1 Flashcards
RFs for endometrial cancer
- high number of ovulations (so OCP PROTECTIVE)
- obesity
- unopposed oestrogen HRT
- PCOS
- tamoxifen
- post-menopausal
features of endometrial cancer
usually adenocarcinoma
- PMB
- IMB
- sometimes pain/discharge present
investigation for endometrial cancer
- TVUS
- endometrial biopsy
- hysteroscopy
- FIGO staging
treatment for endometrial cancer
- hyterectomy + salpingo-oophorectomy +/- pelvic lymph nodes
- radio + chemotherapy
- progesterone in frail/elderly
RFs for cervical cancer
- HPV (16 + 18)
- COCP
- smoking
- STI
features of cervical cancer
usually squamous cell carcinoma
- abnormal vaginal bleed
> post-coital
> IMB
> PMB
- vaginal discharge
- normally picked up on cervical smear testingtreatment of cervical cancer
if fertility is not an aim then hysterectomy with lymph node clearance is best management
- FIGO 1 = LETZ (loop excision of transitional zone)
- FIGO 2+:
> radiotherapy
> chemotherapy
- palliative when appropriate
smear test availability
women aged 25-64 eligible
- 25-49 yrs = every 3 yrs
- 50-64 yrs = every 5 yrs
RFs of ovarian cancer
- BRCA 1/2
- many ovulations (COCP = PROTECTIVE)
features of ovarian cancer
usually serous carcinoma
- commonly asymptomatic and late presenting
- bloating/IBS-like symptoms
- abdominal mass
- urinary frequency
investigations for ovarian cancer
- CA125 (may be raised due to endometriosis/PID/menstruation/ovarian cyst)
- USS abdo/pelvis
- risk of malignancy index (RMI) - CA125 score x USS score (1-3) x pre/post menopausal (1-3)
> score >250 = referral
management of ovarian cancer
- surgery
- chemotherapy
contraindications of COCP
- migraine with aura
- VTE history
- hypertension/IHD/stroke
- BMI > 35
- smoker > 35yrs age
- breast cancer
- liver cirrhosis
SEs of COCP
- Oestrogenic > breast tenderness > headaches > vaginal discharge - Progestogenic > acne > hirsuitism > mood swings/low mood > breakthrough bleeds
implant (implanon)
- progestogin - blocks ovulation + thickens mucus
- lasts up to 3 yrs
- SEs
> irregular bleeds
> mood changes
depo-provera
- progestogen based - inhibits ovulation + thickens mucus
- lasts for 12 wks
- SEs
> weight gain
> delay back to fertility
> decreased BMD
> irreversible once injected
IUD
- copper coil - decreases sperm motility + survival
- lasts up to 5 yrs
- SEs
> perforation risk
> infection risk
> may make bleeding heavier (can give hormonal alongside to relieve)
IUS/Mirena
- progestogen-based - thickens mucus, thins endometrium, inhibits ovulation
- lasts up to 5 yrs
- SEs
> may cause irregular bleeds in first few months, then lighter menses/amenorrhoea and reduced dysmenorrhoea
> perforation risk
> infection risk
early menopause age
<45 yrs
2 yrs period-free if <45 yrs, otherwise 12 months period-free = menopause
premature ovarian insufficiency age
<40 yrs
risks of HRT
increased risk of:
- breast cancer (prog. affects risk) (CI if active or past breast cancer)
- endometrial cancer (if UNOPPOSED oestrogen)
- VTE (transdermal HRT in high-risk)
- stroke (oral HRT slightly increases risk)
benefits of HRT
- symptom relief
- BMD protection
- prevent long-term morbidity (CVD/dementia)
continuous or cyclical HRT?
cyclical if peri-menopausal
continuous if post-menopausal
transdermal HRT in…
- high risk of SEs groups (eg. VTE/hypertension)
- women > 60 yrs
- digestion issues (eg. Crohn’s)
- steady absorption requirement (migraine/epilepsy)
- patient preference
causes of secondary ovarian insufficiency
- autoimmune (thyroiditis/Addison’s/etc.)
