent metrorrhagia - vaginal dx

Pre-eclampsia (PET)

- preeclamptic toxaemia (PET) - New onset hypertension >140/90 from week 20 (4 hours apart) and Proteinuria >300mg/24hrs or evidence of systemic involvement (i.e renal insufficiency- creatinine, liver raised LFTs, thrombocytopaenia, pulmonary oedema or cerebral/visual disturbances) - curable only by delivery of the foetus - Resolves within 6 weeks of delivery - Early-onset PET is complications before 34 weeks, IUGR - Late-onset PET is complications after 34 weeks, no IUGR Grading Mild 140-150 Moderate 150-160 Severe 160+;

what is Manual Vacuum aspiration 2B

- procedure to remove pregnancy tissue from uterus using suction from syringe up to 12 wks - A soft, flexible, plastic cannula is attached to a handheld self-locking syringe. - Evacuation is accomplished by repetitive in-and-out, rotating movements. - procedure used in termination of pregnancy (6-7 wks w/out GA) or missed miscarriage - can be used to obtain biopsy of endometrium - also refereed to as dilation and evacuation/ dilation and curettage - SE include: abdo pain and cramping and bleeding.

Diabetes contractption options

- progestin effects carbohydrate and lipid metabolism and might increase insulin resistance - okay to use OC if they don't have vascular disease

OC suitable for Smokers

- progestin only options - if estrogen is used make it 20 mcg formulation

Features of uterine rupture

- prolonged fetal bradycardia - most common presentation - acute onset of constant lower abdominal pain, may not have pain if receiving epidural analgesia - hyper or hypotonic uterine contractions - vaginal bleeding - intra-abdominal haemorrhage

Intrahepatic cholestasis of pregnancy 2B

- pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. - Due to hormonal changes - Can cause Vit K deficiency - Resolves after delivery

Depo-Provera AE

- reduced bone mineral denisty with chronic use, returns to normal after - amenorrhea - return of fertility may be delayed - weight gain - minor lipid alterations -irregular bleeding -acoid in teens and elderly

Ejaculatory dysfunction

- reduced volume or absence of cum -can occur in diabetic men or result from bladder neck surgery -other causes: -medications ( guanethidine, phentolamine, phenoxybenzamine, thioridazine) -prostatectomy ( removes seminal vesicles)

AEx endometriosis

- retrograde menstruation (Sampson's theory):seeding of endometrial cells by transtubal regurgitation during menstruation , endometrial cells most often found in dependent sites of the pelvis -immunologic theory: altered immunity may limit clearance of transplanted endometrial cells from pelvic cavity (may be due to decreased NK cell activity) - metaplasia of coelomic epithelium ->undefined endogenous biochemical factor may induce undifferentiated peritoneal cells to develop into endometrial tissue - extrapelvic disease may be due to aberrant vascular or lymphatic dissemination of cells e.g. ovarian endometriosis may be due to direct lymphatic flow from uterus to ovarie

ACHES oral contraceptives AEs

- serious AE - *A*bdominal pain (gallbladder disease/hepatic adenoma) - *C*hest pain/cough/SOB (MI or PE) - *H*A, dizziness, numbness, slurred speaking, tingling in extremities (stroke, HTN, migraine) - *E*ye problems, vision loss (stroke, HTN) - *S*evere leg pain (DVT)

Opiates in pregnancy

- stillbirth, IUGR, developmental delay, SIDS, methadone to prevent neonatal withdrawal syndrome

RX Bartholin cysts

- surgical incision, drainage - Abx

Foetal well-being assessment

- symphis-fundal height measured and recorded from 24 wks - USS - Routine doppler - amniocentesis: usually performed 16-18 weeks for DNA, enzyme assays - Chorionic villous sampling (CVS) involves sampling of placental tissue at 9-12 weeks. DNA analysis , cytogenetic testing - Percutaneous umbilical blood sampling (PUBS) involves ultrasoundguided aspiration of fetal blood from the umbilical cord. - USS: growth, age, presentation, death, anomaly - Uterine artery doppler : usually 23 wks, may detect pre-eclampsia or IUGR - Foetal movement: contact doctor if reduced - Auscultation of foetal heart: confirms foetus alive

IUDs AE

- syncope, bradycardia, neurovascular effects with removal/insertion - decreased systemic abs - ectopic pregnancy - PID, sepsis, embedment/perforation into cervix/uterus with improper use -shock -migration -

Rx dysmenorrhoea

- treat with NSAIDs and COCP in primary - in secondary treat underlying cause

ovarian cancer/ neoplasms 1B

- tumour in ovaries - Presents late due to nonspecific or asymptomatic features - Often late stage at presentation, median age of 60 yrs - 90-95% epithelial --> 75% are serous adenocarcinoma, 10% endometrioid, 10% clear cell, 3% mucinous, then germ cell and cord

Estrogen deficiency AE

- vasomotor symptoms - nervousness - decreased libido - early cycle spotting - absence of withdrawal bleeding

