Contraception / Abortion Flashcards
Which COCP may also help with acne
Cyproterone acetate based COCP - Dianette - shouldn’t be used only for contraception due to higher VTE risk
Drospirenone based COCP - Yasmin / Angeliq
Typical failure rate of COCP per 100 women years
9%
Typical Failure rate of POP per 100 women years
9%
Failure rate of mirena per 100 women years
0.2%
Failure rate of depo prova per 100 women years
6%
Failure rate of condom per 100 women years
17-21%
Mechanism of action of COCP
Inhibition of ovulation
Atrophic endometrium
Thickened cervical mucus
Absolute CI to COCP use
0 to <6 weeks postpartum + breastfeeding
0 to <3 weeks postpartum + other VTE risk
Age ≥35 years + 15 cigarettes / day
Hypertension ≥160 / 100
Vascular disease / impaired cardiac function
Hx of DVT / PE / stroke / IHD
Major surgery with prolonged immobilisation
Migraine with aura
Current breast cancer
Viral hepatitis / decompensated cirrhosis / liver tumours
Thrombogenic mutations / Positive antiphospholipid antibodies
SE of COCP
altered mood - no causal relationship with depression Mood swings Headache Loss of libido - no causal relationship Nausea percieved weight gain - no causal relationship Bloatedness Breakthrough bleeding Vaginal discharge Breast pain
Benefits of COCP
Lighter less painful periods Regular bleeds Improved pre-menstrual syndrome Reduced risk of PID Protect against ovarian and endometrial cancer
Mechanism of action of progestogen only methods
Thickened cervical mucus
Thin endometrium
Common SE of progestogen only methods
Irregular / absent menstrual bleeding
Simple ovarian cysts
Breast tenderness
Acne
Risk of depo provera
Reversible loss of bone mineral density
Weight gain
Delay in return of fertility
Irregular / absent menstruation
Mechanism of action of copper IUD
Toxic to egg and sperm
SE of copper IUD
Heavier periods
Increased menstrual pain
Increased spotting
Duration of action of depo, implant, mirena, copper coil
Depo = 12 weeks
Implant = 3 years
Mirena = 5 years
Copper coil = 10 years
CI to intrauterine contraception (UKMEC 4)
Symptomatic chlamydia or gonorrhoea - for initiation
PID
malignant trophoblastic disease
trophoblastic disease with persistently elevated hCG levels
Unexplained vaginal bleeding - initiaiton
Endometrial cancer - initiation
Cervical cancer - awaiting treatment - initiation
Copper allergy
Methods to calculate the fertile window
Change in basal body temp
Change in cervical mucus
Track cycle days
Combination of above
Types of emergency contraception
Levonelle - levonorgestrel
EllaOne - ulipristal acetate
Copper IUD
Early medical termination - drugs used + gestation
Mifepristone oral + misoprostal orally
+ analgesia
4 - 9weeks
Later medical termination - drugs used + gestation
Mifepristone oral + misoprostal PV every 3-6 hours
+ analgesia
12 - 24weeks
surgical termination - technique used + gestation
MVA up to 9 weeks
Suction under GA unto 12-14 weeks
Dilation and evacuation >12 - 24weeks
Possible Complications of termination
Incomplete abortion Endometritis and resultant tubal damage Uterine perforation cervical trauma Psychological SE
Factors decreasing fertility
Increasing age Smoking Less frequent sex Alcohol Obesity NSAIDs Chemotherapy
Presentation of ectopic pregnancy
\+ve pregnancy test Abdo / adnexal pain Vaginal bleeding Cervical excitation fainting
Investigation of ectopic pregnancy
UPT physical obs - BP, HR, RR, temp Hb Group + save Beta-HCG TVUSS
Management of ectopic pregnancy
Either IM methotrexate
Or
laparoscopy - salpingectomy / salpingotomy
Define threatened miscarriage
Vaginal bleeding
Os closed
Define inevitable miscarriage
Vaginal bleeding
Os open
Define incomplete miscarriage
Vaginal bleeding
Os open
products of conception seen in os or on USS
Define complete miscarriage
Pain and bleeding resolved
os closed
No retained products on USS
Define missed miscarriage
Fetal pole present on USS - no heart beat
Or Gestational sac present but no fetal pole
No pain or bleeding
Management of miscarriage
Expectant
Medical - misoprostal
Surgical - SMOM
Define cervical ectropion
Benign condition
Columnar epithelium on vaginal aspect of cervix.
