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
