Gynae Flashcards
Anti-D need in pregnancy for Rh-ve women (non -sensitised)
Any surgical management of miscarriage ectopic
- Needs anti-D
Medical/ expectant miscarriage management at any time
- NO
TOP
- Surgical - give anti-D at any time
- Medical - Give after 10 weeks
Potential miscarriage tests to do
EPAU
TVUS - see if fetus present and viable
- repear in 1 week if doubt (2weeks if abdo)
Blood: bHCG 48h should up by 66% if viable
Progesterone
FBC and inflammatory markers
Group and save if bleeding
Speculum
- If os open deficintely miscarriage
Miscarriage management
Follow up
Contraindications to conservative/medical options
Missed
- 1st line: Expectant for 7-14 days
- Medical - misoprostol
- Surgical - manual vacuum aspiration
Generally
C: Sometimes women’s bodies will pass the pregnancy tissue spontaneously.
If woman willing, no infection, no haemodynamic instability. Within 2-6 weeks
50% success
M: We can give you a tablet to help you pass the pregnancy tissue at home. Misoprostol 600mg PO or PV. - MSD must be <50, CRL <30 - No haemodynamic compromise 85% success
MEDICAL AND EXPECTANT NEED FOLLOW UP IN 1-2 weeks.
“If bleeding is so heavy that you need to change pads more than once every 15 mins or you pass a clot the size of your palm, come back to EPAU or go to A&E”
S: Will be put to sleep and the pregnancy tissue will be removed using gentle suction
SMM - histology for all
- CI if >18/40 usually
- SE: Asherman’s, perforation, Repeat needed, infecton
“Possibility of not removing enough or removing too much tissue plus risks associated with any procedure”
95% success
PUL define
Causes
Management
+ve pregnancy test but can’t see pregnancy in uterus
Causes
- Early
- Miscarriage
- Ectopic (esp if pain and bleeding)
Follow up
Serial HCG (63-66% increase in 48h suggests viable)
- Up 63% or more - US in 7-14 days
- Down more than 50% - Unlikely pregnancy. Pregnancy test in 2 weeks
- Change between the 2: refer to EPAU
Ectopic causes
PID Previous ectopic Any surgery to pelvis Endometriosis? Smoking IVF IUD in situ
Symptoms
- Lower abdo pain - colicky then constant
- Shoulder tip pain (phrenic nerve -C3-4 same cervical nerve origin as supraclavicular)
- Classical ‘abdo pain’, amenorrhoea and vaginal bleed
- D&V!!!!!
O/E
- Tachycardia
- Hypotension = severe
- rebound tenderness
- Cervical excitation
Ectopic investigation
Urinary hCG for any woman with pain, bleed, collapse
TVUS (<9/40) or TAUS (>9/40)
- Result will be PUL, PUV, Ectopic (bagel sign), Free fluid/blood clot or gestation sac +/- fetus in adnexae
Serial bHCG
- > 1,000: intrauterine pregnancy should be visible
- <1,000 but rising 66% in 48h - early but intrauterine likely
- Declining/plateauing = ectopic or non-viable IU preganncy
Progesterone
- <20: Likely failing pregancy
- 20-60: High risk of ectopic
- > 60 Suggests progressing pregnancy, likely IU
MOST SENSITIVE TEST = LAPAROSCOPY
- HCG and US allows for fewer -ve laps
Ectopic management
Symptoms –> admission. IV access and cross match.
Anti-D if Rh-ve
Conservative only if <1000 and declining + NO pain
. Careful observation
No pain, unruptured, no heart beat, adnexal mass <35, not intrauterine, HCG between 1500-5000 (ideally <1500)
- Choice of methotrexate or surgery
- Methotrextate 1 dose. HCG day 4 and 7, weekly until -ve
10% still rupture, 15% require second dose. Wait 3 months to try again
If haemodynamically unstable
- Resuscitation, laparoscopy or laparotomy
- Salpingectomy
Hyperemesis gravidarum
Define
Investigations
Greates risk factors
Management
Prolonged severe N&V resulting in metabolic disturbance
- Dehydration
- Electrolyte imbalance
- Ketonuria
- Weight loss >5% pre-pregnancy weight
Greatest risk factors:
Twins
Trophoblastic disease
Hyperthyroid
Investigations
- Abdo exam
- PUQE
- Urine dip +/- MSU (>1ketones - admit) UTI?
