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Year 3- placement > contracetion and instrumental labur > Flashcards

contracetion and instrumental labur Flashcards

1
Q

Erectile dysfunction- definition

A

Persistent inability to attain and maintain an erection sufficient to perform satisfactory sexual performance. Symptom, not a disease. Causes can be split broadly into organic, psychogenic and mixed

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2
Q

Erectile dysfunction- factors favouring an organic cause

A
  • Gradual onset of symptoms
  • Lack of tumescence (erection)
  • Normal libido
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3
Q

Erectile dysfunction- factors favouring a psychogenic cause

A
  • Sudden onset of symptoms
  • Decreased libido
  • Good quality spontaneous or self-stimulated erections
  • Major life events
  • Problems or changes in a relationship
  • Previous psychological problems
  • History of premature ejaculation
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4
Q

Risk factors for erectile dysfunction

A
  • Increasing age
  • cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
  • alcohol use
  • drugs: SSRIs, beta-blockers
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5
Q

Investigations into erectile dysfunction

A
  • Calculate their 10 year cardiovascular risk by measuring lipids and fasting glucose serum levels
  • Free testosterone should also be measured in the morning between 9 and 11am.
  • If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels.
  • If any of these are abnormal refer to endocrinology for further assessment.
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6
Q

Management of erectile dysfunction

A
  • PDE-5 inhibitors (such as sildenafil, ‘Viagra’)= they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology, sildenafil can be purchased over-the-counter without a prescription.
  • Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
  • for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
  • people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
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7
Q

Imperforate hymen

A

Where the hymen at the entrance of the vagina is fully formed, without an opening.
Imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

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8
Q

Treatment and complications of an imperforate hymen

A

An imperforate hymen can be diagnosed during a clinical examination. Treatment is with surgical incision to create an opening in the hymen.

Theoretically, if an imperforate hymen is not treated retrograde menstruation could occur leading to endometriosis.

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9
Q

Types of twins

A

Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic

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10
Q

Monoamniotic monozygotic twins are associated with

A
  • increased spontaneous miscarriage, perinatal mortality rate
  • increased malformations, IUGR, prematurity
  • twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
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11
Q

Predisposing factors for dizygotic twins

A
  • previous twins
  • family history
    increasing maternal age
  • multigravida
  • induced ovulation and in-vitro fertilisation
  • race e.g. Afro-Caribbean

The rate of monozygotic twins is fairly constant. The incidence of dizygotic twins is increasing mainly due to infertility treatment.

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12
Q

Twins- antenatal complications

A
  • polyhydramnios
  • pregnancy induced hypertension
  • anaemia
  • antepartum haemorrhage
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13
Q

Fetal complications- multiple pregnancies

A
  • perinatal mortality (twins * 5, triplets * 10)
  • prematurity (mean twins = 37 weeks, triplets = 33)
  • light-for date babies
  • malformation (*3, especially monozygotic)

Labour complications: PPH increased, malpresentation, cord prolapse, entanglement

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14
Q

Fetal complications of multiple pregnancies- management during pregnancy

A
  • rest
  • ultrasound for diagnosis + monthly checks
  • additional iron + folate
  • more antenatal care (e.g. weekly > 30 weeks)
  • precautions at labour (e.g. 2 obstetricians present)
  • 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
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15
Q

Two main types of caesarean section

A
  • lower segment caesarean section: now comprises 99% of cases
  • classic caesarean section: longitudinal incision in the upper segment of the uterus
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16
Q

Indications for caesarean section

A
  • absolute cephalopelvic disproportion
  • placenta praevia grades 3/4
  • pre-eclampsia
  • post-maturity
  • IUGR
  • fetal distress in labour/prolapsed cord
  • failure of labour to progress
  • malpresentations: brow
  • placental abruption: only if fetal distress; if dead deliver vaginally
  • vaginal infection e.g. active herpes
  • cervical cancer (disseminates cancer cells)
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17
Q

Caesarean sections may be categorised by the urgency

A
  • Category 1= an immediate threat to the life of the mother or baby. Example indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia. delivery of the baby should occur within 30 minutes of making the decision
  • Category 2= maternal or fetal compromise which is not immediately life-threatening, delivery of the baby should occur within 75 minutes of making the decision
  • Category 3= delivery is required, but mother and baby are stable
  • Category 4= elective caesarean
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18
Q

