Clinical management Flashcards
How is GDM diagnosed?
75g OGTT with 2h glucose
Diagnose gestational diabetes if the woman has either:
- a fasting plasma glucose level of 5.6 mmol/litre or above or
- a 2‑hour plasma glucose level of 7.8 mmol/litre or above.
Who should be offered a OGTT?
Those with risk factors for GDM:
- BMI above 30 kg/m2
- previous macrosomic baby weighing 4.5 kg or more
- previous gestational diabetes
- family history of diabetes (first‑degree relative with diabetes)
- an ethnicity with a high prevalence of diabetes
- glycosuria of 2+ or more on 1 occasion or glycosuria of 1+ on 2 or more occasions
Testing at 24-28 weeks
If previous GDM, offer OGTT ASAP after booking and again at 24-28 weeks if normal.
Suture materials/ techniques for repairing anal mucosa/ IAS/ EAS
AM: continuous or interrupted, 3-0 polyglactin (Vicryl)
IAS: interrupted/ mattress. Monofilament e.g. 3-0 PDS, or 2-0 polyglactin (vicryl).
Sutures must not overlap, end to end only.
EAS: end to end monofilament e.g. 3-0 PDS or 2-0 polyglactin (vicryl)
Sutures can be overlapping or end-to end.
For partial thickness, end to end should be used.
Incidence of OASIS in UK
Prognosis
6.1% for primip
1.7% for multip
60-80% of women asymptomatic 12 months post delivery and EAS repair
Incidence of obstetric cholestasis in UK
OC monitoring
OC implications
0.7%
Itching in general affects 23% of pregnancies
Itching can occur before biochemical changes.
If LFTs normal, but itching continues LFTs should be repeated in 1-2 weeks & consider testing for other causes of itch
If LFTs deranged, should be monitored every 1-2 weeks throughout pregnancy and at least 10 days post natally
OC linked with increased incidence of passage of meconium, premature delivery, fetal distress, stillbirth, delivery by CS and PPH
Different criteria’s used to diagnose BV
Amsels criteria:
3/4 criteria required for confirmation of BV
1. Thin, white, homogeneous discharge
2. Clue cells on microscopy of wet mount
3. pH of vaginal fluid >4.5
4. Release of a fishy odour on adding alkali (10% KOH)
The Nugent score:
Estimates the relative proportions of bacterial morphotypes to give a score between 0 and 10
<4 = normal
4-6 = intermediate
>6 = BV
The Hay/Ison criteria:
- Grade 1 (Normal): Lactobacillus morphotypes predominate
- Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
- Grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli
OSOM BVblue is a commercially available kit that BASHH advises performs adequately compared with Amsel criteria.
Detection of gardnella vaginalis on swab does not confirm BV, as bacteria can be present in up to 50% of women without BV
% of pregnant vs non-pregnant women asymptomatically colonised with candida
Pregnant 40%
Non-pregnant 20%
Uterotonics
Oxytocin:
- Nanopeptide primarily synthezised in the hypothalamus (supraoptic and paraventricular nuclei)
- The oxytocin receptor is a G-protein-coupled receptor requiring Mg2+ and cholesterol.
Prostaglandins
- Misoprostal (Synthetic Prostaglandin E1 analogue) half-life 40 minutes
- Dinoprostone (Naturally occurring Prostaglandin E2)
- Dinoprost (Naturally occurring Prostaglandin F2 Alpha)
- Carboprost (Synthetic Prostaglandin F2 Alpha analogue)
Ergometrine
- Ergot Alkaloid
- Stimulates 5HT2, dopamine and alpha adrenergic receptors but smooth muscle contraction mechanism of action not fully understood.
