GOSH MANAGEMENT Flashcards
SFD/Reduced Foetal Movements
>28 weeks
Auscultation –> CTG
USS – abdo circumference, foetal weight (within 24 hours), amniotic fluid volume (determine whether SFGA), biophysical profile
RFM –> lie on left for 2 hours - < 10 movements –> ANDU
PPROM?
Admit for 24-48 hours - examination, bloods, swabs
Steroids – Betamethasone 12mg IM (2 doses 24 hours apart)
Abx – Erythromycin 250mg QDS 10 Days
IUGR?
Weekly umbilical artery Doppler and 2 weekly growth scans
Daily CTG if Doppler abnormal
BP/urine checks
Delivery at 37 weeks or earlier if significant maternal or foetal compromise
Pre-eclampsia?
Investigations
o Urine PCR (confirm diagnosis)
o Serial BP, FBC, U+E, LFTs and clotting
o Umbilical artery Doppler and daily CTG if abnormal
Antihypertensives – Labetolol, methyldopa, nifedipine
Delivery at 34-36 weeks – Steroids if < 34 weeks
Magnesium sulphate (prophylactic use)
Hyperemesis?
IV rehydration
Antiemetics (cyclizine/promethazine/steroids)
Vitamin B supplementation
Growth scans (IUGR)
Gestational diabetes?
Diet/exercise for 2 weeks - if not working –> Metformin/Insulin - regular self-monitoring
Folic Acid 5mg until 12 weeks, Aspirin 75mg from 12 weeks
Scans
o Growth scans + liquor volume – 4 weekly from 28 weeks onwards
o Anomaly/specialist cardiac USS
Urine PCR every 4 weeks
Preterm labour?
Investigations = foetal state (CTG/USS), likelihood (foetal fibronectin, TV USS cervical length), infection (HVS, CRP, FBC)
Steroids
Tocolytics – Nifedipine/Atsodiban (no more than 24 hours)
If chorioamnionitis - IV abx and immediate delivery
Abx for delivery if risk of GBS
Placenta Praevia
APH - NO VAGINAL EXAMINATION UNTIL AFTER A SCAN
Admit at 37 weeks or anytime if bleeding – maintain IV access and keep blood available
Anti D for Rhesus -ve women
Elective caesarean at 39 weeks
Placental Abruption
APH - NO VAGINAL EXAMINATION UNTIL AFTER A SCAN
Admission
IV fluids – consider transfusion
Anti D for Rhesus -ve women
Delivery
o > 37 weeks – Induce if no foetal distress, urgent C-section if foetal distress
o < 34 weeks – steroids
o Can be managed conservatively if no foetal distress and abruption minor – monitor on ward.
Primary PPH?
Atonic Uterus o Ergometrine IV bolus o Syntocinon infusion o Prostaglandins if no response o May need examination under anaesthesia +/- laparotomy
Genital Tract Trauma – repair
Persistent Bleeding
o Rusch balloon, brace suture, uterine artery embolization
Endometritis? (secondary PPH)
Investigations = FBC, CRP, HVS, blood cultures
Co-amoxiclav or Cefuroxime and Metronidazole
Other secondary PPH?
Vaginal swabs,, FBC, X-match
USS
Abx
Evacuation retained products (ERPC)
Eclampsia
ABC –> recovery position, bloods (FBC, U+E, coag – HELLP)
Magnesium sulphate/diazepam to stop fits
Magnesium sulphate infusion
Stabilise blood pressure and maternal condition –> deliver baby
Pulmonary Embolus
ABCDE, O2, ABG, CXR, ECG
V/Q scan
Anticoagulate during remainder of pregnancy and post-partum
o LMWH – tinzaparin, enoxaparin
o NOT warfarin
Menorrhagia?
Not trying to conceive
1st line = Mirena IUS;
2nd line = COCP;
3rd line = GnRH agonists
Trying to conceive
1st line = Tranexamic acid/Mefanamic acid;
2nd line = Progestogens
Surgery
Endometrial ablation; Uterine artery embolization; Hysterectomy
Irregular periods?
1st line = IUS or COCP
2nd line = Progestogens
Dysmenorrhoea?
1st line = NSAIDs or COCP
PCOS? (increased risk of diabetes and endometrial cancer)
Weight reduction
COCP – need 3-4 bleeds per year to protect endometrium
Antiandrogens – Cyproterone acetate/Spironolactone – conception must be avoided. Topical eflonithine for facial hirsutism.
Metformin - ↓insulin levels –> ↓androgens and hirsutism
Endometriosis? (mimic pregnancy)
Medical
NSAIDs
COCP (not older women or smokers – back to back pills)
Progestogens (endometrial and ovarian suppression)
GnRH Analogues (only 6 months due to bone demineralisation)
Surgical
Laparoscopic ablation, resection or cystectomy/oophorectomy
Hysterectomy (last resort)
PID?