RISK FACTORS for HELLP

- white ethnicity - maternal age >35 years - obesity - chronic hypertension - diabetes mellitus - autoimmune disorders - abnormal placentation (e.g., molar pregnancy) - previous pregnancy with preeclampsia with/without HELLP syndrome

Iso-immunisation/ Rh incompatibility 1B

- woman is Rh-ve and baby is Rh +ve ( most people are Rh positive) - The mother mounts an immune response against foetal red cell antigens - The mother produces anti-D IgG antibodies which can cross the placenta in future pregnancies and cause haemolysis and haemolytic disease of the newborn - Hemolytic anemia is a condition in which red blood cells are destroyed faster than the body can replace them. Red blood cells carry oxygen to all parts of the body.--> low oxygen which can affect baby - Can cause hydrops fetalis --> HF in babies due to haemolytic anaemia. Less RBC carrying oxygen heart pumpsharder - First baby is usually fine - Foetus is screened at booking and 28 weeks' - Maternal anti-D levels are measured

Return of fertility after contraception info

- women taking OCs may take longer for fertility to return - traditionally allow 2-3 menstrual cycles before becoming pregnant - no harm if you become pregnant immediately

GDM risk factors

- ¬older age - Obesity - Smoking - PCOS - Non-white - FH DM - Weight gain as adult - Sedentary lifestyle

sex cord tumors

-10% of ovarian tumors, arise from primitive sex cord or connective tissue of developing ovary mean age diagnosis 50 -inc. granulosa cell tumour (70%) -sertoli-leydig tumour Rx: Hysterectomy, BSO (or fertility-sparing USO), and staging.

Diabetes in pregnancy

-3-5% women -anti-insulin factors produced by placenta and high maternal cortisol levels create increased peripheral insulin resistance - leading to GDM and/or exacerbating pre-existing DM -Glucose tolerance reduces in pregnancy -Impaired glucose tolerance can become diabetes in pregnancy -Raised foetal glucose levels secondary to maternal diabetes leads to hyperinsulinaemia and macrosomia -Increased insulin requirements for pre-existing DM -Gestational DM is glucose intolerance diagnosed in pregnancy -Fasting glucose >5.6mmol/L -2 hr plasma >7.8mmol/L -no insulin is required for 48-72 h *postpartum* in most type 1 DM

vagina

-A muscular, elastic passageway extending from cervix to vulva - supplied by branches internal pudendal artery with anastamoses from uterine, inferior vesical, and middle rectal arteries

Bicornuate uterus

-A uterus with paired uterine horns extending to the uterine tubes -associated with preterm birth, breech, reccuurent miscarri

uterine sarcoma// leiomyosarcoma (not on matrix)

-Account for 3%of Uterine CAs -Arise from stromal components of the uterus **Endometrial stroma **Mesenchymal and myometrial tissue -Usually advanced at time of diagnosis -Hematogenous dissemination -Lower survival rates -painful, rappid uterine enlargemnet -RX- chemo, radiotherapy

Abnormal Uterine Bleeding (AUB)

-Change in regularity, frequency, duration and amount of blood flow Causes (PALM-COEIN): Structural: - Polyps --> TVS -->polypectomy - Adenomyosis -->TVS, MRI - Leiomyoma -> TVS, SIS, diagnostic hysterescopy - Malignancy & hyperplasia - fistulas Non-structural: - Coagulopathy - Ovulatory dysfunction e.g. PCOS - Endometrial - Iatrogenic - Not known

Long-acting reversible contraceptives (LARCs)

-Depo-Provera -Nexplanon implant -Copper IUD -Mirena coil

Types of emergency contranception

-EllaONE -Lenovelle -copper IUD

Paget's disease of the breast

-Formal of DCIS extending to skin and nipple + areola - Malignant cells from DCIS reach the nipple skin via sinuses -Features: Unilateral erythematous eruption with scaling, crusting, dx - Pruritus - Doesn't cross basement membrane - Women have underlying invasive carcinoma in situ Risk factors - Jogging without bras - - IX - biopsy, cytology of exudate - ER-negative, HER2-positive

Aetiology of amenorrhoea

-Hypergonadotro ic hy ogonadism -Eugonadism - Low FSH without breast development -hypogonadism -anatomic

support of the uterus

-Muscles of the pelvic floor -Round ligaments (from uteruss, through broad ligament, inguinal canal to labia majora, anteverts the uterus) -*Transverse cervical ligaments (cardinal (ligaments)* (from lateral pelvic walls and insert into lateral cervix and vagin, prevents prolapse) -Uterosacral ligaments (sacrocervical ligaments) -broad ligamant : from lateral pelvic wall to sides of uterus; contain fallopian tube, round ligament, ovarian ligament, nerves, vessels, and lymphatics

uterine polyps (not on matrix)

-Overgrowth of uterine tissue into the endometrial cavity. -asymptmatic but also - Heavy menstrual bleeding, intermenstrual bleeding - Can prolapse through the cervix - USS and hysteroscopy, avulsion with histology, resection or diathermy

Vulval intraepithelial neoplasia (VIN)