- iatrogenic - surgery/chemo/radio
- metabolic disorder
diagnosed with FSH levels (2 samples 4 weeks apart, with 4 months amenorrhoea)
types of incontinence
- stress (sphincter weakness)
- urge (detrusor overactivity)
- overflow (obstruction of bladder outlet)
- mixed (urge and stress)
others include fistula/ neurological/functional/etc.
assessment of incontinence
- history - type of incont./caffeine/fluid intake/etc
- fluid volume chart
- ePAQ questionnaire
- urinalysis
- residual urine measurement
treatment of urge incontinence
- education (eg. fruit juice and coffee)
- bladder retraining
- anticholinergics (oxybutynin)
> mirabegron (adrenergic) if frailty (due to risk of falls in anticholinergics) - sphincter botox
treatment of stress incontinence
- pelvic floor exercises/physiotherapy
- surgery (sling, suspension, TVT - tension-free transvaginal tape)
- duloxetine if unsuitable for/declined surgery
- pads for leaks
markers of ovarian cancer
- CA125
- alpha fetoprotein
- beta-hCG
- inhibin A
- LH
physiological ovarian cyst
commonest = follicular cysts
- due to failed follicle atresia
- usually regresses after a few menstrual cycles
also corpus luteum cysts
- normally corpus luteum breaks down if follicle not fertilised, if not then it can fill with blood/fluid
- can present as intraperitoneal bleeding
- take a few cycles to resolve
benign germ cell tumours
commonest = dermoid cyst (cystic teratoma)
- epithelial tissue lining so can contain hair/teeth/etc
- usually asymptomatic
benign epithelial tumours
- serous cystadenoma
- mucinous cystadenoma
ectopic pregnancy risk
- 1% in general population
- 10% if already had an ectopic preg
RFs for ectopic pregnancy
- PID/genital infection
- previous ectopic
- tubular surgery
- endometriosis
- IVF
treatment options for ectopic preg
- conservative (monitor B-hCG)
- medical - one off methotrexate dose
- surgery - salpingectomy/salpingotomy
primary amenorrhoea definition
- no menses by age 16 WITH secondary sex characteristics
- no menses by 13 WITHOUT secondary sex characteristics
STI Mx
- chlamydia = doxycycline for 7 days PO (azithromycin PO can be given but may predispose to mycoplasma genitalium)
- gonorrhoea = IM ceftriaxone (unless sensitive to ciprofloxacin, in which case give PO cipro)
- BV = metronidazole PO
- trichomoniasis = metronidazole PO
- thrush = fluconazole PO/fluconazole pessary (do not give PO therapy in pregnancy, pessary only)
USS findings suggestive of malignancy for ovarian mass
- multilobularity
- solid areas
- bilateral masses
- ascites
- evidence of metastases
tests for ovulation
- mid-luteal (day 21) progesterone
- US follicular tracking
- LH-based urine predictor kit
test for tubal patency
- hysterosalpingogram
PCOS Mx
- weight loss
- clomifene
- metformin
- ovarian drilling for infertility
management of hyperthyroidism in pregnancy
- propylthiouracil (1st trimestre)
- carbimazole (after 1st tri)
causes of antepartum haemorrhage
- placental abruption
- placenta praevia (low-lying)
- placenta accreta (vessels deep into uterus)
- vasa praevia
- genital tract infection
- cervical ectropion
causes of postpartum haemorrhage
4Ts
- tone
> uterine atony
- tissue
> retained placenta
> retained products of conception
- trauma
> genital tract trauma
>macrosomic baby
- thrombin
> clotting disordersRFs for maternal sepsis
- history of GBS
- diabetes/obesity
- amniocentesis
- prolonged SROM
- hx of genital infection
- immunocompromised
- anaemia
fetal complications of shoulder dystocia
- hypoxia
- fits
- cerebral palsy
- Erb’s palsy due to brachial plexus injury
management of shoulder dystocia
CALL FOR HELP
- McRoberts manoeuvre
- all fours manoeuvre
- episiotomy
