Gynae Flashcards
What are the mechanisms of contraception in the COCP
inhibit ovulation.
inhibit proliferation of the endometrium, creating unfavourable conditions for implantation
increases the thickness of cervical mucus, preventing passage of sperm.
How does the COCP inhibit ovulation
negative feedback effect of the oestrogen and progesterone on the hypothalamo-pituitary axis prevents the surge in LH
thus preventing ovulation
What is the difference between monophasic and phasic COCP
Monophasic pills: every pill contains the same levels of oestrogen and progesterone.
Phasic pills: the level of oestrogen and progesterone in the pills changes throughout the cycle.
What are the advantages of the COCP
Non-invasive method.
Menses tend to become regular, lighter and less painful.
Running packets together allows control of timing of menses for events such as holidays, exams, and sporting competitions.
improves acne.
It may help symptoms of premenstrual syndrome (PMS).
reduce the risk of ovarian, endometrial and colorectal cancer
It may reduce risk of ovarian cysts.
Normal fertility returns immediately after stopping usage
What are the disadvantages of the COCP
User-dependent - relies on remembering to take it regularly
Side effects - headaches, breast tenderness and mood changes
increased risk VTE
May cause an increase in blood pressure.
Breakthrough bleeding (BTB) may occur, particularly in the first few months of use.
Who should not take the COCP
BMI greater than 35
Breast feeding
Smoking >15 per day over the age of 35
Hypertension
History of or family history of venous thromboembolisms
Prolonged immobility due to surgery or disability
Diabetes mellitus with complications e.g. retinopathy
History of migraines with aura
Breast cancer or primary liver tumours
Heart disease - IHD, Valvular or congenital heart disease with complications. Also cardiomyopathy with impaired cardiac function, Atrial fibrillation.
What are some side effects of the COCP
Breakthrough bleeding. Weight gain and Mood changes - but no evidence breast tenderness, headaches nausea.
How is the COCP taken?
The COC pill should be started on the first day of menstrual bleeding, but can be started up to day 5 without the need for extra protection.
When started at any other time in the cycle, additional contraceptive precautions (eg, condoms) should be used for seven days
taken for 21 consecutive days, at approximately the same time of day
followed by seven pill-free days (or seven days of neutral tablets) to allow endometrial shedding and a withdrawal bleed. Contraception is still provided during the hormone-free interval.
Explain that only the first pill is taken on the first day of the woman’s period. Future packets will all be started on the same day of the week as the first packet, following a strict 28-day cycle.
What counts as a missed COCP?
If they take it more than 48 hours after the last pill (ie more than 24 hours late) it counts as a missed pill.
What is the advice given for a single missed COCP
The last pill missed should be taken now, even if it means taking two pills in one day.
The rest of the pack should be taken as usual.
No additional contraception is needed.
The seven-day break is taken as normal.
What is the advice given for two or more missed COCP
The last pill missed should be taken now, even if it means taking two pills in one day.
Any earlier missed pills should be left.
The rest of the pack should be taken as usual and additional precautions (eg, condoms or abstinence) should be taken for the next seven days.
If the pills are missed in the first week of a pack (pills 1-7): emergency contraception should be considered if the patient had unprotected sex in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval.
If the pills are missed in the second week of a pack (pills 8-14): there is no need for emergency contraception as long as the pills in the preceding seven days have been taken correctly. The packet should be finished and the usual pill-free interval taken.
If the pills are missed in the third week of a pack (pills 15-21): the next pack of pills should be started without a break - ie the pill-free interval is omitted. If taking a packet with dummy/placebo pills, these should be discarded, and the new packet started. Emergency contraception is not required.
How often should a woman taking the COCP be followed up?
After the first prescription, review at 3 months.
If all is well, follow up at 6- to 12-month intervals.
Supplies of up to a year may be issued.
How is the COCP managed around the time of surgery?
discontinued 4 weeks before elective major surgery
restarted on day one of the next period, occurring at least 2 weeks after mobilisation.
Progestogen-only contraception can be offered as an alternative during this time.
Women requiring emergency surgery should receive subcutaneous heparin and compression stockings.