Investigations o Abdo exam, speculum + bimanual o All the swabs/HIV syphilis bloods/urine dipstick o Temperature o FBC/U+E/CRP/LFTs
Ceftriaxone 250mg IM stat
Doxycycline 100mg BD PO 14 days
Metronidazole 400mg BD PO 7-14 days (if suspected vaginitis)
Miscarriage? (Incomplete, inevitable, missed)
Medical
Misoprostol
Surgical
Evacuation of uterus (under GA)
Ectopic pregnancy?
Medical
Methotrexate IM – if < 3cm in size, no FH seen on scan.
Surgical
Salpingectomy (usually laparoscopic)
Fibroids?
Medical
1st line = Tranexamic acid; NSAIDs; Progestogens
GnRH analogues – to shrink before surgery
If small/intramural and causing menorrhagia - COIL
Surgical Hysteroscopic resection of fibroids Hysterectomy Myomectomy – preserves fertility Uterine artery embolisation – effect on fertility unclear
Stress incontinence?
• Conservative
Pelvic floor muscle training
• Medical
Duloxetine
• Surgical
TVT/TOT; Colposuspension = old-fashioned
Urge incontinence?
• Conservative
Avoiding caffeine, fluid intake etc
Bladder training – educaton, timed voiding, +ve reinforcement
• Medical
Anticholinergics (oxybutynin) – dry mouth, constipation etc
Oestrogens (if post-menopausal)
Botulinum Toxin A – paralyses muscle
Infertility?
Investigations
Infection - chlamydia, rubella
Egg – FSH, LH + oestradiol (day 1-5) mid-luteal serum progesterone
Sperm – semen analysis
Where they meet – USS, hysterosalpingogram, lap + dye
Management
Group 1 (hypogonadotrophic hypogonadism) – increase weight, moderate exercise levels. Group 2 (PCOS) – clomifene, metformin (no ↑multiple prego), gonadotrophins (↑multiple prego), ovarian diathermy. Group 3 (premature ovarian insufficiency) – referral to various specialists, fertility treatment (egg donation), HRT o Intrauterine insemination/IVF
Termination of pregnnacy?
• Medical
Mifepristone and Misoprostol (< 9 weeks)
• Surgical
Manual vacuum aspiration (9-12 weeks, continuous sedation)
Surgical evacuation (7-15 weeks, under GA)
Dilatation/evacuation (15-18 weeks, under GA)
Surgical evacuation without feticide (19-22 weeks)
Surgical feticide (22-24 weeks – KCl to stop foetal heart)
Menopause?
HRT
Oes + prog (if no hysterectomy) - oestrogen protects against osteoporosis and alleviates vasomotor symptoms.
Regulates irregular bleeding. Reduces Protective against bowel cancer, alzheimers. Makes skin and hair look better.
Risk of breast ca, VTE and CVD.
If bleed in last 12 months - cyclical –> withdrawal bleed. Continuous if not.
Contraindications to HRT?
Current breast/endometrial ca, undiagnosed vaginal bleeding, thrombosis, breast mass, acute liver disease
Endometriosis, fibroids, fam or past hx breast cancer/thrombotic disease
Endometrial hyperplasia? (>5mm)
With atypical cells - hysterectomy
Without atypical cells - high dose progestogens (oral or oral + mirena)
Chlamydia?
Azithromycin 1g stat (safe in pregnancy
OR
Doxycycline 100mg BD 1/52 (not safe in pregnancy)
Partner notification
No sex until both partners finished course
Gonorrhoea?
Ceftriaxone 500mg IM stat
Azithromycin 1g PO stat (cover for chlamydia too + guards against resistance)
BV?
Metronidazole 400mg PO BD 7/7 OR Clindamycin 300mg BD 7/7 OR Tinidazole 2g stat
TV?
Metronidazole 400mg PO BD 7/7
Abstain until both partners treated
Candida?
Clotrimazole (canesten – topical antifungal) BD until symptoms resolved
Lichen Planus/Lichen Sclerosis
Planus = self-limiting
Sclerosis = potent topical steroid follow-up long term due to risk of malignant transformation
Scabies/Pubic Lice
Topical Permethrin – treat all household/sexual contacts
Lymphogranuloma Venerum
Doxycycline 100mg BD
Epididymo-Orchitis
STI cause likely –> Ceftriaxone 250mg IM stat and Doyxcycline 100mg PO 2/52
STI cause unlikely (enteric) –> Ofloxacin 200mg PO BD 2/52
or
Ciprofloxacin 500mg PO BD 10 days
Neonatal pnuemonitis?
Erythromycin
Herpes simplex?
Aciclovir 400mg TDS 5 days
Genital warts?
Ablative – cryotherapy, podophyllotoxin cream/solution (teratogenic), electrocautery
Immune modulation – imiquimod 5% cream
Surgical – cutterage, excision, debulking
Smoking cessation
Syphilis?
< 2 YEARS
Benzathine penicillin 2.4MU IM stat
Doxycycline in penicillin allergic
> 2 YEARS
3x IM ben pen 1 week apart