- Often used as combined preparation with Oxytocin (syntometrine)
- Should not be used in HTN
Medication regimes for medical abortion depending on gestation
All gestations, begin with Mifepristone 200mg PO
<7 weeks days:
24-48h later: 400mcg PO misoprostol
7-8 weeks:
24-48h later: 400mcg PO misoprostol + 2nd dose 400mcg PV or PO if no abortion 4h later
<9 weekss:
24-48h later: 800mcg misoprostol (PV/ buccal/ sublingual)
9-13 weeks:
36-48h later: 800mcg misoprostol PV. Up to 4 further doses of 400mcg misoprostol (PO/PV) at 3 hourly intervals
13-24 weeks:
- 36-48h later: 800mcg misoprostol PV. Up to 4 further doses of 400mcg misoprostol (PO/PV) at 3 hourly intervals.
- If abortion has not occurred, mifepristone can be repeated 3h after the last misoprostol followed by misoprostol 12 hours after that.
Who should be given anti-D in cases of abortion?
Rhesus Anti-D IgG should be given, by injection into the deltoid muscle, to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation.
Anti-D prophylaxis should not be given to women who are having a medical abortion up to and including 10+0 weeks’ gestation.
Anti-D prophylaxis should be considered for women who are rhesus D negative and are having a surgical abortion up to and including 10+0 weeks’ gestation.
Prophylactic Abx regimes for surgical abortions
Doxycycline 100mg BD for 3 days
Metronidazole 1g PR or 800mg PO if tested negative for chlamydia
When to restart COCP following abortion/ miscarriage
Immediately
Risk factors for GDM
- Increasing age
- Certain ethnic groups (Asian, African Americans, Hispanic/Latino Americans and Pima Indians)
- High BMI before pregnancy (three-fold risk for obese women compared to non-obese women)
- Smoking doubles the risk of GDM
- Change in weight between pregnancies - an inter-pregnancy gain of more than three units (of BMI) doubles the risk of GDM
- Short interval between pregnancies
- Previous unexplained stillbirth
- Previous macrosomia
- Family history of type 2 diabetes or GDM - more relevant in nulliparous than parous women
Blood test monitoring on methotrexate
FBC/ U&E/ LTF every 1-2 weeks when initiating treatment.
Once established, every 2-3 months.
Risk of blood dyscradias (myelosuppression) and liver cirrhosis
Risk of complications with laparoscopy
Overall risk of ‘serious complications’ is 2/1000
Risk of bowel injury 0.4/1000
Risk of vascular injury 0.2/1000
Risk of death is 0.05 in 1000
Women must be informed of the risks and potential complications associated with laparoscopy. This should include discussion of the risks of the entry technique used: specifically, injury to the bowel, urinary tract and major blood vessels, and later complications associated with the entry ports: specifically, hernia formation.
No significant safety advantage to open (Hasson)/ closed entry techniques
Reduced risk of uterine injury in Hasson compared to verses
Management of sub fertility in WHO group I ovulation disorders
Group I: hypothalamic pituitary failure (stress, anorexia, exercise induced)
Increase BMI if <19
Reduce exercise if high levels
Pulsatile GnRH or gonadotropins with LH activity to induce ovulation
Management of sub fertility in WHO group II ovulation disorders
WHO group II: hypothalamic-pituitary-ovarian dysfunction
Weight reduction if BMI >30
Clomiphene (1st line)
Metformin (1st line)
Clomiphene & metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)
Management of sub fertility in WHO group III ovulation disorders
Consider IVF with donor eggs
Management of hyperprolactinaemia
Investigate cause e.g. MRI head (?pituitary adenoma) medication review (some antipsychotic medications for example can cause prolactin rise)
Dopamine agonist (Bromocriptine advised by NICE as 1st line)
What should be given/ avoided in hyperemesis to reduce the risk of Wernicke’s encephalopathy?
Avoid dextrose: can exacerbate Wernickes.