What is the mechanism of action of the POCP
thickens the cervical mucus due to the high levels of progesterone. This prevents the entry of sperm and thereby fertilisation of the oocyte.
suppression ovulation (60% of cycles with pills containing levonorgestrel, 97% of cycles with desogestrel)
thinning of the endometrium which inhibits implantation.
What are the advantages of the POCP compared to the COCP
It is an effective and safe form where oestrogens are contra-indicated
It contains an even lower dose of progestogen than low-dose combined contraceptives and no oestrogen.
It can be used during breast-feeding.
It is suitable for women about to undergo major surgery or surgery on their legs.
There is no evidence that the POCP is associated with an increased risk of VTE
What are the disadvantages of the POCP
It has to be taken meticulously at the same time each day. (three hours window for traditional, 12 hours in newer with desogestrel)
It is just as susceptible to substances that cause enzyme induction, like rifampicin, many anticonvulsants and St John’s wort.
It does not control the menstrual cycle as effectively as the COCP - causes irregular menstruation or amenorrhoea.
There may be minor side-effects such as breast tenderness, skin changes, and headaches. These usually improve with time.
There is an increased risk of ovarian cysts, perhaps up to 30%.
There may be a small increased risk of breast cancer for women taking the POCP.
What are some contraindications to the POCP
Past history of breast cancer.
Severe cirrhosis.
Liver tumours.
Stroke and coronary heart disease
Systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies.
Those on medication, including antiretroviral therapy, enzyme-inducing anticonvulsants (but not lamotrigine which is contra-indicated with the COCP), and enzyme-inducing antibiotics such as rifampicin and rifabutin.
How should the POCP be started?
on the first day of menstruation, giving immediate contraceptive cover
If started any day up to the fifth day from the start of menstruation, no additional contraceptive precautions are required.
If started at any other time in the cycle, pregnancy should be excluded first, and additional contraceptive precautions should be used for 48 hours (eg, condoms or abstinence).
What should a woman do if she misses her POCP
She should take the missed pill as soon as she remembers and resume her usual pill-taking schedule - even if this means taking two pills on the same day, ie one when she remembers and the next pill on time.
In addition, if the pill is more than three hours late (12 hours for desogestrel pills such as Cerazette®) other contraceptive precautions are required (eg, condoms) or abstinence for the next 48 hours.
Consider emergency contraception if there was unprotected sexual intercourse 2-3 days prior to the missed pills, or there has been intercourse since the missed pill(s).
What are the common side effects of POCP
Irregular menstrual bleeding patterns
Which drugs are liver enzyme inducers and therefore alter the effectiveness of the pill?
Anticonvulsants such as carbamazepine, oxcarbazepine, phenytoin, barbiturates, primidone, and topiramate.
NB: Lamotrigine does not affect the POCP.
Antibiotics - rifabutin and rifampicin (potent enzyme inducers).
St John’s wort.
Antiretrovirals - particularly ritonavir-boosted protease inhibitors.
How does the IUD work?
It releases copper, which makes the uterus an unfavourable environment for sperm.
creates an endometrial inflammatory reaction, inhibiting implantation if fertilisation has already occurred.
How soon does the IUD work as a contraceptive?
immediately
What are the advantages of the IUD
Rapid return of fertility post-removal.
Convenience (long-lasting method that is independent of intercourse).
No hormonal content.
What are the disadvantages of the IUD
heavier and more painful menstruation
discomfort of fitting.
What are absolute contraindications to using the IUD
Infection
History of pelvic inflammatory disease (PID) or purulent cervicitis in prev 3 months
Recent exposure to sexually transmitted infection (STI).
Septic abortion or postpartum endometritis in the previous 3 months.
Pregnancy
Current pregnancy.
Between 48 hours and 4 weeks postpartum.
Uterine factors
Uterine abnormality distorting the uterine cavity - eg, fibroids, bicornuate uterus.
Uterus less than 5.5 cm in length on sounding. (The device may be expelled, but may also be less effective eg, if placed in one horn of bicornuate uterus)
Gynaecological cancers
Ovarian, cervical or endometrial cancer.
Malignant trophoblastic disease.
Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy.
Adverse reactions to copper
Copper allergy or Wilson’s disease.
Other factors
Previous history of bacterial endocarditis after prosthetic valve replacement.
Significant immunosuppression.
What are the side effects of the IUD
prolonged, heavier and more painful periods
There is a sixfold increase in risk of PID in the first 20 days following insertion.