> aids internal manoeuvres such as Woods' screw/zavanellianalgesia options in labour
systemic analgesia - paracetamol/codeine - opioids (morphine, diamorphine, pethidine, fentanyl) gas and air - entonox spinal - spinal - epidural - combined spinal-epidural (CSE)
non-pharma pain relief options in labour
- trained support
- hydrotherapy
- acupuncture
- TENS
- massage
SEs of opiate use in labour
MATERNAL - sedation - N+V - euphoria - lengthened stage 1 and 2 of labour FETAL - respiratory distress - diminished breast-seeking behaviour
contraindications of epidural/spinal/CSE
ABSOLUTE - local infection - allergy RELATIVE - coagulopathy - systemic infection - hypovolaemia - abnormal anatomy
SEs of spinal/epidural/CSE
Maternal
- lenghened stages 1 and 2 of labour
- increased likelihood of
> malpresentation
> instrumental delivery
> increased need for oxytocin
- decreases
> mobility
> bladder control
Fetal
- diminished feeding behaviourscardiotocography
Dr = define risk
C = contractions (regular 4 in 10 mins in true labour)
Bra = baseline rate
V = variability
- >5bpm = reassuring
- <5bpm for between 40 and 90 mins = non-reassuring
- <5bpm for > 90 mins = abnormal
A = accelerations (presence = reassuring)
D = decelerations
- early decels = reassuring
- variable decels = non-reassuring
- late/prolonged decels = abnormal
O = overall assessmentCTG - reassuring or not?
normal CTG = all 4 (Bra, V, A, D) = reassuring
suspicious = 1 non-reassuring
pathological = 2+ non-reassuring OR 1+ = abnormal
RFs for breast cancer
- lobular carcinoma in situ (LCIS)
> not cancer but increased risk
> LCIS = micro-calcifications on imaging
- late first childbirth (>35yrs)
- alcohol
- COCP
- HRT use > 5yrs
- atypical ductal hyperplasia
ALSO GENETICSbreast screening
women aged 47-73 invited for screening every 3 yrs
- triple assessment from:
> clinical score (1-5)
> imaging score (1-5)
> biopsy score (1-5)presentation of breast cancer
- painless lump
> irregular
> hard
> fixed
- nipple discharge
- nipple in-drawing + skin tetheringblood tests for infertility
- LH
- FSH
- testosterone
- TSH
- prolactin
SEs of axillary lymph node clearance
- lymphoedema of arm
- arm stiffness
- axillary numbness
causes of nipple discharge
- physiological = reassurance > on squeezing > bilateral > yellow/creamy - hormonal = pregnancy test/serum hormones > milky multiduct > large volume - duct ectasia = reassure > green/brown/bloody > multiduct - papilloma OR DCIS = imaging and microdochectomy > clear or bloody > uniduct
booking visit
8-12 wks
- general info
- BP/urine dipstick
- BMI
- blood test
- infectious disease screen (hep C, syphilis, rubella, HIV)
dating scan
10-14 wks
- confirm dates
- multiple preg?
- Down’s screening offered (combined test = nuchal translucency + serum testing)
anomaly scan
18-21 wks (20wk scan)
- infection screen offered again
- whooping cough vaccine advised to be given after this scan
combined test for Down’s syndrome
11-13 wks
- nuchal translucency
- serum testing
> PAPP-A (preg. associated plasma protein-A)
> free beta hCGquadruple test for Down’s syndrome
after 13 wks
- serum markers
> alpha fetoprotein
> total beta-hCG
> oestriol
> inhibin A (not included in triple test)anti D given for Rh- at:
- first dose at 28wks
- second dose at 34wks
newborn blood spot screen
at 5-8 days age Tests for: - sickle cell - thalassaemia - cystic fibrosis - congenital hypothyroid - 6 inherited metabolic disorders (phenylketonuria/homocysteinuria/maple syrup disease/etc.)
newborn hearing screen
within 4wks age
- otoacoustic emission test
if abnormal then
- auditory brainstem response test
newborn + infant physical examination (NIPE)
within 72hrs age
- testes - undescended?