Give IV pabrinex (10ml solution in 100ml saline)
Rotterdam criteria for diagnosing PCOS
Two of the three following criteria are diagnostic of the condition:
- Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3)
- Oligo-ovulation or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
Typical Biochemistry
- Elevated LH
- FSH normal or low
- LH:FSH >2 (normal is 1:1 ratio, PCOS is often 3:1)
- Testosterone, oestrogen, prolactin all typically normal or elevated
- SHBG normal or reduced
Associated Endocrine Disorders
- Diabetes
- Hypothyroidism
Recommendation regarding periods in PCOS
Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma.
It is good practice to recommend treatment with gestogens to induce a withdrawal bleed at least every 3 to 4 months
Changes to reproductive system following delivery
Afterpains may continue for 2-3 days
Uterine involution takes 4-6 weeks
Lochia flow 3-6 weeks
Cervical constriction takes up to 7 days
Vaginal contraction and return of tone takes 4-6 weeks
Amniotic fluid volume- peak gestation and volume
Peaks at 35 weeks, then decreases until term
Fetal contributions to amniotic fluid
Fetal Urine
- First fetal urine produced at 8-11 weeks
- By term fetus produces approximately 800ml urine per day
Fetal Swallowing
- Fetus starts swallowing 12 weeks
- 250ml swallowed per day
Fetal Lung Secretions
- 300ml/day by 2nd trimester
Erb’s palsy following shoulder dystocia- which nerve roots are affected?
C5 & C6
Which uterotonic is most associated with coronary artery spasm?
Ergometrine
Stages of syphilis, time from primary infection and symptoms
Primary: 3-90 days: chancre, lymphadenopathy
Secondary: 4-10 weeks: widespread rash typically affecting hands and soles of feet. Wart lesions (condyloma latum) of mucus membranes
Latent: early <1yr after secondary stage, late >2 year after secondary stage: asymptomatic.
Tertiary: 3+ years after primary infection. Gummas (mass of dead and swollen giber-like tissue- most often seen on liver) OR neurosyphilis OR cardiovascular syphilis
Management of trichomoniasis in HIV positive patients vs other patient groups
HIV positive: 500mg BD metronidazole for 7 days
Others: 400mg BD for 5-7 days
Radiation risk to breast tissue/ fetus of CTPA
Radiation risks to the fetus is low - 0.1mGy
Radiation to breast tissue is considerable: 10- 20 mGy.
Delivery of 10mGy of radiation to a woman’s breast has been estimated to increase her lifetime risk of developing breast ca. by 13.6%. Background risk =12%.
Relative and absolute risk of VTE in pregnancy & incidence in UK
Relative risk of VTE in pregnancy is increased 4 to 6 fold compared to non-pregnancy
Absolute risk of VTE in pregnancy and the puerperium is 1-2/1000 pregnancies
Incidence of Pulmonary Embolism in the UK is 1.3/10,000 maternities
10-20% of VTEs are PE’s. The majority are DVT
Inherited Thrombophilia is present in approximately 40% of women with pregnancy associated VTE
Cut off risk for CVS/ amniocentesis following pre-natal screening for Down’s syndrome
1 in 150
CVS should not be performed before 10 (10+0) completed weeks of gestation
Histopathology features specific to serous and mucinous ovarian tumour types
Serous tumours = Psammoma bodies
Mucinous tumours = Mucin vacoules
Management of menorrhagia
1st Line
Levonorgestrel-releasing intrauterine system (IUS eg Mirena)
2nd Line
Tranexamic Acid, NSAIDs (eg Mefenamic Acid), COCP
3rd Line
Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens
Prelabour Rupture of Membranes (PROM)
Risk of serious neonatal infection
1% (vs 0.5% with intact membranes)
Prelabour Rupture of Membranes (PROM)
How any go into labour in first 24h?
60%
Prelabour Rupture of Membranes (PROM)
When to induce?
Induction appropriate if >34 weeks gestation and >24 hours post rupture and patients labour hasn’t started.