Ectopic pregnancy is increased relative to normal pregnancies where copper devices are used.
Failure of insertion
Syncope at insertion
Suspected perforation at insertion
Cramping after insertion
Expulsion
Infection
Lost threads
What is the mechanism of action of the IUS
suppressant effect on the endometrium, which prevents implantation
There is an increase in endometrial phagocytic cells which also prevents implantation.
Decreased sperm penetration of cervical mucus and impaired sperm migration.
What are the advantages of the IUS
Rapid return of fertility post-removal.
Reduced menstrual loss and dysmenorrhoea.
Convenience (long-lasting method that is independent of intercourse).
Lack of significant interactions with hepatic enzyme-inducing drugs.
Compared to long-acting injectable depot contraceptives there is no demonstrable effect on bone mineral density (BMD),
What are the disadvantages of the IUS
Initial menstrual irregularities.
Fitting an IUS is technically more difficult (in view of its larger diameter) than fitting an IUCD, particularly in nulliparous or perimenopausal women.
What are the absolute contraindications to using the IUS
Infection:
History of pelvic inflammatory disease (PID) or purulent cervicitis in prev 3 months
Recent exposure to sexually transmitted infection.
Septic abortion or postpartum endometritis in the previous three months.
Pregnancy.
Current pregnancy.
Between 48 hours and four weeks postpartum
Uterine factors:
Uterine abnormality distorting the uterine cavity - eg, fibroids, bicornuate uterus. This is mainly due to difficulties with insertion.
Uterus less than 5.5 cm in length on sounding: the device may be expelled, but may also be less effective (eg, if placed in one horn of bicornuate uterus).
Gynaecological cancers:
Ovarian, cervical, breast or endometrial cancer.
Malignant trophoblastic disease.
Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy.
Contra-indications to LNG:
Current deep vein thrombosis (DVT) or pulmonary embolus (PE).
Ischaemic heart disease.
Active viral hepatitis, severe decompensated cirrhosis, benign liver tumours or malignant hepatomas.
Breast cancer within the preceding five years.
Other:
Previous history of bacterial endocarditis after prosthetic valve replacement.
Significant immunosuppression.
What are the side effects and complications of the IUS
Irregular bleeding and spotting are common in the first six months with an LNG-IUS.
Oligomenorrhoea or amenorrhoea likely if persisting for one year.
Acne, headaches, breast tenderness and nausea are reported by LNG-IUS users but these do not differ significantly from IUCD users.
If a woman does become pregnant with an LNG-IUS in situ, ectopic pregnancy risk is 1 in 20, so she should seek medical advice to exclude it.
There is a six-fold increase in risk of PID in the first 20 days following insertion.
Failure of insertion
Syncope at insertion
Suspected perforation at insertion
Cramping after insertion
Expulsion
Infection
Lost threads
What kinds of emergency contraception are there
oral progestogen-only emergency contraceptive = levonorgestrel 1.5mg
selective progesterone receptor modulator (SPRM) = ullipristal acetate 30mg
IUD
How do the hormonal methods of emergency contraception work
delay ovulation for 5-7 days
therefore sperm are no longer viable
no known effect on disruption/inhibition of implantation
How does the IUD work as emergency contraception
inhibitory effect on both fertilisation and implantation.
Fertilisation inhibition occurs through direct toxicity effects of the copper on both ovum and sperm.
Inflammatory reaction effects on the endometrium due to the Cu-IUCD being in situ can also prevent implantation.
If fertilisation has occurred, the mode of action is by preventing a fertilised egg implanting.
What factors should be taken into account when deciding which form of emergency contraception to use?
Time since sexual intercourse
Note what contraception was used at the time of intercourse, if any.
Go through menstrual history:
What was the date of the last menstrual period?
Was the last period normal?
What is the usual cycle length?
Is ovulation likely to have taken place yet this cycle?
Could implantation of a fertilised ovum have occurred this cycle?
Note whether there has been any other unprotected intercourse this cycle and whether the woman might already be pregnant.
Establish whether there has been any previous use of EC.
Ask whether the woman is breast-feeding.
Discuss obstetric and gynaecological history (with particular attention to history of pelvic inflammatory disease (PID), current vaginal discharge, history of ectopic pregnancy).