-Premalignancy -Atypical cells within epithelium, -AEx: by HPV 16, smoking, CIN, immune suppression, multifocal lesions, paget's dz, lischen sclerosus (differentiated subtype) -Symptoms include pain and pruritus, mass, Dx, bleeding, inguinal adenopathy Ix: - Biopsy and histology - CXR, MRI, PET-CT, CT -RX : emollients, steroids, excision, imiquimod, laser ablation

Orgasm problems in females

-Psychological -Medication - SSRI induced bupropion -Vibro-stimulation - selected cases

Mullerian ducts

-The müllerian ducts are the primordial anlage of the female reproductive tract. - They differentiate to form the fallopian tubes, uterus, the uterine cervix, and the superior aspect of the vagina.

premature ejaculation and Rx

-a condition in which the male reaches climax too soon, usually before, or shortly after, penetration of the female -caused by sexual inexperience, anxiety or psychological factors and not disease -Rx--> sex therapy, TCA or SSRIs

sexual dysfunction & aetiology

-a disorder marked by a persistent inability to function normally in some area of the sexual response cycle Aex: psychological or emotional: depression, abuse • hormonal: menopause • neurologic dysfunction: spinal cord injury • vascular insufficiency: DM • drug side effects: -blockers • trauma: episiotomy

Priapism

-a painful erection that lasts 4 hours or more but is not accompanied by sexual excitement -common in 5-10 yer and 20-50 YO men -usually due to ischaemia--> failure of venous outflow -can also be due to drugs: alprostadil, papaverine, phentolamine, cocaine, amphetamines , betaboclers, nifedipine, warfarin, trozadone, lithium haematological causes: leukaemia, sickle cell, lymphoma, thalassaemia Rx- underlying cause, drugs, aspiration of blood in ischaemic,

Dyskariosis

-abnormal cells on screening - test for HHPV - if positive --> colposcopy - Moderate --> consistent with CIN II, urgent colposcopy within 2 weeks - Severe -- consistent with CIN III, urgent colposcopy within 2 weeks - Inadequate sample --> repeat smear, if inadequate 3 times then colposcopy

Methods of contraception

-behavioral -barrier (condom, diaphragm) -hormonal (COC, mini-pill, progestogen depot) -intrauterine devices (copper, mirena (levonogestrel) -emergency contraception -sterilization

anatomic causes of amenorrhoes

-cervical stenosis : -intrauterine adhesions (surgery, miscarriage, ahemorrhage, elective abortion) -Th is process can also be termed premature menopause or premature ovarian ailure (POF), with a current trend toward the term premature ovarian insufienciency or primary ovarian insuficiency (POI)

causes of vaginal dx

-chlamydia - asymptomatic; or purulent or mucopurulent discharge from endocervix, intermenstrual or postcoital bleeding, dysuria, urinary -gonorrhoea- asymptomatic; or vaginal pruritus and/or a mucopurulent discharge -Trichomoniasis ( protozoan) --> purulent (green frothy), malodorous, thin discharge.. strawberry cervix, pruritis, dysuria -bacterial vaginosis --> fishy, thin off-white greyish mucus Candidiasis- cottage cheese Herpes- watery vaginal dx. sores or ulcers, vesicles

Progesterone only pill MOA

-contains progesterone only -Progestogen thickens cervical mucus and makes the environment hostile to sperm -suitable for older women and women with VTE, stroke risk -requires better timing (3-12 hour window) Missed Pill back up if missed more than opening window Advantages Effective 0.3% failure (9% typical) less risk of VT /stroke less risk of cancer Disadvantages 1. ectopic pregnancy 2. irregular periods, spotting, weight gain, mood swings, hirsutism 3. ovarian cysts

hypergonadotroic hypogonadism amennorhoea

-decresed/ absent ovarian function due to to absent negative sex-steroid eedback, the gonadotropins, LH and FSH, have increased serum levels (hypergonadotropic)

components of sexual response

-desire: allows people to respond to secual stimulation -arousal: physical/emotional stimulation of breast & genital vasodilation and clitoral engorgement -orgasm: physical and emotional stimulation is maximized, allowing the individual to relinquish their sense of control -resolution: most of the congestion and tension resolves within seconds, complete resolution may take up to 60 min

LEnovelle

-emergency conraception - Levonorgestrel dose - Take up to 72 hours - AE: Vomiting, menstrual disturbance

ELLAONE

-emergency contraception - Ulipristal acetate - Prevents ovulation - 120 hours - Progesterone blockade so efficacy of progesterone contraception is reduced in next period - use condoms or avoid sex

Polyhydraminos

-excessive amount of amniotic fluid - Idiopathic - Maternal DM, GDM or CHF - Foetal neural tube defects - Foetal GI defects leading to impaired swallowing of amniotic fluid - oesophageal atresia, duodenal atresia, gastroschisis, omphalocele - Foetal cardiovascular defects - Foetal thoracic defects - TTTS - Hydrops foetalis

Infertility/ subfetility

-failure to conceive after regular unprotected sexual intercourse for year in absence of know fertility

cervical polyp

-hyperplastic protrusion of the epithelium of the cervix; may be broad based or pedunculated - Asymptomatic or intermenstrual bleeding, post-menopausal bleeding - IX : colposcopy with histology, speculum - RX :polyectomy, avulsion and histology, resection, diathermy, cautery with silver nitrate stick