- hips - dev dysplasia?
- eyes - cataracts?
- heart - defects?
VTE RFs in pregnancy
4+ RFs indicates IMMEDIATE LMW HEPARIN until 6wks post-natal
- age >35yrs
- BMI > 30
- parity >3
- smoker
- pre-eclampsia in current preg
- prev VTE
- varicose veins
- multiple pregnancy
- IVF
- immobility
RFs for gestational DM
- BMI > 30
- prev macrosomic baby (>4kg)
- prev gest. DM
- 1st degree relative diabetic
- ethnicity (S asian, black, middle eastern)
OGTT at 24-28wks if 1+ RF
If already had GDM before then OGTT asap and if normal then another OGTT at 24-28wks
management of gestation DM
If pre-existing DM
- stop diabetes medications except for metformin, then add insulin
Gestational
- if dietary control preferred then must be effective in 1-2 weeks
- metformin
- then insulin if needed
- FOLIC ACID 5mg/day in diabetics
pre-eclampsia complications
MATERNAL - eclampsia - haemorrhage (placental abruption/intra-abdo/intra-cerebral) - HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) - organ failure - DIC FOETAL - prematurity/IUGR - neonatal hypoxia
RFs for pre-eclampsia (high risk) - 5
- previous hypertension in preg
- CKD
- SLE/antiphospholipid
- DM1/2
- chronic hypertension
1+ = aspirin prophylaxis (75mg)
RFs for pre-eclampsia (moderate) - 6
- nulliparous
- 40yrs +
- pregnancy interval of 10+ yrs
- BMI>35
- multiple pregnancy
- FH of pre-eclampsia
2 or more = aspirin prophylaxis (75mg)
stage 1 of labour
from the onset of labour to full dilation of cervix Latent phase - 0-3cm dilation - normally lasts ~6hrs (can last 2-3 days) - IRREGULAR CONTRACTIONS - cervix effacing + thickening Active phase - 4-10cm (progresses 1cm/hr) - REGULAR CONTRACTIONS - role of prostaglandins and oxytocin
stage 2 of labour
from full dilation to delivery of baby
- head visible
primigravida = ~3hrs from start of pushing
multi = ~2hrs from start of pushing
stage 3 of labour
delivery of fetus to delivery of placenta + membranes
contents of colostrum
- growth factors
- Vit A
- antimicrobials
- proteins
- NaCl
where is prolactin secreted from?
anterior pituitary (lactocytes produce milk) (prolactin suppresses ovulation)
where is oxytocin secreted from?
posterior pituitary (myoepithelial cells expel milk) (post pit = oxy + ADH)
causes of secondary PPH
- endometritis
- retained products of conception
- subinvolution of placental implantation site
- poorly healed perineal tear
complications of premature birth
- developmental delay
- visual impairment
- chronic lung disease
- necrotising enterocolitis
- cerebral palsy
- perinatal mortality
RFs for PTB
non-recurrent - APH - multiple pregnancy recurrent - race - prev. PTB - genital infection (particularly BV)/UTI - socioeconomics
RFs for hypertension in preg
- young mother
- black/afro-caribbean
- multiple pregnancy
- underlying hypertension
- renal disease
severe pre-eclampsia signs
- BP > 170/110
- proteinuria > 0.3g/24hrs (3+ urine dip)
- visual disturbance
- RUQ/epigastric pain
- brisk reflexes/clonus
- HELLP syndrome
- IUGR (intra-uterine growth restriction)
maternal indications for delivery in pre-eclampsia
- gestation 38wks+
- thrombocytopenia
- progressive liver/kidney deterioration
- placental abruption
- CNS symptoms
fetal indications for delivery in pre-eclampsia
- severe IUGR
- non-reassuring fetal monitoring
- oligohydramnios
treatment for pre-eclampsia
- if at risk of pre-eclampsia = low dose aspirin 12wks-birth
- labetalol
- nifedipine (2nd line antihypertensive - eg. in asthma)
- MgSO4 (anticonvulsant)
symptoms of endometriosis
- chronic/cyclical pelvic pain
- dysmenorrhoea
- deep dyspareunia
- subfertility
- non-gynae (urinary, bowel - diarrhoea/constipation)
investigations for endometriosis
- LAPAROSCOPY
- pelvic exam = posterior fornix tenderness, reduced organ mobility
- speculum = visible endometriomas
- pelvic USS
adenomyosis
- endometrial tisue in myometrium
- more common in older/multiparous
- dysmenorrhoea
- menorrhagia
- enlarged boggy uterus
NO EFFECT ON FERTILITY
fibroid epidem + symptoms