Discuss current requirement for contraception.
Note medications used - eg, enzyme-inducing agents such as phenytoin (ask about over-the-counter enzyme inducers such as St John’s wort).
Take account of general health, looking for any contra-indications - eg, liver disease, porphyria.
Sexual history - consider the risk of sexually transmitted infection (STI).
How is the likely date of implantation calculated?
Implantation occurs no earlier than five days after ovulation.
To calculate the likely date of implantation, subtract 14 days from the date of the expected date of the next period and add five days
When can the hormonal emegency contraceptives be used
progestogen - up to 72 hours after intercourse
When can the hormonal emergency contraceptives be used
progestogen - up to 72 hours after intercourse
ullipristal acetate - up to 120 hours after intercourse
What are the contraindications to using the progestogen emergency contraception
Hypersensitivity to LNG.
Acute porphyria.
Severe liver disease.
Severe malabsorption syndromes (eg, Crohn’s disease) might impair the efficacy of LNG-EC.
Rare hereditary problems of galactose intolerance
Caution is recommended if there is a history of ectopic pregnancy. Previous ectopic pregnancy is not an absolute contra-indication
What are the contraindications to using the ullipristal acetate
Pregnancy or suspected pregnancy
Severe liver disease
uncontrolled asthma
Repeated use within the same menstrual cycle
When can the IUD be used as emergency contraception
Can be used up to five days after sexual intercourse
If the timing of ovulation can be estimated, insertion can be beyond five days after UPSI, as long as insertion does not occur beyond five days from ovulation.
What precautions should be taken when inserting an IUD as emergency contraception
There is a potential risk of PID when inserting an IUCD in a woman who has had UPSI.
It is recommended that, as a minimum, women at higher risk of STI (age ≤25 years, new sexual partner or ≥1 sexual partner in the previous year) should be offered testing for chlamydia.
For such high-risk women, the use of prophylactic antibiotics should also be considered when the IUCD is inserted.
Which contraceptives take 7 days to become effective if not started on first day of period
combined oral contraceptive pill
Depo Provera (injectable contraceptive)
intrauterine system (e.g. Mirena)
Nexplanon (implantable contraceptive)
Which contraceptives take 2 days to become effective if not started on first day of period
progestogen only pill
Which method of contraception decreases the risk of endometrial cancer
COCP
Which method of contraception causes weight gain
Depo Provera is the only method of contraception which has a proven link with weight gain.
What is the contraception advice post partum?
The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum.
Therefore, contraception is required from day 21 onwards, as sperm can survive for up to 7 days.
A woman who is exclusively breastfeeding will take longer to ovulate, however, contraception should still be advised if pregnancy is not desired.
The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.
What is an ectopic pregnancy
a pregnancy that implants outside the uterine cavity.
Where are ectopic pregnancies most common
fallopian tubes
most in ampulla. also isthmus or fimbriae
What is a heterotropic pregnancy
coexistence of both an intrauterine pregnancy and an extrauterine pregnancy
What are the risk factors for ectopic pregnancy
PID prev ectopic IVF adhesions IUD/IUS POCP smoking >35y
What are the symptoms of an ectopic pregancy
severe abdominal/pelvic pain amenorrhoea, missed period PV bleed - clots? dizziness, fainting, syncope shoulder tip pain shock
What causes shoulder tip pain in an ectopic pregnancy
rupture, leakage of blood, irritates diaphragm
What are the signs of ectopic pregnancy
abdominal or pelvic tendernes
cervical motion tenderness
pallor
tachycardia, low BP
Give some differentials for ectopic pregnancy
gynae: miscarriage molar pregnancy ruptured ovarian cyst ovarian torsion PID
gastro:
constipation
crohn’s
appendicitis
urinary:
UTI
renal colic
What investigations should be done in suspected ectopic pregnancy
pregnancy test
serum hCG
PV USS
What are the options in management of ectopic pregnancy
expectant
medical
surgical
When is expectant management suitable for ectopic pregnancy
unruptured <30mm no heart beat visible asymptomatic serum hCG <200 and falling
When is medical management suitable for ectopic pregnancy
All four requirement fulfilled:
No significant pain.
An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
Serum hCG level less than 1500 IU/L.