Erectile dysfunction, Aex and Ix

-inability to attain or sustain an erection satisfactory for sexual intercourse -can be primary--> never erectile, can be psychological or due to anatomical abnormalities -secondary- more common (90%) , reactive psychological difficulties in most cases including guilt, fear of intimacy, depression, or anxiety - organic causes Aex: vascular: atherosclerosis in cavernous arteries of penis due to diabetes or smoking. limits arterial and SM relaxation limiting blood that enters penis. Hx: gradual onset , normal libido. neurologic: stroke, partial complex seizures, MS, spinal cord injury, peripheral and autonomic neuropathies . diabetic neuropathy , spinal cord disease psychologic: sudden onset , early collapse, self-simulated/waking erections hormonal probs -surgery: Surgery or radiotherapy to the pelvis or retroperitoneum - eg, radical prostatectomy (25-75% of these men have ED). drugs : b-blockers, clonidine, loop and thiazide diuretics and spironaloctone . opioids,MOAI, SSRIs, TCAs llifestyle: Alcohol , smoking -Ix: screening for underlying disorders, measuring testosterone levels , prolactin and LH -

Cervititis: S&S, Rx, AEx 2A

-inflammation of the cervix -can be infectious or non infectious -symptoms : asymptomatic, vaginal discharge, vaginal bleeding, and cervical erythema and friability, dyspareunia, vulvar and/or vaginal irritation, and/or dysuria -commonly caused by STIs: Chlamydia, gonorrhoea, herpes, mycoplasma gen -non infectious causes: gynecologic procedures, foreign bodies (eg, pessaries, barrier contraceptive devices), chemicals (eg, in douches or contraceptive creams), and allergens (eg, latex). Ix: STD testing, RX- treat chlamydia/gonorrhoea (azithromycin/Ceftriaxone) with Abx, contact tracing complcations: PID as bacteria go up UT

breast fibrocystic changes

-mastalgia, cysts and nondescript benign breast masses. - Non-proliferative condition of lump breasts - Dense and cystic on mammography - Cysts are due to dilated lobules which can undergo calcification -can be due to oestrogen and progesterone stimulation -can make it diffult to spot breast ca+ -biopsy rue out ca+ - Treat with fine needle aspiration cytology

cervix of uterus

-narrow neck which projects into the vagina inferiorly -supplied by branch of uterine artery

Fibroadenoma of breast

-noncancerous breast tumours composed of fibrous and glandular tissue- stromal tissue common iin young women 20s --Increases in size during pregnancy or raised oestrogen levels - Well-circumscribed, rubbery nodule that bulges over tissue - very mobile, non-tender, solitary and firm - described as a breast mouse - Popcorn calcification on mammography Ix- USS better in young girls Rx- surgival removal, leave i

Combined oral contraceptives (COCs) MOA and types

-oestrogen & Progesterone combination -come in ring patch: every 3 weeks pill: every day , -Daily dose, intra-vaginal for 3 weeks then 7 days off then another ring inside, remove 3 hrs for sex -Negative feedback on the pituitary gland -Leads to reduced FSH and LH release and ovulation is therefore inhibited by prevention of the LH surge -Endometrium undergoes thinning, preventing implantation -Cervical mucus thickens, preventing entry of sperm -effective 0.2% failure rate ( typical use 9%) If missed take ASAP more than 2 use condom for 7 days CONTRAINDICATED 1. migraines 2. thrombotic disorders 3. impaired liver function 4. CAD, PAD, uncontrolled HTN 5. pregnancy 6. >35 YO smokers CONTRAINDICATED DRUGS 1. rifampicin , rifabutin 2. antiseizures: phenytoin, phenobarbital carbamazepine, 3. Anti-retrovirals: ritonavir, Darunavir, Nelfinavir, Lopinavir, Fosamprenavir 4. st johns, modafinil, Disadvantages - stroke, VTE, MI, cervical and breast cancer. - Risk multiplied with smoking, older age, obesity -others: spotting, mood changes, weight gain Advantages effective, regular, lighter periods Protection against ovarian cysts, breast cysts, uterine fibroids, endometriosis Improvement of acne, hirsutism Reduced incidence of ovarian, endometrial and bowel cancer

endometriosis (not on matrix)

-presence of endometrial stroma and glands outside uterus -A chronic, oestrogen-dependent disease which regresses spontaneously during pregnancy and menopause -Deposits cause inflammation, pain, fibrosis and inflammatory adhesions which can lead to frozen pelvis in severe cases -- Uterosacral ligaments - Ovaries - Umbilicus - Scars - Vagina, bladder, rectum - Lungs - Peritoneum - Pouch of Douglas - Distant sites