- Bloods: U&E, LFTs, TFTs, HCG, Ca, Mg
- Abdo US: Multiple, molar?
Management
- ABCDE
C: assess dehydration.
- Anti-emetics e.g. Cyclixine, metoclopramide, ondansetron.
- Fluid resus and maintenance.
- VTE prophylaxis
D:
- Folic acid!
- Thiamine!
- Re-feeding
E: xclude other causes
- Urinalysis +/- MSU
- Bloods: U&Es, LFTs, TFTs, HCG, Ca, Mg
Complications
- Mallory Weiss tear
- Wernicke’s encephalopathy
- Renal damage
POP mechanism of action
Contraindications
Window for taking
What if antibiotics given?
Thickens cervical mucus
- Inhibits ovulation in 50%
CI:
Liver disease
Current/past breast cancer
Stroke/CHD
3 h (12 for cerazette)
- Take as soon as remember
- 2 days extra protection if out of this window
What if antibiotics given?
Nothin - all good - UNLESS alter p450 system e.g. rifampicin
Contraindications to Nexplanon
Mechanism of action
Pregnancy, unexplained PV bleed
Hx/current breast cancer
Liver cirrhosis
Stoke/TIA whilst on implahnt
MOA:
Inhibits ovulation!!!
Depo-provera
Contraindications
IM injecton every 12 weeks
WEIGHT GAIN PROVEN
Contraindications
- Breast cancer within 5y
- Severe arterial disease or risk factors
- Pregnancy
- Diabetes with vascular disease
- People who will want fertility to return quickly (takes 1 yr)
Emergency contraceptions
IUD- copper
= Immediate and most effective
<5 days (120h) after UPSI, apparently 5 days after likely ovulation is ok too??
- Risks: Infection, bleeding, puncturing, expulsion
Levonorgestel aka progesterone (Inhibits ovulation and stops implantation) <72h of UPSI (84% effective) - More effective the sooner it's taken - SE: Nausea, vom, dizzy, abdo pain - Take again if vomit within 2 h - Affects next period - Take 2 if BMI >26
Ulipristal acetate aka selective progesterone receptor modulator (Inhibits ovulation)
<120h of UPSI
- More effective the sooner it’s taken
- SE: Painful peridos, mood swins, aches
- Take aain if vomit in 3 h
- Delay breasfeeding for 7 days after taking
MEDS NEED PREGNANCY TEST 3 weeks after UPSI
- ALSO do if you don’t have period within 3 weeks of taking
- Abstain until next period
CONTRAINDICATIONS
To the tablets: no absolute contraindications but certain things may make it less effective e.g. malabsorption problems, enzyme inducing drugs e.g. rifampicin
- Avoid breastfeeding 7 days after Ulipristal acetate
To copper IUD:
- Copper allergy
- Fibroids distorting cavity
- PID/STI suspected
Always GUM clinic, safegurarding, safety net, safe sex in the future!!
Female sterilisation
Options
Success
Disasvantages
Tubal ligation with flishie clips = GA laproscopic.
