G Flashcards
Miscarriage
• Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g.
uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use,
underweight or overweight
• Breaking bad news
o Explain the diagnosis
o Reassure that this is common and under-reported (1 in 5 pregnancies)
Explain that risk increases with age
If asked about cause: explain that most of the time there is no cause
o Explain the management options (expectant, medical and surgical)
If medical: explain what to expect (pain, bleeding, nausea)
Antiemetics and pain relief will be given
o Advise to do a pregnancy test after 3 weeks
• Safety net: return if symptoms get worse, bleeding persists after 7-14 days
Ectopic
Risk Factors: PID, smoking, IUD/IUS, assisted reproductive technology, tubal surgery
o Explain the diagnosis (implantation of a pregnancy outside the womb, meaning that it is not viable)
o Explain the risks of an ectopic (damage to surrounding structures, bleeding and rupture)
o Explain that the treatment options available are based on ultrasound findings and
the level of a pregnancy hormone in the blood (and explain which options are
available)
• Medical Management
o Explain administration (1 x IM injection)
o Manage expectations (tummy pain, nausea, diarrhoea – should pass within a few days)
o Explain that they can go home after the injection but will need to come back a couple of times over the next week for a blood test
o Avoid sex during treatment, don’t conceive for 6 months and avoid drinking alcohol
and excessive exposure to sunlight
o Explain that there is a risk of treatment failure, requiring further intervention
• Surgical Management
o Explain that salpingectomy is the best procedure (but salpingotomy can be
considered if fertility issues or problems with contralateral tube)
o Explain that salpingotomy has a 1 in 5 risk of requiring further intervention
o Reassure that fertility isn’t drastically reduced by salpingectomy vs salpingotomy (salpingotomy still leaves behind a damaged tube)
o Explain follow-up
• Discuss ongoing contraception
Gestational Trophoblastic Disease
• Risk Factors: advanced maternal age (or younger than 20), prior molar pregnancy (1-2%
risk of recurrence), prior miscarriages, Asian heritage
• Breaking bad news
o Explain the diagnosis (when the foetus doesn’t form properly, and a baby doesn’t develop, instead there is an irregular mass of pregnancy tissue)
o Explain risks (important to treat because it can invade and damage other tissues)
o Explain immediate management (suction curettage)
o Explain follow-up (referral to trophoblastic screening centre to monitor pregnancy
hormone levels)
o Molar pregnancy does not affect fertility (but there is a 1 in 80 chance of recurrence)
o Do not try to get pregnant until after follow-up is complete
Polycystic Ovarian Syndrome (PCOS)
Risk Factors: family history, obesity
• Explain the diagnosis (a disease with no clear cause that leads to abnormalities in hormone levels (which, in turn, result in the symptoms experienced))
• Explain that it is very common (1 in 10 in the UK (many are unaware))
• Explain the main consequences (irregular periods, subfertility, metabolic syndrome,
cardiovascular disease, acne)
• Explain the management tailored to patient’s biggest concern:
o Fertility: recommend weight loss → clomiphene +/- metformin → consider LOD
o Periods: COCP or progestogens (aiming for at least 3-4 bleeds per year)
o Metabolic Syndrome: check for DM, high cholesterol, heart disease (manage accordingly)
TOP
Explain the options available based on the gestation (medical and surgical)
o Explain that the best option is dependent on how many weeks pregnant they are
(higher gestation = more pregnancy tissue)
• Medical: explain that one pill will be taken by mouth followed by another in 24-48 hours
either buccal/sublingual/oral
o Bleeding can last about 2 weeks
o Pregnancy test after 3 weeks
o Occasionally unsuccessful and requires surgical removal
• Surgical: explain that it involves gently dilating the cervix and removing the pregnancy
tissue using a suction tube (only takes about 10 mins)
o May need to ripen cervix before hand
o Can be done under local or general anaesthesia
Subfertility
• Risk Factors: advanced maternal age, smoking and alcohol use, obesity, irregular periods,
STI
• Explain that there is still a chance of getting pregnant naturally (15% of couples fail to