Germ cell ovarian tumors

-present younger Px 20 years mean -dygermiomas more common --> highly curable -yolk-sac tumour --> . α-Fetoprotein (AFP) is a highly accurate tumor marker. The most lethal variant. RX: Fertility-sparing USO and surgical staging, . Bleomycin, etoposide, and cisplatin (BEP) chemotherapy

inflammatory breast cancer

-rare but aggressive form of breast cancer in which the cancer cells block the lymphatic vessels in the skin of the breast -clinical features: erythema, skin edema, warm, swollen, and tender breast ± lump - peau d'orange indicates advanced disease (IIIb-IV)

vulvar endometriomas

-rare, painful cysts that result from extrauterine implantation of functioning endometrial tissue (endometriosis) in the vulva.

cervical insufficiency/incompetence 2B

-silent, painless dilation of the cervix which means pregnancy cannot be supported -due to weakness of cervical tissue that contributes to or causes premature delivery - aetiology unknown -results in delivery of live fetus during the 2nd trimester -cervical incompetence

cervical dysplasia 2B

-the growth of abnormal cells in the cervix -caused by HPV viruses (6,11,16,18) - Dyskariosis - large nuclei, frequent mitoses - CIN is graded 1-3 - Peak incidence in women aged 25-29 - CIN 1 - atypical cells present in lower 1/3 epithelium - CIN 2 - atypical cells present in lower 2/3 epithelium - CIN 3 - atypical cells throughout the full thickness of the epithelium - 33% of women with CIN2/3 develop cancer in 10 years - CIN 1 may progress to 2/3 or regress spontaneously -can become cancerous - stages of cervical intraepithelial neoplasia: CIN I, II, III , moderate, sever. severe needs treatment -asymptomatic, if bleeding it has progressed to cervical cancer Ix: Pap test , cervical biopsy, colposcopy rx- cryo, laser

features of ovarian Ca+

-vague -absent -IBS symptoms in older women -distension bloating, fullness and early satiety - Anorexia - Pelvic or abdominal pain - Abnormal vaginal or postmenopausal bleeding - Cachexia, abdominal mass, ascites, adenopathy, pleural effusions - Symptoms present for 3 months or more EXAM: adnexal mass

- Grading of prolapse1B

1. >1cm above the hymenal ring 2. >1cm above to 1cm below the hymenal ring 3. >1cm below the hymenal ring 4. Complete vaginal eversion - procidentia

PLACENTA PRAEVIA 1B

1. Low lying placenta implanted near cervical OS. If 20 weeks it can move upwards to lie normally by 28 weeks - Marginal/partial = low lying, doesn't cover the os - Major/complete = completely or partially covers the os AEx - Twins, Multiparity - Older maternal age - Scarred uterus - Assisted conception - Uterine fibroids & Endometritis - Dilatation and curettage - Previous placenta praevia - Previous termination - Smoking S&S: 1. PAINLESS bright red bleeding after 20-24 weeks . 2. possible hypovolemic shock 3. breech, transverse lie Ix 1. TVS 2. MRI, CTG, 3. FBC, clotting 4. crossmatch, group and save Rx ABCDE bore IV fluids, blood products, anti-D, steroids, delivery DO NOT PV EXAM - aggravates bleeding avoid intercourse - Minor - normal vaginal delivery - Major - elective C section at 39 weeks' gestation

MENSTRUAL CYCLE

1. MENSTRUAL PHASE - days 1-4 - menstrual bleeding as uterine lining sheds result of declining oestrogen and progesterone in absence of pregnancy 2. Day 5-13- FOLLICULAR PHASE 1. FSH secreted in pulses (GnrH from H) ➡ matures oocytes, maturing oocytes release oestradiol ➡ inhibits FSH secretion ➡ low FSH but enough for dominant follicle with most receptors to mature ➡ dominant follicle secrete LOTS of estradiol which +ve feedback to pit to release LH➡ release of egg ( day 14) --> OVULATION 3. LUTEAL PHASE corpus luteum formed (triggered by the LH surge), remnant of expelled ovum. secretes progesterone from day 15-28. as LH drops corpeus luteum degenerates. If not pregnant , oetrogen and progesterone drop --> CL -> corpus albicans, no progresterone, endometrium sheds--> period -if pregnancy occurs hCG rescues corpus luteum by binding to and activating the LH receptor on luteal cells. -progesterone oestrogen continues to be released. -oestrogen thicken lining and spiral arteries -Following menstruation the mucus is thick and forms a plug across the external os -hCG maintains endometrial stability - spiral artery development (progesterone)

Functions of the Female Reproductive System

1. Make gametes in ovaries using meiosis (gametogenesis) 2. Store, nourish and transport gametes 3. Make sex hormones for development of female reproductive structures, maintain pregnancy, and formation of ovum

ABRUPTIO PLACENTA 1B

1. Placenta separating away from site of implantation before delivery of the foetus - Leads to maternal bleeding behind the placenta and foetal hypoxia 2. Risk factors -multiparity -old age - IUGR - Pre-eclampsia, Hypertension - Smoking, cocaine - Trauma - PROM - Polyhydramnios - Older age - Thrombophilia Signs and sympmtoms 1. Painful bleeding - Dark) 2. Pain no bleeding 3. Hypotension, shock, tachy, 4. tender, hard, woody uterus 5. Absent or abnormal foetal heartbeat due to hypoxia/distress Ix - Urine output - Foetal distress - CTG, USS, foetal blood sampling - FBC, clotting, cross-match, group and save, catheterisation, U&Es Rx - Acute - admission, ABCDE, resuscitation, steroids, opioids, anti-D, oxygen - Stabilise mother first then if there is foetal hypoxia, perform emergency C section - If >37 weeks induction of labour - For minor abruption without foetal hypoxia or major symptoms steroids and monitoring just in case emergency C section is required complication - Hypoxia, perinatal mortality - Mum: Haemorrhagic shock, sheehan syndrome (pituitary necrosis), amniotic fluid embolus