benign smooth muscle tumour - rare before puberty/after menopause (role of oestrogen) - more common black/afro-caribbean Symptoms - menorrhagia - lower abdo pain/cramps - bloating - urinary symptoms (larger fibroid) SUBFERTILITY
polyps symptoms and associations
overgrowth of endometrium - can be pre-malignant - menorrhagia - intermenstrual bleeds - SUBFERTILITY Associations - peri/post-menopausal - hypertension - high BMI - tamoxifen
complications of PID
- infertility
- chronic pelvic pain
- ectopic pregnancy
risk factors for placenta praevia
- multiparity
- multiple pregnancy
- embryos are more likely to implant on a lower segment scar from previous caesarean section
features of placenta praevia
- shock in proportion to visible loss
- painless bleed and non-tender uterus
- suspect in bleed after 24 weeks gestation, may be picked up in 20 week scan
management of known stable placenta praevia pre-term
- USS monitoring
- advise pelvic rest (no penetrative intercourse) and hospital if significant bleeding
management of bleeding with known placenta praevia
- ABCDE
- emergency C-section if unable to stabilise
- consider corticosteroids if 24-34 weeks and risk of preterm labour
management of bleeding with unknown placenta praevia
- ABCDE
- urgent USS if stable
- if unable to stabilise, emergency C-section
definition of placenta accreta
adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle
definition of placenta percreta
- the villi invade through the full thickness of the myometrium to the serosa
- there is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum
definition of placenta increta
the villi invade into but not through the myometrium
management of placental abnormality (accreta/increta/percreta)
- safest management plan is elective Caesarean section and abdominal hysterectomy
- if maintaining fertility is vital then a less destructive placental resection may be attempted
features of placental abruption
premature separation of the placenta from the uterine wall during pregnancy, resulting in maternal haemorrhage
- abdominal pain (often sudden and severe)
- “woody” hard uterus
- hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible
- contractions
- reduced foetal movements and abnormal CTG
RFs for placental abruption
- maternal trauma eg. assault, road traffic accident
- pre-eclampsia or hypertension
- multiparity or increased maternal age
- polyhydramnios
- previous history of abruption
- substance abuse during pregnancy (particularly smoking and cocaine)
- coagulation disorders
management of placental abruption
- ABCDE
- C-section if maternal/foetal compromise
- induction of labour if no compromise, at term
- conservative management if marginal abruption with no compromise and not at term
epilepsy in pregnancy
- pregnancy lowers threshold for fits
- seizure can cause foetal hypoxia
- maternal use of anti-convulsants associated with congenital abnormalities
- safest anti-convulsants in pregnancy = carbamazepine and lamotrigine
- folate supplementation (5mg) required in first trimester (and prior if possible) to reduce neural tube defect risk
- regular monitoring of foetus required when taking anti-convulsants (serial growth and anomaly scans)
- breastfeeding on anti-convulsants likely safe
causes of oligohydramnios
oligohydramnios = lower than normal volume of amniotic fluid in the uterus UTEROPLACENTAL INSUFFICIENCY - chronic hypertension/pre-eclampsia - placental abruption - maternal smoking FOETAL URINARY ABNORMALITY - renal agenesis - PKD MISCELLANEOUS - premature rupture of membranes (PROM) - post-term gestation - chromosomal anomalies
complication of oligohydramnios
Potter’s syndrome
- clubbed feet
- hip dysplasia
- facial deformity
- pulmonary hypoplasia
classification of perineal tears
1st degree tear = tear limited to the superficial perineal skin or vaginal mucosa only
2nd degree tear = tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
3rd degree tear