No intrauterine pregnancy (as confirmed on an ultrasound scan).
When is surgical management suitable for ectopic pregnancy
Any of:
Significant pain.
Adnexal mass of 35 mm or larger.
Fetal heartbeat visible on an ultrasound scan.
Serum hCG level of 5000 IU/L or more.
Describe the expectant management of ectopic pregnancy
monitor serum hCG over 48 hours
if increasing, active management is required
Describe the medical management of ectopic pregnancy
one off dose of methotrexate
most patients experience abdominal pain 2-3 days after administration of methotrexate.
Other side-effects include nausea, vomiting and reversible impaired liver function.
Women should have blood taken for LFTs and to ensure hCG levels are dropping.
Describe the surgical management of ectopic pregnancy
laparoscopic salpingectomy or salpingotomy
When is a salpingotomy used in the management of ectopic pregnancy
if the woman has other risk factors for infertility
When do women get a choice between medical and surgical management for ectopic pregnancy
serum hCG level of at least 1500 IU/L and less than 5000 IU/L, are able to return for follow up, and meet all of the following criteria:
No significant pain.
An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
No intrauterine pregnancy (as confirmed on an ultrasound scan).
What advice is given to women after medical managemet of an ectopic pregnancy
use contraception for next 3-6m
risk of teratogenicity of methotrexate to fetus
What follow up is needed after management of an ectopic pregnancy
serum hCG levels - check they are falling
anti D rhesus prophylaxis if mother rhesus -ve
offer early scan at 6-7 in future pregnancies to establish location and viability
What are the potential complications of an ectopic pregnancy
tubal rupture, leading to massive haemorrhage, DIC, shock and death
recurrent ectopic pregnancy - 18.5%
psychological - grief, anxiety, depression
Define a miscarriage.
What is early/late
loss of a pregnancy before 24 weeks
early - <12
late - 13-24
What are the risk factors for miscarriage
> 30 years, even more common in those aged >35 years
Cigarette smoking
Excess alcohol
Low pre-pregnancy BMI.
Paternal age >45 years (independent of maternal age).
Fertility problems and taking longer to conceive.
Illicit drug use.
Uterine surgery or abnormalities - eg, incompetent cervix.
Connective tissue disorders (systemic lupus erythematosus, antiphospholipid antibodies - lupus anticoagulant/anticardiolipin antibody).
Uncontrolled diabetes mellitus.
Being stressed, anxious or experiencing one or more stressful or traumatic events.
What are potential causes of a miscarriage
Unknown!
Abnormal fetal development. Genetically balanced parental translocation. Uterine abnormality. Incompetent cervix (second trimester). Placental failure. Multiple pregnancy. Polycystic ovary syndrome. Antiphospholipid syndrome. Inherited thrombophilias. Infections. Poorly controlled diabetes. Poorly controlled thyroid disease.
What is a threatened miscarriage
vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation.
mild symptoms of bleeding.
Usually little or no pain.
cervical os is closed
What is an inevitable miscarriage
a diagnosed non-viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus.
The pregnancy will not continue and will proceed to incomplete or complete miscarriage.
presents with heavy bleeding with clots and pain.
What is an incomplete miscarriage
diagnosed non-viable pregnancy in which bleeding has begun but pregnancy tissue remains in the uterus.
previous proof of pregnancy
What is a complete miscarriage
all the products of conception have been expelled from the uterus and bleeding has stopped.
presents with a history of confirmed intrauterine pregnancy, followed by heavy bleeding and clots but a subsequent ultrasound scan shows no pregnancy tissue in the uterine cavity
What is a missed miscarriage
diagnosed when a non-viable pregnancy is identified on ultrasound scan, without associated pain and bleeding.
the fetus is dead but retained.
The uterus is small for dates.
A pregnancy test can remain positive for several days or even weeks in some cases.
Early pregnancy symptoms may have decreased or gone.
What are the symptoms and signs of miscarriage
PV bleed - clots, POC,
haemodynamic instability - dizzy, SOB
cramping suprapubic pain - worse than a period
if fever or rigors - SEPTIC???
What should be examined in a potential miscarriage
general - signs of haemodynamic instability
abdo - tenderness, distended (?ectopic)
speculum - open or closed os, POC in vaginal canal
bimanual - cervical motion tenderness