AEx: of labour dystocia

4 Ps Power, passenger , passage , psyche - Power (leading cause): contractions (hypotonic, incoordinate), inadequate maternal expulsive efforts - Passenger: fetal position, attitude, size, anomalies (hydrocephalus) - Passage: pelvic structure (CPD), maternal soft tissue factors (tumours, full bladder or rectum, vaginal septum) - Psyche: hormones released in response to stress may contribute to dystocia

Other causes of maternal collapse

: - Eclampsia - Intracranial haemorrhage - Pulmonary embolism - Amniotic fluid embolism - Anaphylaxis - Magnesium sulphate - Anaesthesia - Aortic dissection - Arrhythmias - MI - Cardiomyopathy - Haemorrhage due to rupture of the splenic artery - Uterine APH or PPH - Sepsis - Hypoglycaemia

Sensitising events causing antigen production

: - Termination of pregnancy - Evacuation of retained products of conception - Miscarriage - Ectopic pregnancy - Vaginal bleeding - ECV - Amniocentesis - Intrauterine death - Delivery

fecundity

: monthly probability of pregnancy

Vaginal Septum

A congenital anomaly. Extra tissue divides the vagina either longitudinally or horizontally. -A longitudinal vaginal septum sometimes is called a double vagina. - Female reproductive system not fully developed leaving a dividing wall in vagina - Horizontal/transverse or longitudinal - Associated with pain, discomfort, or an -unusual menstrual flow which signal condition : longer periods due to slow flow/ blockage, amenorrhoea due to blockage - Often realised during sexual intercourse. - Some women never get symptoms - Can result in longer perios, pain from blood collecting due to bloackage - Ix: USS, MRI - Rx: surgical removal of septum

clitoris

A female sex organ consisting of a shaft and glans located above the urethral opening. It is extremely sensitive to sexual sensations.

secondary oocyte

An oocyte in which the first meiotic division is completed. The second meiotic division usually stops short of completion unless fertilization occurs.

Treatment of endometriosis (not on matrix)

Analgesia: - NSAIDs - mefenamic acid - Paracetamol - Opioids Hormonal - mimics pregnancy and suppresses ovarian function - COCP - Oral progestogens - Mirena IUS Hormonal therapy - mimics menopause - GNRH analogues e.g. gonadorelin, leuprorelin - Over-stimulation of pituitary leads to downregulation of GnRH receptors - Add-back therapy needed to prevent osteoporosis Rarely - androgens - danazol, gestrinone, severe side effects so not used Surgery - Laparoscopy and diathermy, laser ablation and excision of endometriotic deposits - Ovarian cystectomy of chocolate cysts - Adhesiolysis - Hysterectomy with BSO - Uterine artery embolisation - Surgery helps fertility too but many have relapse/recurrence

SLE options for contraception

Avoid COC and recommend progestin only options

Lactation contraception options & advice

Avoid COC for 6 weeks then progestin-only after that

-UKMEC 2

Benefits likely to outweigh theoretical risks

Cancer options for contraception

Benign breast cancer not a contraindication even with positive family history

breast cancer

Breast mass, pain, or swelling

Haematocolpos

Condition which presents with cyclical pain in young girls (teens) in absence of menstruation Due to collection blood and imperforate hymen

Sickle cell disease options for contraception

Depo provera

Investigation of infertility in men and women

Examination both: secondary characteristics - ovulatory function : day 3 FSH (<9), LH, prolactin, GHEA, free testosterone - day 21-23: Progesterone, postcoital mucus evaluation, HSG, SHG - anovulatory: hypogonadotropic hormone , exercise, starvation, Anti Mullerian hormone anytime of cycle (5-25), Antral follicle count - Hypergonatrophic: high FSH too many eggs - menopause - Ovarian reserve : IVF produce more eggs (10-13 eggs) , more embryos - Fallopian tube - TVUS - Uterine cavity :Congenital abnormalities, scaring/ fibrosis due to previous infections - Semen analysis - Abnormal semen

Hypogonadotropic hypogonadism

FSH+LH are low to normal -> hypothalamic or pituitary problem Next step: prolactin, TSH, free T4, CBC, ESR, LFTs, MRI (last step) if all negative -> constitutional delay

Postpartum options contraception adivce

For the first 21 days no estrogen and recommend progestin only or IUD from 4 weeks

Pregnancy terms

Gravida-> total number of pregnancies Parity: gravida 24 weeks regardless of outcome + N (any miscarriages or abortions)

- anterior apical compartment prolapse

Hernia of anterior vaginal wall often associated with descent of the bladder or urethra - Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystocele - Prolapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele - Complete anterior vaginal wall prolapse is called cysto-urethrocele

Approach to vaginal discharge

History -Age--> sexual activity -sexual hx--> new partners -Dysuria --> frequency and haematuria -soaps, detergents, doucing, IUD

Female Sexual Dysfunction

Includes -sexual interest/arousal disorder (SIAD), -female orgasmic disorder (FOD) - genito-pelvic penetration pain disorder (GPPPD) --> combines the frequently overlapping diagnoses of vaginismus and dyspareunia. Aex: depression, anxiety, neglect and abuse.