Maternal risks of a caesarian section (serious)

A
  • emergency hysterectomy
  • need for further surgery at a later date, including curettage (retained placental tissue)
  • admission to intensive care unit
  • thromboembolic disease
  • bladder injury
  • ureteric injury
  • death (1 in 12,000)
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19
Q

Risks of caesarian section- further pregnancies

A
  • increased risk of uterine rupture during subsequent pregnancies/deliveries
  • increased risk of antepartum stillbirth
  • increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
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20
Q

Maternal risks of a caesarian section (frequent)

A
  • persistent wound and abdominal discomfort in the first few months after surgery
  • increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
  • readmission to hospital
  • haemorrhage
  • infection (wound, endometritis, UTI)
    Fetal: lacerations, one to two babies in every 100
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21
Q

Indications for a forceps delivery include

A
  • fetal distress in the second stage of labour
  • maternal distress in the second stage of labour
  • failure to progress in the second stage of labour
  • control of head in breech deliver
  • Maternal exhaustion

10% of births in the UK are instrumental. A single dose of co-amoxiclav is given after instrumental delivery to reduce the risk of maternal infection.

22
Q

Maternal risks of an instrumental delivery

A
  • Postpartum haemorrhage
  • Episiotomy
  • Perineal tears
  • Injury to the anal sphincter
  • Incontinence of the bladder or bowel
  • Nerve injury (obturator or femoral nerve)
23
Q

Instrumental risks- key risks to the baby are

A
  • Cephalohematoma with ventouse
  • Facial nerve palsy with forceps
  • Serious risks: subgaleal haemorrhage (most dangerous)
24
Q

Forceps

A
  • They come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina.
  • The main complication for the baby is facial nerve palsy, with facial paralysis on one side.
  • Forceps delivery can leave bruises on the baby’s face. Rarely the baby can develop fat necrosis, leading to hardened lumps of fat on their cheeks. This resolves spontaneously over time.
25
Q

Instrumental delivery- Nerve injury

A
  • Instrumental delivery can cause nerve injury to the mother, usually resolves over 6-8 weeks. The affected nerves are: femoral nerve, obturator nerve
  • Femoral nerve damage: weakness of knee extension, loss of patella reflex and numbness of the anterior thigh and medial lower leg
  • Obturator nerve damage: weakness of hip adduction and rotation, the numbess of the medial thigh
26
Q

The three other nerve injuries that can occur during birth, that are usually unrelated to instrumental delivery:

A
  • Lateral cutaneous nerve of the thigh: causes numbness of the anterolateral thigh
  • Lumbosacral plexus: foot drop and numbness of the anterolateral thigh, lower leg and foot
  • Common peroneal nerve: foot drop and numbness in the lateral lower leg
27
Q

Vaginal birth after caesarean (VBAC)

A
  • planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
  • around 70-75% of women in this situation have a successful vaginal delivery
  • contraindications include previous uterine rupture or classical caesarean scar
28
Q

Breast screening

A

The NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments.

29
Q

Potential downsides to breast screening

A
  • Anxiety and stress
  • Exposure to radiation, with a very small risk of causing breast cancer
  • Missing cancer, leading to false reassurance
  • Unnecessary further tests or treatment where findings would not have otherwise caused harm

What is involved: mammogram

30
Q

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:

A
  • age of diagnosis < 40 years
  • bilateral breast cancer
  • male breast cancer
  • ovarian cancer
  • Jewish ancestry
  • sarcoma in a relative younger than age 45 years
  • glioma or childhood adrenal cortical carcinomas
  • complicated patterns of multiple cancers at a young age
  • paternal history of breast cancer (two or more relatives on the father’s side of the family)
31
Q

Women who are at an increased risk of breast cancer due to their family history may be offered screening from a younger age. The following patients should be referred to the breast clinic for further assessment:

A
  • one first-degree female relative diagnosed with breast cancer younger than age 40 years, or
  • one first-degree male relative diagnosed with breast cancer at any age, or
  • one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or
  • two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or
  • one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age, or
  • three first-degree or second-degree relatives diagnosed with breast cancer at any age
32
Q

Condoms

A
  • MOA: physical barrier
  • Relatively low success rate, particularly when used by young people
  • Helps protect against STI’s
33
Q