or
Transcervical sterilisation = hysteroscopy
- needs confirmation 3 m after
Failure 1/200
Can’t be reversed. Doesn’t affect periods
Avoid sex for 1 week after
Contraception for 4 weeks (3m if transcervical)
Under 25s contraception
Best = Implant
Grade 2 are IUS and IUD if <20
Depo-provera = concerns about bone mineral density
Remember consent rules
- Capacity
- Won’t tell parents
- Likely to have sex with or without
- Physical/mental health will suffer without
- Best interests
NB: <13 cannot consent. CHILD PROTECTION
Age of consent = 16yo
Causes of infertility (%)
Male factors (30%) Ovulatory (25%) Tubal damage (20%) Uterine (10%) Endometriosis (5-15%) Unexplained (25%) Both male and female (40%)
Female age
- Drops at 38. 35yo half as fertile as 31yo, halved again a 38
Male age
- 1/3 over 40s can impregnate partners in 6 months vs <25yos
Semen analysis
Volume >/= 1.5ml pH >/= 7.2 Sperm conc >/= 15milllion per ml Total sperm count >/= 39mill per ejaculate Motility >/=40% or 32% progressive Sperm morphology >/= 4%
Repeat in 3 months if abnormal
When is IVF/ICSI indicated
After 2 years of unexplained fertility (inc mild endometriosis/mild male factors)
Azoospermia
Bilateral tubal occlusion
+ woman aged 23-42, gets 3 IVF cycles offered
Process
- Pituitary down regulation - GnRH agonists
- Ovarian stimulation - gonadotrophins
- Ovulatio trigger
- Egg collection
- Fertilisation (ICSI if needed)
- Embryo transfer
- Luteal suppot
Most common STI 1st and 2nd
PID causes organisms
PID risk factors
1st = Chlamydia 2nd = Herpes
PID causes
- 25% N.gonorrhoea and C.trachomatis
- Organisms from normal flora: Anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram -ves, Strep agalactiae
- Mycoplasma
PID risk factors
- Sexual behaviour: early age of 1st coitus, <25yos, partner in last 3 months, hx of STI in partner
- Instrumentation of uterus/interruption of cervical barrier: TOP, IUD, Hysterosalpingography, IVF, IUI
PID presentation
Management
Lower abdo pain, deep dyspareunia, Abnormal bleed (post-coital, IMB and menorrhagia), abnormal disharge, cervical motion tenderness, adnexal tenderness, Fever >38
Endocervical swabs: Gonorrhoea and Chlamydia High vaginal swabs: TV and BV NAAT!!! Full STI screen Urine dip +MSU Pregnancy test TVUS Lap (only if severe and uncertain)
14 DAYS IMMEDIATELY Ceftriaxone (IM) + Doxy (100mg BD) + Metron (400mg BD) Analgesia Avoid intercourse until cleared Partners testing of last 6 months
FOLLOW UP IN 72H + 2-4 weeks
Chlamydia presentation
Investigation
Management
TOC =?
Aymptomatic in 70% Increased discharge PCB and IMB Low abdo pain Deep dyspareunia
Non-genitourinary: Pharynx, rectal, conjunctivitis
NAAT. Vulvovaginal swab 1st choice, endocervical
Swab non-genitourinary if indicated
Management
- Doxyclycine 100mg 7 days (CI in pregnancy)
- Azithryomycin (1g single dose)
TOC only for:
- Pregnant
- Persisting 4 weeks
<45yos fter 3 months
Gonnorhoea
presentation
Investigation
Management
TOC?
Complications
Altered discharge - thin, watery, green, yellow Dysuria Dyspareunia Lower abdo pain Rarely IMB/PCB
Muculopurulent discharge
Eaasily induced cervical bleeding
50% asymotomatic
Refer to GUM. NAAT. Vulvovaginal swab. MCS of endocervical swab if +ve. Thraay, eye retum if indicated
Management
- Single dose ceftriaxone 1g if diagnosed on micrscopy, NAAT, culture of partner
Follow up in 1 week
TOC for all treated!