If <34 weeks induction of labour should not be carried out unless there are additional obstetric indications e.g. infection
Endometrial cancer
Stages and 5 year survival
Stage 1: confined to uterus
1A <1/2 depth of myometrium
1B >1/2 depth myometrium
85-90% 5 year survival
Stage 2: cervical stormal invasion, not beyond uterus. 65% 5 year survival
Stage 3: Extension beyond uterus
3A: invades serosa or adnexa
3B: Vaginal and/ or parametrial invasion
3C1: Pelvic nodal involvement
3C2: Para aortic nodal involvement
45-60% 5 year survival
Stage 4: distant metastasis
4A Tumor invasion bladder and/or bowel mucosa
4B Distant metastases including abdominal metastases and/or inguinal lymph nodes
15% 5 year survival
What is the risk of chlamydia infection following intercourse with an asymptomatic chlamydia positive partner?
65%
What percentage of men and women are asymptomatic of chlamydia following initial infection?
> 50% men and 80% of women asymptomatic after initial infection
FIGO staging of vulval ca
Stage 1: Confined to vulva
1A Lesions <=2cm with <1mm stromal invasion
1B Lesions > 2 cm in size or with stromal invasion > 1 mm confined to the vulva or perineum
Stage 2: Tumour of any size with extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus) with negative nodes
Stage 3: Tumour of any size with or without extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus) with positive inguinofemoral nodes
3A (I) With 1 lymph node metastasis ( ≥5 mm)
OR (II) 1 to 2 lymph node metastasis(es) (< 5 mm)
3B (I) With 2 or more lymph node metastases ( ≥5 mm)
OR (II) 3 or more lymph node metastases (< 5 mm)
3C Positive nodes with extra capsular spread
Stage 4: Tumour invades other regional (upper 2/3 urethra; 2/3 vagina) or distant structures
Tumour invades any of the following:
4A (I) Upper urethral and/or vaginal mucosa; bladder mucosa; rectal mucosa or fixed to pelvic bone
OR (II) Fixed or ulcerated inguinofemoral lymph nodes
4B Any distant metastasis including pelvic lymph nodes
FIGO classification of cervical cancer
Stage IA: Invasive carcinoma diagnosed only by microscopy with maximum depth of
invasion <5mm
IA1: Stromal invasion ≤3 mm deep
IA2: Stromal invasion >3 mm and ≤5 mm deep
Stage IB: Invasive carcinoma with measured deepest invasion >5 mm, lesion limited to the cervix:
IB1: Invasive carcinoma >/= 5 mm depth of stromal invasion, and <2 cm in greatest dimension
IB2: Invasive carcinoma >/= 2 cm and < 4 cm in greatest dimension
IB3: Invasive carcinoma >/= 4 cm in greatest dimension
Stage IIA: Involvement limited to the upper two-thirds of the vagina without parametrial involvement:
IIA1: Invasive carcinoma < 4cm in greatest dimension
IIA2: Invasive carcinoma >/= 4 cm in greatest dimension
Stage IIB: With parametrial involvement but not up to the pelvic wall
Stage IIIA: Carcinoma involves the lower third of the vagina with no extension to the pelvic wall
Stage IIIB: Extension to the pelvic wall and and/or causes hydronephrosis or non-functioning kidney
Stage IIIC: Involvement of pelvic and/or para-aortic lymph nodes:
IIIC1: Pelvic lymph node metastasis only
IIIC2: Para-aortic lymph node metastasis
Stage IVA: Spread to adjacent pelvic organs
Stage IVB: Spread to distant organs
Incidence of molar pregnancy in the UK
1 in 600- 1 in 2000
What is the luteo-placental shift and when does it happen?
When the placenta takes over from the corpus luteum for production of oestrogen and progesterone
6-8 weeks
Strong cytochrome P450 inducers (can reduce contraceptive effect of some hormonal forms of contraception)
Carbemazepine
Phenytoin
Phenobarbital
Esclicarbazepine
Oxcarbazepine
Primidone
St John’s Wort
Topiramate
Rifampicin