Transforms to squamous epithelium
Define nabothian follicle
Mucus filled cyst within the ectocervix - not significant - no tx needed
COMMON causes of cervical ectropion
Puberty
COCP
Pregnancy
Causes of cervical stenosis
Usually iatrogenic
Cervical cone biopsy / LLETZ
Endometrial ablation devices
What is asherman’s syndrome
Endometrial cavity fibrosis and adhesion
What is a uterine fibroid
Benign tumour of uterine smooth muscle = leiomyoma
Risk factors for uterine fibroids
Nulliparity
Obesity
Family history
Black African / Caribbean ethnicity
Symptoms of uterine fibroids
Pelvic mass
Menstrual disturbance - often HMB
Pressure symptoms - urinary frequency
Management of fibroids
Conservative Medical tx for heavy menstrual bleeding Uterine artery embolisation Myomectomy Hysterectomy
Cell types of endo and ecto cervix
Endocervix = canal = columnar glandular epithelium Ectocervix = external = squamous epithelium
Symptoms and causes of acute cervicitis
Irritation, mucus / pus discharge Dyspaerunia Post coital bleeding Inter-menstrual bleeding STIs
Cell type of cervical polyp
Endocervical = columnar (glandular) epithelium
symptoms of cervical polyp
Asymptomatic
Intermenstrual bleeding
Post coital bleeding
Rarely >1cm
What is cervical dysplasia
Cervical intraepithelial neoplasia.
Atypical cells in the squamous epithelium
If untreated what % of CIN develop cancer over 10 years
1/3 with CIN II or III
CIN Commonly regresses - can progress to CIN II or III
What age is CIN most common
90% <45yo
Peak incidence 25-29
Aetiology of cervical cancers
HPV 16, 18, 31, and 33 most common.
HPV vaccine is for 16 and 18
Oral contraceptives
Smoking
Biggest risk factor for the development of cervical cancer
Non-attendance for cervical screening
Who is invited for cervical screening + how often
25-64
Every 3 years until 50
5 yearly from age 50 until 65.
Annually if HIV +ve
Describe colposcopy
Speculum ex + microscope magnification 10-20x
Acetic acid stain + iodine
+ biopsy
What is a LLETZ procedure + what’s it for
Large loop excision of the transformation zone
For CIN II or III
Possible complications of LLETZ
Haemorrhage
Cervical stenosis
Slight increased risk of preterm delivery
Peak incidence of cervical carcinoma
2 peaks - 30s and 80s
Types of cervical carcinoma
90% squamous malignancies
10% adenocarcinomas (worse prognosis)
What is Stress incontinence
Involuntary leakage of urine on effort / exertion /sneezing / coughing.
Due to an incompetent sphincter.
May be associated with genitourinary prolapse.
What is Urge incontinence
Involuntary urine leakage
Accompanied by/ immediately preceded by urgency.
Due to detrusor instability or hyperreflexia leading to involuntary detrusor contraction.
What is Mixed incontinence
Involuntary leakage of urine associated with urgency and exertion/effort/sneezing/ coughing.
What is Overactive bladder syndrome (OAB)
Urgency with or without urge incontinence
+ usually frequency and nocturia.
+/- Incontinence
What is Overflow incontinence
Due to chronic bladder outflow obstruction.
Often due to prostate disease in M.
Can be due to a neurogenic bladder.
What is ‘True incontinence’
continuous urine leakage
May be due to a ureto/urethro/bladder-vaginal fistula
What is tranexamic acid
Anti-fibrinolytic
What is 3rd degree uterine prolapse?
Uterine descent with cervical protrusion beyond the introitus
Is 3rd degree uterine prolapse painful?