conceive after 1 year)
• Explain that you would like to start investigations (blood test looking at hormone levels,
ultrasound scan looking at structure of the uterus and follicle count and HSG if there are risk
factors)
• Encourage continuing regular unprotected sex at least every other day
• Discuss management options depending on likely cause of subfertility
Menopause
• Explain that changes that typically occur at menopause (hot flushes, sexual dysfunction, mood changes)
• Explain lifestyle factors (healthy diet, weight loss, smoking cessation)
• Explain medical options (HRT, SSRIs, topical lubricants/oestrogens)
o Tailor to needs of the patient
o Explain risks/side-effects
• Explain need for contraception
o Until > 1 year amenorrhoeic if > 50 yrs
• Until > 2 years amenorrhoeic if < 50 yrs
• Advice on bone health, keeping up to dat
Vulvovaginal Candidiasis
• Risk Factors: recent antibiotic use, oral contraceptives, diabetes mellitus, excessive
washing
• Explain the diagnosis
• Explain treatment (usually either intravaginal clotrimazole or oral fluconazole)
• Explain hygiene measures (not cleaning too often, avoiding using fabric conditioners and
soap substitutes)
Pelvic inflammatory disease
• Risk Factors: younger women (< 25 years), STI, multiple sexual partners, past PID
• Assess whether severely unwell and needing admission
• Explain diagnosis (infection that has spread up to the womb)
• Explain risks of PID: infertility, ectopic pregnancy, chronic pelvic pain
• It will be treated with antibiotics (1 injection and 2 tablets taken for 14 days)
• Do not have sex until course is complete
o Recommend full STI screen and encourage contact tracing
• Discuss contraception (consider removal of IUD if present)
• Follow Up: in 3 days’ time and in 2-4 weeks
Urinary Incontinence/Overactive Bladder Syndrome
• Risk Factors
o Stress: age, traumatic delivery (forceps), obesity, previous pelvic surgery
o Urge: age, obesity, smoking, family history, diabetes mellitus
• Explain diagnosis and mechanism
• Explain lifestyle measures (e.g. controlling fluid intake, avoiding caffeine, losing weight)
• Explain treatment
o Urge: bladder retraining for 6 weeks – trying to gradually increase the time in between going to the toilet
o Stress: pelvic floor training for 3 months
• Explain medical and surgical options
Vaginal prolapse
- Risk Factors: multiparity, age, obesity, prolonged second stage of labour, heavy lifting
- Explain the diagnosis
- Explain lifestyle modifications (lose weight, healthy diet, stop smoking)
- Explain conservative management (pelvic floor exercises, oestrogens)
- Explain ring pessary or surgery
Bartholin’s Cyst/Abscess
• Risk Factors: nulliparous, child-bearing age, previous Bartholin’s cyst
• Explain the diagnosis (blockage of a duct in your vagina, it has become infected)
• Explain management
o Conservative: observation and antibiotics
o Word catheter insertion
o Marsupialisation
• Recommend STI screen
Endometriosis
Risk Factors: early menarche, family history, nulliparity, prolonged menstruation (> 5 days),
short menstrual cycles (< 28 days)
• Explain diagnosis (a condition where the tissue that lines the womb starts appearing outside
the womb)
• Explain that it is very common (10% of women of reproductive age)
• Explain management options
o Conservative: NSAIDs
o Medical: COCP, LNG-IUS, POP
o Surgical: diagnostic laparoscopy and excision/ablation
• Explain potential impact on fertility
Fibroids
• Risk Factors: increasing age until menopause, early puberty, obesity, Afro-Caribbean,
family history
• Explain the diagnosis (common smooth muscle masses that can cause heavy menstrual
bleeding and fertility issues)
• Explain that it is very common (increases in prevalence with age until menopause – 20-50%
of women over 30 years)
• Explain the management
o HMB: LNG-IUS, COCP
o Fertility: surgery, tranexamic acid
o Symptomatic: tranexamic acid
Cervical Intraepithelial Neoplasia (CIN) + Cervical Cancer
• Explain the purpose of screening and the results
• Explain that management:
o CIN1: repeat smear in 1 year
o CIN2, CIN3 and CGIN: LLETZ or cone biopsy
LLETZ: outpatient procedure with local anaesthetic
Cone biopsy: used for larger lesions and done under general anaesthetic
Risk: mid-trimester loss and preterm birth (may need prophylactic cerclage)
• Explain follow up:
o Repeat smear in 6 months for test of cure