Ix and Rx for PPH

Ix: assess degree of blood loss and shock by clinical exam, examine uterus for tone, tissue or trauma Rx: - ABCDE - ocygen - Fluids and transfusion - Drugs: oxytocin 5U IV bolus, ergometrine , misoprostol, Acarboprost, PGF2a - Tone: bimanual compression --> elevate uterus , uterine packing, bakri balloon - Surgical: embolization, hysterectomy, laparotomy

Complications of shoulder dystocia

Klumpke's palsy - Forearm and hand paralysis - Due to brachial plexus injury of C8 and T1 - Due to excessive upward traction of the arm - Horner's syndrome and clawing of the hand - Hand is supinated, wrist is extended and fingers are clawed Erb's palsy - Paralysis of the arm due to C5-6 injury - Due to traction at the neck - Elbow extension, medial rotation, adducted shoulder, internally rotated shoulder - The "waiter's tip" position

breast cancer treatment

Lumpectomy and radiation for most single lesions (standard of care) masectomy chemotherapy for large lesions or poor prognosis Tamoxifen/aromatase inhiitors for ER positive tumors Herceptin for Her2 positive tumors

UKMEC 4:

Method is contraindicated in women with this condition

Emergency contraception time frame

Most effective in first 24-72 hours or within 5-7 days

Pain relief in labour

Non-pharmacological: - Mobility - Water at body temperature - TENS - Hypnotherapy - Acupuncture - Localised back pressure - Heat and cold packs - Massage - Aromatherapy Entonox - 50% oxygen and 50% NO - Rapid onset - Mild analgesia - Dizziness, hyperventilation, nausea Opioids - Pethidine - Diamorphine Epidural analgesia - Fentanyl injected alongside bupivacaine into epidural space between L3-4 or L4-5 - Leads to anaesthesia of T10-S5 pain fibres - Loading dose then top-up doses controlled by patient - Reduced catecholamine secretion - lowers blood pressure

Complications of multifetal pregnancy in the mother

Obstetric risks - Gestational diabetes - Pre-eclampsia - Anaemia - Operative delivery - Polyhydramnios - C-section - IUGR - Postpartum haemorrhage - Hyperemesis gravidarum - death

vulvodynia & Rx

Persistent unexplained pain , often with a burning quality on light stimulus or touch. unknown Aex associated w/ fribromyalgia, IBS, CFS, UTI, endo RX Topical - lidocaine Medical - TCA, Gabapentin Physio Psychological Surgical

Thromboembolism contracttion options

Recommend DepoProvera and levonorgestrel IUD

Erectile dysfunction Rx 1B

Rx: oral phosphodiesterase inhibitors ( sildenafil, vardenafil, avanafil--> promote SM relaxation) , -SE for PDI flushing, visual abnormalities, hearing loss, dyspepsia - intraurethral or intracavernosal prostaglandins--> can produce erections with a mean duration of 30 to 60 min -vacuum erection devices, and surgical implants.: cylinder over penis--> fills with blood then ring fitted -lifestyle advice: stop smoking, alcohol reduce, less cyling <3 hrs per week

labia minora

Smaller pair of skin folds that protect the vaginal opening

zona pellucida

Surrounds the oocyte and is an acellular mixture of glycoproteins that protect the oocyte and contain the compounds necessary for sperm cell binding.

greater vestribular glands (Bartholin's glands)

The Bartholin's glands (also called Bartholin glands or greater vestibular glands) are two pea sized compound racemose glands located slightly posterior and to the left and right of the opening of the vagina. They secrete mucus to lubricate the vagina and are homologous to bulbourethral glands in males.

stratum funcionalis of endometrium (functional layer)

The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer; the functional layer thickens and then is sloughed during the menstural cycle or estrous cycle

fundus of uterus

The fundus of the uterus is the top portion, opposite from the cervix. Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates. -supplied by uterine artery (branch of internal iliac)

broad ligament

The ligament extending from the lateral margins of the uterus to the pelvic wall; keeps the uterus centrally placed and provides stability within the pelvic cavity.

perimetrium=visceral serous membrane

The perimetrium (or serous coat of uterus) is the outer serosa layer of the uterus, equivalent to peritoneum. It is embrionically derived from visceral peritoneum.

corpus albicans

The scar tissue that replaces the corpus luteum. it is caused by the drop of LH levels in the blood at the end of the 28 day-cycle. as soon as progesterone production ends, the corpus luteum begins to degenerate and is replaced by this.

suspenspory ligament of ovary

The suspensory ligament of the ovary, also infundibulopelvic ligament (commonly abbreviated IP ligament or simply IP), is a fold of peritoneum that extends out from the ovary to the wall of the pelvis.