Not usually
Unless ulcerated
Does 3rd degree uterine prolapse cause difficulty defecating?
Yes by pressure on the anterior wall of the rectum.
Can 3rd degree uterine prolapse cause urinary incontinence?
Yes.
Or retention
Possible symptoms of endometriosis
Ovulation pain Mid cycle lower abdominal pain Heavy menstruation Dysmenorrhoea Dysparunia Dysuria Haematuria
What is the guidance on pregnancy tests before sterilisation
ALL women should have a UPT on the day of sterilisation to identify current pregnancies
Failure rate of Cu-IUD per 100 women years
0.8%
Failure rate of implant per 100 women years
0.05%
% women becoming pregnant in the first year of using no method of contraception
80-85%
Typical failure rate of FAM per 100 women years
24%
Typical failure rate of the diaphragm per 100 women years
12%
Typical failure rate of Female condom per 100 women years
20%
Typical failure rate of Female sterilisation per 100 women years
0.5%
Typical failure rate of vasectomy per 100 women years
0.15%
UKMEC for Implant or POP post-partum at 0 - <3 weeks with or without risk factors for VTE
UKMEC for implant or POP - Post partum 0 - <3 weeks
with risk factors for VTE = 1
without risk factors for VTE = 1
UKMEC for DMPA post-partum at 0 - <3 weeks with or without risk factors for VTE
UKMEC for DMPA - Post partum 0 - <3 weeks
with risk factors for VTE = 2
without risk factors for VTE = 2
UKMEC for CHC post-partum at 0 - <3 weeks with or without risk factors for VTE
UKMEC for CHC - Post partum 0 - <3 weeks
with risk factors for VTE = 4
without risk factors for VTE = 3
UKMEC for CHC post-partum at 3 - 6 weeks with or without risk factors for VTE
UKMEC for CHC - Post partum 3 - 6 weeks
with risk factors for VTE = 3
without risk factors for VTE = 2
UKMEC for DMPA post-partum at 3 - 6 weeks with or without risk factors for VTE
UKMEC for DMPA - Post partum 3 - 6 weeks
with risk factors for VTE = 2
without risk factors for VTE = 1
UKMEC for CHC post-partum at 6+ weeks
UKMEC for CHC post-partum at 6+ weeks
= 1
UKMEC for CHC post-partum at 0-6 weeks AND breastfeeding
UKMEC for CHC post-partum at 0-6 weeks AND breastfeeding
= 4
UKMEC for CHC post-partum at 6 weeks to 6months AND breastfeeding
UKMEC for CHC post-partum at 6 weeks to 6months AND breastfeeding
= 2
UKMEC for CHC post-partum at >6months AND breastfeeding
UKMEC for CHC post-partum at >6months AND breastfeeding
= 1
UKMEC for DMPA post-partum at 0-6 weeks AND breastfeeding
UKMEC for DMPA post-partum at 0-6 weeks AND breastfeeding
= 2
UKMEC for IUD / IUS with post-partum sepsis
UKMEC for IUD / IUS with post-partum sepsis
= 4
may substantially worsen the condition
UKMEC for IUD / IUS at 0-48 hours post-partum
UKMEC for IUD / IUS at 0-48 hours post-partum
= 1
UKMEC for IUD / IUS at 48 - <4 weeks post-partum
UKMEC for IUD / IUS at 48 - <4 weeks post-partum
= 3
UKMEC for IUD / IUS at >4 weeks post-partum
UKMEC for IUD / IUS at >4 weeks post-partum
= 1
What are risk factors for VTE postpartum
Immobility transfusion at delivery BMI >30 PPH C/S delivery ART / IVF multiple pregnancy Hyperemesis Current systemic infection smoking PET Age >35 Parity >3 Varicose veins
When can contraception be stopped after laparoscopic tubal sterilisation
Method dependant
If Cu-IUD / IUS - retain for 7/7 after procedure
If implant - retain for 7/7 after procedure
injection - procedure should be done within its 14 week licence
if CHC - can stop on day of surgery if taken correctly for 7/7 before, if in HFI restart and continue for 7/7
If POP - traditional - continue for 7/7, if desogestrel could stop on day of procedure
Diagnostic criteria for migraine
>/= 5x headache attacks - each lasts 4 - 72 hours AND 2 or more features of: - unilateral - pulsating - inhibits or prohibits ADLs - aggravated by walking / stairs / routine movement AND 1 or more of: - photophobia - nausea / vomiting