- 3a: less than 50% of the thickness of the external anal sphincter is torn
- 3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
- 3c: external and internal anal sphincters are torn, but anal mucosa is intact
4th degree tear = perineal skin, muscle, anal sphincter and anal mucosa are torn
congenital rubella syndrome features
- sensorineural deafness
- cataracts or retinopathy
- congenital heart disease
timings for external cephalic version (ECV) in breech presentation
nulliparous = 36 wks multiparous = 37 wks
absolute contraindications for external cephalic version (ECV)
- caesarean section is already indicated for other reason
- antepartum haemorrhage has occurred in the last 7 days
- non-reassuring cardiotocograph
- major uterine abnormality
- placental abruption or placenta praevia
- PROM
- multiple pregnancy (but may be considered for delivery of the second twin)
features of hydatidiform molar pregnancy
COMPLETE MOLE
- 1 sperm and an empty egg with no genetic material
- no foetal tissue present; just a proliferation of swollen chorionic villi
- snowstorm appearance on TVUS
PARTIAL MOLE
- 2 sperms and a normal egg
- variable evidence of foetal parts
BOTH
- B-hCG levels often much higher than expected
- uterus larger than expected for gestation
- vaginal bleeding
- hyperemesis gravidarum
maternal causes of miscarriage
- idiopathic
- uterine abnormality
- cervical incompetence
- PCOS
- poorly controlled diabetes
- poorly controlled thyroid disease
- anti-phospholipid syndrome
threatened miscarriage
- mild symptoms of bleeding
- foetus retained within the uterus as the cervical os is closed
- little or no pain
inevitable miscarriage
- often heavy bleeding and pain
- the foetus is intrauterine but the cervical os is open
complete miscarriage
- intrauterine pregnancy with has now fully miscarried, with all products of conception expelled
- uterus is empty
- os is usually closed
- patient may have had pain and bleeding
missed miscarriage
- uterus still contains foetal tissue, but the foetus is no longer alive
- miscarriage is ‘missed’ as often the woman is asymptomatic
- cervical os is closed
investigations for recurrent miscarriage (3+ consecutive miscarriages)
- antiphospholipid antibodies
- thrombophilia screen
- cytology of products of conception (karyotype parents if abnormal)
- pelvic USS (for uterine abnormalities)
listeria monocytogenes in pregnancy
listeriosis typically follows eating soft cheeses or unpasteurised milk
- infection can travel through placenta and infect foetus via amniotic fluid
- can cause:
> neonatal sepsis
> meningitis
> resp distress
features of congenital varicella zoster virus
VZV infection in non immune mother in first trimester
- skin scarring
- microcephaly
- eye defects
- learning disability
management of congenital VZV
- immunoglobulin given as prevention if comes into contact with virus
- aciclovir for mother and foetus if maternal infection (within 24hrs rash in mother, IV after delivery for foetus)
choice of antibiotic for group B strep infection
- benzylpenicillin (vancomycin in pen resistance)
first line tocolytic in pre-term labour
nifedipine
triad for diagnosing hyperemesis gravidarum
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
management of hyperemesis gravidarum
- ABCDE
- cyclizine or promethazine (antihistamines)
- ondansetron (second line)
risks of inducing labour
- induction may be unsuccessful, requiring emergency caesarean section
- uterine hyper-stimulation, excessive contractions can lead to foetal bradycardia increasing risk of uterine rupture and placental abruption
- cord prolapse
- uterine rupture - greater risk in women with previous caesarean section/uterine surgery
ovarian hyperstimulation syndrome
FSH used in IVF leads to enlarged ovaries due to excessive oestrogen, progesterone and VEGF
- leads to
> bloating/abdo discomfort (enlarged ovaries)
> oedema/ascites/pleural effusion/weight gain (leaky vessels due to VEGF)
causes of polyhydramnios
