Clinical management Flashcards
Uterotonics
Oxytocin
- 1st choice uterotonic in preventing PPH
- Nanopeptide primarily synthezised in the hypothalamus (supraoptic and paraventricular nuclei)
- Half-life approximately 5 minutes
Prostaglandins
eg Misoprostal (half life 20-40 mins) and carboprost
- physiologically active lipid compounds, autocrine or paracrine factors not true endocrine hormones
Ergometrin
- 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)
- half-life is 30-120 minutes
- regulated as chemically similar to LSD and LSD can be manufactured from Ergometrine.
Obstetric Cholestasis
- intense itching without rash and abnormal LFTs beyond normal pregnancy ranges
- itching can occur before biochemical changes. If LFTs normal but itching continues LFTs should be repeated in 1-2 weeks and consider testing for other causes of itch.
- if LFTs deranged they should be monitored every 1-2 weeks during pregnancy and at least 10 days postnatally
- linked with an increased incidence of passage of meconium, premature delivery, fetal distress, delivery by C-section and PPH
- Ursodeoxycholic acid (UDCA) improves pruritus and liver function in OC
Bacterial vaginosis
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)
- overgrowth of anaerobic bacteria in the vagina.
- not considered a sexually transmitted disease
- more common in those with IUCD and smokers
- treatment typically with 7 days oral metronidazole
Gonorrhoea
Neisseria Gonorrhoeae - gram negative diplococci
Lichen sclerosus
Signs:
Pale white atrophic areas - smooth porcelain wrinkled skin
Itching
Purpura are common
Fissuring
Erosions
Narrowed introitus
Vaginal mucosa NEVER involved
Histological features:
Epidermal atrophy (or thinning)
Hydropic degeneration of the basal layer (sub-epidermal hyalinisation)
Dermal inflammation.
Progression to SCC in <5%
Lichen simplex
Four underlying causes:
- Underlying dermatoses
- Systemic conditions causing pruritus
- Environmental factors
- Psychiatric disorders
Signs:
Lichenification (thickened pale leathery skin)
Erosions and fissuring
Excoriation
Loss of pubic hair where scratching
Histological features:
Epithelial thickening
Increased mitosis in basal and prikle layers
Lichen planus
Signs:
Itch, soreness, dysuria, dyspareunia
Violaceous plaques and papules with white reticular pattern overlying (Wickham striae)
Erosive form has glazed areas of erythema and is common to genital and buccal mucosa (this form associated with pain)
Can involve vagina (unlike sclerosus)
Risk progression to SCC 3%
On histology see irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction. Band-like dermal infiltrate mainly lymphocytic
Vulval intraepithelial neoplasia
VIN
- presents with pruritus
- 40% under age 40
- lesions are usually raised with a rough surface and variable colour, multi-focal and may involve skin appendages to a depth of several mm
- turn white with acetic acid and may show mosaic punctuation
- malignant potential unclear, more likely in older women, immuno-compromised and those with other genital tract malignancies
- labia majora most common site for ca
Histological features:
Epithelial nuclear atypia
Loss of surface differentiation
Increased mitosis
Tocolytics
- to suppress contractions
- NOT associated with a clear reduction in perinatal or neonatal mortality, or neonatal morbidity
- used for very preterm labour, those needing transfer to a hospital which can provide neonatal intensive care and those who have not yet completed a full course of corticosteroids
Choice of tocolytic (NICE)
1st line: Nifedipine
2nd line: Oxytocin receptor antagonists e.g. atosiban
Polymorphic eruption of pregnancy
- benign and typically self limiting condition
- symptom relief with emollients +/- topical steroids/antihistamines or in severe cases oral steroids
- most common in women during their first pregnancy
- associated with multiple gestation pregnancies, excessive maternal weight, Rh-positive blood type
Risk of Malignancy Index
For ovarian cancer
RMI = ultrasound score x menopausal score x CA-125 level in U/ml
USS score 0-3:
Multilocular cyst
Solid areas
Ascites
Intra-abdominal mets
Menopause score: 1 premenopausal, 3 post
Ovarian cancers
- Epithelial Ovarian Cancers (EOCs) are the most common type with high grade serous ovarian carcinomas the most common subtype. EOCs comprise:
Serous (68%)
Clear cell (13%)
Endometrioid (9%)
Mucinous (3%)
5 year survival is 43%
Lifetime risk is 1 in 70
PCOS
Rotterdam criteria - need 2/3 of:
- 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
LH:FSH >2 (normal is 1:1 ratio)
Associated with diabetes and hypothyroidism
Endometrial hyperplasia
With or without atypia
Risks:
Oestragen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant)
Without atypia:
Progression to cancer <5% over 20 years
Majority regress spontaneously
Progestogen treatment higher disease regression rate than conservative management
IUS 1st line treatment (continuous oral progesterones alternative but regression rate lower)
Endometrial 6 monthly surveillance
Hysterectomy may be considered especially if treatment failure
Endometrial ablation is not recommended
Atypical Hyperplasia:
Total hysterectomy indicated as risk of underlying malignancy or progression to cancer risk (studies show progression risk over 10+ years is 25-30%)
IUS or oral progesterones alternatives for women who decline surgery.