Septated uterus

The two Müllerian ducts have fused, but the partition between them is still present, splitting the system into two parts. With a complete septum the vagina, cervix and the uterus can be partitioned. -common cause of miscarriage

uterine tube (=Fallopian=oviducts)

The uterine tubes, also known as oviducts or fallopian tubes, are the female structures that transport the ova from the ovary to the uterus

oocytes

a cell in an ovary that may undergo meiotic division to form an ovum.

Graafian (tertiary/mature) follicle

a fluid-filled structure in the mammalian ovary within which an ovum develops before ovulation.

mons pubis

a mound of fatty tissue covering the pubic area in women

areola

a small circular area, in particular the ring of pigmented skin surrounding a nipple.

Vaginismus

aginismus: - Involuntary contraction of the vaginal musculature, which usually results in the failure of penetration physical or psychological Hx: lack of interest in sex, inability to be aroused, dryness, cant use tampons, cant acheive orgasm

ovarian ligament

anchors the ovary medially to the uterus

stratum basale of endometrium (basal layer)

basal layer of endometrium: the deepest layer of the endometrium, which contains the blind ends of the uterine glands; the cells of this layer undergo minimal ...

breast fat necrosis

benign, usually painless lump forms as result of injury to breast tissue -Fat from damaged adipocytes undergoes phagocytosis by macrophages and causes scar tissue formation, dystrophic calcification on mammography Ix mammogram: abnormal calcification biopsy: necrotic fat, giant cells, exclude B Ca+ up to 50% pts may not resport trauma Rx: fine needle aspiration

oogonium

cell which undergoes chromosome replication to produce an oocyte

Primary subfertility

conception has never taken place

Unicornuate uterus

congenital malformation of the uterus that results in a uterus with one horn -normal pregnancy can occur -ectopic -miscarriage -preterm delivery

Uterus didelphys

congenital malformation of the uterus that results in the complete duplication of the uterus, cervix, and vagina -mullerian ducts do not fuse -double births -associated with breech, premature delivery, C-section

round ligament

connects lateral uterus to lateral pelvic wall obliquely

Estrogen effects on lipids

decrease LDL, increase HDL, increase TG

primary oocyte

diploid cell in prophase 1 of meiosis that can be hormonally triggered to develop into an ovum

excessive spotting, breakthrough bleeding maybe signs of ?

endometrial, cervical, or vaginal cancer

corona radiata

first barrier between the sperm and egg

corpus lutem

follicle after ovulation also called yellow body because of its yellow color.

Oogenesis

formation of oocytes in ovarian follicles of ovaries from oogenic cells

Gestational HTN

hypertension without proteinuria or other findings of preeclampsia; it first occurs at > 20 wk gestation in women known not to have hypertension before pregnancy and resolves by 12 wk post-partum

perineum

in females, the area between the anus and the vagina

pelvic inflammatory disease (PID)

inflammation and infection of organs in the pelvic region; salpingitis, oophoritis, endometritis, endocervicitis AEx: STIs Features: dyspareunia, intermenstrual bleeding, dysuria COmplications ectopic pregnancy due to adhesions

Breast Abscess

localized collection of pus in the breast tissue may or may not be associate with mastitis

MI options for contraception

low dose estrogen OC

lactiferous ducts

milk ducts which carry milk from the mammary glands to the nipple The 15-24 milk ducts that collect milk from ductules and carry it to the nipple. If the alveoli are the "grapes" these structures would be the "stems"

- Symptoms of Bartholin cysts

most asymptomatic but can have vulvar irritation, dyspareunia, pain during walking, and vulvar asymmetry

myometrium

muscular middle layer of the uterus

Investigation for genital warts

none, cervical smears

Causes of infertility in males

o infection, trauma, inflammation, undescended testicles (infertile) , testicular torsion, hernias (block sperm cords) o Alcohol, smoking, marijuana (significant effect of sperm quality), steroids (suppress FSH) , ejaculatory dysfunction (MS, diabetes) - Personal and lifestyle hhx o Immune to rubella o Chlamydia screen o Alcohol, smoking, healhylifestyle, folic acid - FHx o Genetic abnormalities

cervical os (F)

opening of the cervix to the uterus

Layers of the uterus

perimetrium, myometrium, endometrium

Obesity options for contraception

prefer Depo Provera, and intrauterine levonorgestrel

features of cervical insufficiency 2B

regional anesthesia (epidural block, combined spinal-epidural, spinal)regional anesthesia (epidural block, combined spinal-epidural, spinal)

infundibulum

the funnel-shaped opening into the fallopian tube near the ovary

nipple

the protuberance of a mammary gland upon which in the female the lactiferous ducts open and from which milk is drawn.

fallopian tubes

tubes which carry eggs from the ovaries to the uterus and which provides the place where fertilization occurs -supplied by uterine and ovarian arteries

Stage 2 of labour

typically lasts from a half an hour to two hours and involves the actual delivery of the baby