EXCESS PRODUCTION - maternal diabetes - foetal renal disorder - foetal anaemia - twin-twin transfusion syndrome INSUFFICIENT REMOVAL - oesophageal/duodenal atresia - diaphragmatic hernia - chromosomal abnormalities
complications of polyhydramnios
MATERNAL - respiratory compromise - worsened pregnancy symptoms, eg. GORD, constipation, peripheral oedema - increased risk of UTI FETAL - preterm - PROM - malpresentation - cord prolapse
Bishop score is used for…
assessing whether a patient is likely a good candidate for induction of labour
- score of 9+ = good candidate for vaginal delivery by induction
- lower score = less likely
treatment for obstetric cholestasis
ursodeoxycholic acid for cholestasis
chlorphenamine for pruritis
contraception post-partum
- no need for contraception for 3 weeks post-partum
- convenient to start contraception post-partum and most methods are suitable immediately, however COCP contraindicated due to VTE risk
- IUS/IUD may be inserted immediately following delivery, but if not within 48hrs must delay for 28 days
supplementation in pregnancy
FOLIC ACID
- high risk of neural tube defects = 5mg/d
- low risk woman aiming to conceive = 400mcg/d
VIT D
- 400 units/d
medical termination of pregnancy drugs
- mifepristone
FOLLOWED BY - misoprostol
management of uterine fibroids
symptomatic (dysmenorhoea/menorrhagia) - IUS (consider family planning)/COCP/POP - mefenamic acid - tranexamic acid surgical - myomectomy - uterine artery embolisation - hysterectomy (if completed family)
management of endometriosis
analgesia - NSAID/paracetamol - COCP/depo-provera surgical - diathermy of lesions - bilateral oophorectomy (consider family planning)
causes of post-menopausal bleed
- HRT breakthrough bleed (common in first 3-6 months on combined HRT)
- vaginal atrophy
- endometrial cancer
gynaecological causes of menorrhagia
- fibroids
- adenomyosis
- endometrial polyps
- endometriosis
- pelvic inflammatory disease
- endometrial cancer (be wary if there is postmenopausal bleeding)
systemic causes of menorrhagia
- bleeding disorders
- hypothyroidism
- liver and kidney disease
- obesity
management of menorrhagia
treat underlying cause if possible, if dysfunctional uterine bleeding then:
- IUS/COCP
- mefenamic acid
- tranexamic acid
- norethisterone can be given for acute menorrhagia
cervical screening criteria
national cervical screening programme runs for women aged 25 to 64. From 25 to 49 women are called every three years, and afterwards every five years
- aim is to identify dyskaryotic
- if negative then no action required until next screen
- if borderline (mild dyskaryosis) then HPV tested, if positive then colposcopy within 6 weeks
- if positive (moderate/severe dyskaryosis) then colposcopy within 2 weeks
diagnostic criteria of PCOS
Rotterdam criteria - assuming that other causes have been excluded, PCOS can be diagnosed if two of the following are present:
- polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
- oligo-/anovulation
- clinical or biochemical features of hyperandrogenism
biochemical investigations for PCOS
- high LH:FSH ratio (>2), normal ratio excludes menopause
- slightly high/normal free testosterone
also consider: - OGTT
- TFTs
- prolactin
- urinary cortisol (Cushing’s)
causes of post-coital bleeding
- sexually transmitted infections
- endocervical and cervical polyps
- cervical ectropion
- cervical cancer
- atrophic vaginitis
Fraser guidelines
1) . they have sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
2) . they cannot be persuaded to tell their parents or to allow the doctor to tell them
3) . they are very likely to begin or continue having sexual intercourse with or without contraceptive treatment
4) . their physical or mental health is likely to suffer unless they receive the advice or treatment
5) . the advice or treatment is in the person’s best interests
management of antiphospholipid syndrome in pregnancy
- low dose aspirin from positive pregnancy test
- LMWH from fetal heart on USS, discontinued at 34 wks