GDM diagnostic
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
Acute fatty liver of pregnancy
Abdominal pain
Lethargy/Malaise
Jaundice
Derranged liver function
Coagulopathy
Hypoglycaemia/hyperuricaemia
Risk:
Primigravida
Male fetus
Multiple pregnancy
Obesity
- 1 in 10,000 to 20,000 pregnancies
- Fetal & Maternal mortality approximately 20%
- due to fetal deficiency of long-chain 3-hydroxyl-CoA dehydrogenase (LCHAD)
Infertility - Hypothalamic pituitary failure
WHO group 1 - stress, anorexia, exercise infuced
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation
Infertility - Hypothalamic-pituitary-ovarian dysfunction
WHO group 2 - PCOS
Weight reduction if BMI >30
Clomifene/Clomiphene (1st line)
Meformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)
Infertility - ovarian failure
WHO Group 3
IVF with donor eggs
COCP UKMEC 4
<6 weeks postpartum (breastfeeding)
<3 weeks postpartum (not breastfeeding) + other risk factor VTE
Age ≥ 35 and smoking ≥15 cigarettes/day
Systolic BP ≥160mmHg
Diastolic BP ≥100mmHg
Vascular disease
Ischaemic heart disease
Stroke
History VTE
VTE currently being treated with antioagulants
Major surgery with prolonged immobilisation
Known thrombogenic mutations eg factor V Leiden
Complicated valvular heart disease eg history SBE, tetralogy of Fallot, aortic stenosis.
Cardiomyopathy with impaired cardiac function
Atrial fibrillation
Migraine with Aura
Current breast cancer
Severe (decompensated) liver cirrhosis
Benign hepatocellular adenoma
Hepatocellular carcinoma
Positive antiphospholipid antibodies
Overactive bladder
CONSERVATIVE FIRST
Bladder training
Treat vaginal atrophy and nocturia with topical oestrogen and desmopressin respectively before commencing treatments below.
Consider catheterisation if chronic retention
1st line treatments:
1. Oxybutynin - NOT for frail/elderly
2. Tolterodine
3. Darifenacin
2nd line treatment:
Consider transdermal anticholinergic (antimuscarinic)
Mirabegron
Pre-eclampsia diagnostic criteria
New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy
PLUS one of the following:
Proteinuria (urine protein:creatinine ratio of ≥ 30 mg/mmol or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) OR
Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more) OR
Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain) OR
Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata OR
Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis OR
Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.
Laparoscopy entry methods
Normal BMI
- no preference
Morbid Obesity (BMI>40):
- Hasson technique or entry at Palmers point, as difficult penetration with Varess needle
Very Thin Patients:
- Hasson technique or insertion at Palmers point, as higher risk of vascular injury
Gestational trophoblastic disease
Complete Molar: Abnormal diploid conceptus with absence of foetus (typically 46XX)
On USS see snowstorm or granular appearance, bunch of grapes sign, no identifiable fetal tissue or gestational sac.