Diagnostic criteria for migraine with aura
Diagnostic criteria for migraine
PLUS 2+ attacks with 3 of:
- aura symptom develops gradually over >4 mins or 2 symptoms in succession
- no aura symptom lasts >60 mins
- a fully reservable symptom of focal cerebral cortical for brain stem function
- headache follows aura with a free interval of >60 mins or both start simultaneously
When is EC indicated for late / missed POP
Desogestrel = >12hr late (i.e. 36 hr after last)
Traditional = >3hr (i.e. 27 hr after last)
When is EC indicated for late / missed COCP
> 2 pills missed
= 48 hours late
Or extension of the HFI by 48 hrs
When is EC indicated for late / lost combined patch or ring
if patch detached / ring removed for >48 hours
Or extension of the HFI by 48 hrs
If the hormone free interval is extended beyond 7 / 7 when can an IUD be offered
Em IUD can be offered upto day 13 after the start of the HFI
What is the timeframe for interaction of hormonal contraception with ulipristal acetate EHC
UPA EHC efficacy may be decreased if
progestogen or combined hormone used in the:
7 days prior
and 5 days after
How common is gestational trophoblastic disease?
Hydatidiform mole affects 1-3 in every 1000 pregnancies.
10% of those transform into malignant gestational trophoblastic disease
What is hydatidiform mole
abnormal conceptions
with excessive placental development
and little or no fetal development
2 major types = complete and partial
Types of gestational trophoblastic disease
Benign forms =
- Partial hydatidiform mole
- Complete hydatidiform mole
Malignant forms =
- Invasive hydatidiform mole
- Choriocarcinoma
- Placental site trophoblastic tumour
- Epithelioid trophoblastic tumour
Presentation of gestational trophoblastic disease
Positive pregnancy test
+ vaginal bleeding or suspected miscarriage
+/- hyperemesis
USS - suspect diagnosis
histological diagnosis
USS features of gestational trophoblastic disease made?
grape-like or hydropic changes
snowstorm-like appearance
What is the difference between complete and partial molar pregnancies
Genetically distinct
But both over-express paternal genes
Complete hydatidiform moles = diploid, as a result of duplication without mitosis after monospermic fertilisation (or rarely, dispermic fertilisation of an anucleate oocyte)
Partial hydatidiform moles = triploid, as a result of dispermic fertilisation.
most common site of metastatic gestational trophoblastic disease
The lung
associated with dyspnoea, cough, haemoptysis, and chest pain
What contraception is safe following a diagnosis of GTD and when should it be commenced?
use barrier methods until hCG levels normalise
Then can use hormonal contraception (including COCP or POP)
IUCDs can be fitted once the hCG levels are normal - not before due to the risk of perforation
Management of a molar pregnancy
Suction curettage is the method of choice of evacuation
Send to histology
UPT in 3/52
+/- Anti- D
If hCG normalises within 56 days then follow up is for 6 months from the date of evacuation.
If hCG normalises after 56 days follow-up is 6 months from normalisation of the hCG level
When can women whose last pregnancy was a complete or partial hydatidiform molar pregnancy try to conceive in the future and what is the outcome of subsequent pregnancies?
Advised not to conceive until their follow-up is complete
Women who undergo chemotherapy for GTN are advised not to conceive for 1 year after completion of treatment
LOW risk of a further molar pregnancy (1/80)
> 98% of pregnancies following a molar pregnancy are not molar
no increased risk of obstetric complications
What is the long-term outcome of women treated for GTN?
hemotherapy for GTN = earlier menopause likely
multi-agent chemotherapy including etoposide = increased risk of developing secondary cancers