Combined oral contraceptive pill

A
  • Inhibits ovulation
  • Increases risk of Venous thromboembolism
  • Increases risk of breast and cervical cancer
34
Q

Progesterone only pill (excluding desogestrel)

A
  • Thickens cervical mucus
  • Irregular bleeding a common side effect
35
Q

Injectable contraception

A
  • Medroxyprogesterone acetate
  • Primary: inhibits ovulation also thickens cervical mucus
  • Lasts 12 weeks
36
Q

Implantable contraception

A
  • Etanogestrel
  • Primary: inhibits ovulation, also thickens cervical mucus
  • Irregular bleeding a common side effect, lasts 3 years
37
Q

Intrauterine contraception: MoA

A

Intrauterine contraceptive device: decreases sperm motility and survival

Intrauterine system (levonorgestrel)
* Primary: prevents endometrial proliferation also thicken cervical mucus
* Irregular bleeding is a common side effect

38
Q

Emergency contraception

A

There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.

39
Q

Levonorgestrel

A
  • Acts both to stop ovulation and inhibit implantation
  • should be taken as soon as possible - efficacy decreases with time
  • must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
  • single dose of levonorgestrel 1.5mg (a progesterone)
  • the dose should be doubled for those with a BMI >26 or weight over 70kg
  • levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
  • if vomiting occurs within 3 hours then the dose should be repeated
  • can be used more than once in a menstrual cycle if clinically indicated
  • hormonal contraception can be started immediately afterwards
40
Q

Ulipristal

A
  • a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
  • 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
  • concomitant use with levonorgestrel is not recommended
41
Q

Ulipristal- taking with other medication

A
  • Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
  • caution should be exercised in patients with severe asthma
  • Can be used more than once in the same cycle
  • breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
42
Q

Intrauterine device (IUD)- emergency contraception

A
  • a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
  • in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
  • must be inserted within 5 days of UPSI, or
  • if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
  • may inhibit fertilisation or implantation
  • may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
43
Q

COCP- absolute contraindications

A
  • more than 35 years old and smoking more than 15 cigarettes/day
  • migraine with aura
  • history of thromboembolic disease or thrombogenic mutation
  • history of stroke or ischaemic heart disease
  • breast feeding < 6 weeks post-partum
  • uncontrolled hypertension
  • current breast cancer
  • major surgery with prolonged immobilisation
  • positive antiphospholipid antibodies (e.g. in SLE)
44
Q

COCP- relative contraindications

A
  • more than 35 years old and smoking less than 15 cigarettes/day
  • BMI > 35 kg/m^2*
  • family history of thromboembolic disease in first degree relatives < 45 years
  • controlled hypertension
  • immobility e.g. wheel chair use
  • carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
  • current gallbladder disease
45
Q

COCP: if 1 pill is missed

A
  • Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
  • No additional contraceptive protection needed
46
Q

COCP: if 2 or more pills are missed

A
  • Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
  • the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
  • if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
  • if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
  • if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
47
Q

Advice on taking the COCP

A

If the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days. Should be taken at the same time everyday.

48
Q

Advantages of the combines oral contraceptive pill

A
  • highly effective (failure rate < 1 per 100 woman years)
  • doesn’t interfere with sex
  • contraceptive effects reversible upon stopping
  • usually makes periods regular, lighter and less painful
  • reduced risk of ovarian, endometrial cancer - this effect may last for several decades after cessation
  • reduced risk of colorectal cancer
  • may protect against pelvic inflammatory disease
  • may reduce ovarian cysts, benign breast disease, acne vulgaris
49
Q

Disadvantages of the combined oral contraceptive pill

A
  • people may forget to take it
  • offers no protection against sexually transmitted infections
  • increased risk of venous thromboembolic disease
  • increased risk of breast and cervical cancer
  • increased risk of stroke and ischaemic heart disease (especially in smokers)
  • temporary side-effects such as headache, nausea, breast tenderness may be seen
50
Q

Problems of intrauterine contraceptive device

A
  • uterine perforation
  • the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
  • infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
  • expulsion: most likely to occur in the first 3 months
51
Q

Problems of IUS and IUD

A
  • IUDs make periods heavier, longer and more painful
  • the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic

Year 3- placement (34 decks)

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