Partial Molar: Abnormal triploid conceptus that may have fetal tissue (typically 69XXY)
On USS see enlarged placenta with multiple diffuse anechoic lesions, fetus with severe structural abnormalities or growth restriction
Choriocarcinoma: Malignant tumour of trophoblast
70% of choriocarcinoma occurs after molar pregnancy (20% after TOP & 10% after normal pregnancy)
Irregular vaginal bleeding
Hyperemesis
Large for gestational age uterus
Early Miscarriage
Excessive HCG production
Trichomoniasis Vaginalis
Flagellate protazoan
- Up to 50% of women have no symptoms
- Classic discharge described as frothy and yellow-green
- Other symptoms are vulvovaginal soreness and itching, offensive odour, lower abdo pain, dysuria and dyspareunia
- strawberry cervix (cervicitis - 2% of cases)
- diagnose with wet smear microscopy or culture/PCR
Metronidazole 400 to 500 mg twice a day for 5 to 7 days
TOP
- Mifepristone 200mg orally (anti-progestogen)
- Misoprostol (dose depends on gestation) 24-48 hours later (synthetic prostaglandin)
+ Rhesus antiD if Rh- and >10 weeks gestation (give for all gestations if surgical management)
+ doxy or met if having surgical management
Penicillins and Cephalosporins mechanism
Beta-Lactam inhibit peptidoglycan cross-links in bacterial cell wall
eg Amoxicillin, Flucloxacillin
Cephalosporins same mechanism, ~1% cross-reactivity if allergic, eg Cefalexin, Ceftriaxone, Cefuroxime
Macrolides mechanism
Peptidyltransferase Inhibitor
eg Erythromycin, Clarithromycin, Azithromycin
Quinolones mechanism
DNA Gyrase Inhibitor
eg Ciprofloxacin, Levofloxacin, Moxifloxacin
Tetracyclines mechanism
Bind to 30S subunit of microbial ribosomes blocking attachment of aminoacyl-tRNA to the A site on the ribosome
eg Lymecycline, Oxytetracyline, Doxycycline
Nitrofurantoin mechanism
Damages bacterial DNA via multiple reactive intermediaries
Trimethoprim mechanism
Dihydrofolate Reductase Inhibitor
Breastfeeding
Milk constitutes: 1% Protein, 4% fat and 7% sugar
- Oxytocin stimulates the milk ejection reflex (let-down) in response to suckling
- Prolactin maintains galactopoiesis
Congenital pyloric stenosis
Presents at 4-8weeks
Non bloody non bilious vomiting, increasingly projectile
Can often feel ‘olive’ in abdomen
Can lead to dehydration, poor weight gain, malnutrition, metabolic alterations (hypochloremic, hypokalemic metabolic alkalosis), lethargy and severe constipation
Diagnosed by USS
Most common condition requiring surgery in infancy
= functional gastric outlet obstruction as a result of hypertrophy and hyperplasia of the muscular layers of the pylorus
Urethral caruncle
- benign, distal urethral lesion
- postmenopausal women
- from posterior lip of the urethra, fleshy outgrowths of distal urethral mucosa. Can grow to 1 cm or more in diameter
- distal urethral prolapse caused by urogenital atrophy, from estrogen deficiency followed by chronic irritation, where the urethral mucosa is exposed, contributing to the growth, hemorrhage, and necrosis of the lesion
- usually asymptomatic, may be painful, associated with dysuria or present with bleeding
- pink or reddish exophytic lesion at the urethral meatus, may be purple or black secondary to thrombosis
- conservative therapy with topical estrogen creams or topical anti-inflammatory, surgical intervention possible
Clear cell adenocarcinoma of vagina / cervix
Rare
If exposed to diethylstilbestrol in pregnancy 40x increased risk so can be young, otherwise only postmenopausal
Can present as early as age 8
Also increased risk breast ca
Need regular screening
Vaginal adenosis is congenital abnormality characterised by the presence of glands or cysts in the submucosa of the upper third of the vagina or by surface glandular change, also assoc with DES