- Asymptomatic 2 weeks after tx
- Symptoms - culture 3 days after treatment
Rarely
- PID, Arthrits, Skin lesions etc
Define early syphilis
Late syphilis
Bacteria name
Investigation
Management
Early = 1st 2 yrs after infection (early latent if in 2yrs and no symptoms)
Late = 2 phases
- Late latent +ve serology, 2 yrs after infection, no symptoms
- Tertiary syphilis - neurosyphilis, cardio and gummatois
Bacteria = Treponema pallidum
Dark ground microscopy of chancre fluid - detect spirochaete in primary syphilis
PCR from lesion
Serology: Treponemal tests and non treponemal tests
LP for CSF antibody in neurosyphilis
Management
- Early: Single doe Ben pen
- Late: Weekly ben pen for 3 weeks
- Neurosyphilis - Procaine penicillin + Probenicid daily for 14 days or ben pen 4hours for 14days
HSV treatment
Primary infection: Aciclovir
Recurrent outbreaks - OTC painkillers, petroleum jelly, ice packs
- If recurrent then aciclovir as soon as symptoms begin to reuce severity of outbreak
- If v frequent (>6 in a year) - suppressive therapy of aciclovir
Herpes in pregnancy
SEM
CNS
Disseminated
Vaginal ph>4.5
Offensive smelly, fishy discharge
Thin white homegenous grey discharge
NOT itchy
Bacterial vaginosis - not an STI
- Often garderella vaginalis, anaerobes and mycoplasma predominate due to disturbance in normal fora
50% asymptomatic. Other have features described
Diagnosis requires 3/4: Microscopy: Clue cells >20% pH >4.5 KOH whiff test fishy Homogenous non clumpy vaginal discharge
Microscopy also shows reduced lactobacilli, reduced pus cells
Conservative if asymptomatic
Metronidazole 7 days
Trichomonas vaginalis
STRAWBERRY CERVIX
Protozoan trichomonas vaginalis
- Curable STI
Offensive odour, ITCHY, Abnormal discharge - thick, thin, frothy, yello, green, sore vulva, Dyspareuni, Dysuria
MAnagement
- Metronidazole 2g single dose
- or 7 days 400-500mg BD
TOP options
Anti-D?
anything else?
MEDICAL
Early: Up to 9+6
- Mifepristone (antiprogesterone) oral
- 48h after Misoprostol (prostaglandin analogue)
Late medical: After 9+6
- In hospital if after 13/24
- KCl feticide if after 22/40
- Takes longer but same process and may need more misoprostol
SURGICAL
7-15/40: LA/GA.
- Suction curettage. Misoprostol used to soften cervix
15-24/40: GA.
- Surgical dilation and evacuation.
- Misoprostol PV or PO before on day
- Forceps
Anti-D for ALL within 72h
Antibiotics for surgical
2 week follow up for all - 24h helpline and safety net
Investigations to do prior
- Pregnancy test
- Determine gestation
- Abdo and pelvic exam
- CHLAMYDIA for all and assess risk for other (HIV, syphilis, gonorrhoea)
- Hb, blood group, Rh status
- Medical hx
Management of PMS
MENSTRUAL DIARY FOR 2 CYCLES to be done first
- Symptoms: Tension, irritable, aggression, depression, bloated, GI upsey
1) Exercise, CBT, Vit B6
Pill, clyclic or continuous
Continuous or luteal (d14-28) low dose SSRI
2) Estradiol patches + micronised progesterone or LNG IUS
Higher dose SSRI continuous or luteal
3) GnRH analogues + add back up HRT
4) SUrgical tx +/- HRT
PCB causes
1) Cervical - ectropion, polyps, cancer
2) Vaginal - atrophic vaginitis
3) STI?
Irregular and IMB causes
1) If mid cycle - ovulation aka physiologica
2) Cervical - polyps, ectropion,
3) Endometrial - fibroids, polyps, adenomyosis, cysts, chronic pelvic infection
4) Iatrogenic - IUD, hormonal contraception
Amenorrrhoea causes
Investgations
1) Phsyiological - pregnancy, menopause, lactation, constituitional delay
2) Pathological
- Hypothalamus - Low weight/anorexia/excess exercise, rarely a tumour
- Pituitary - hyperprolactinaemia, Sheehan’s
- Adrenal/thyroid - Hyper/hypo thyroid, CAH
- Ovary - PCOS, POI, Turner’s, Gonadal agenesis, Androgen insensitivity
- Outflow tract - Asherman’s syndrome, Imperforate hymen/septum, Absence of vagina and uterus (Rokitansky syndrome), Cervical stenosis
3) Iatrogenic
- Progesterone contraceptives
- GnRH analogues
4) Endocrinopathies
1st line: Pregnancy test, TFTs, LH/FSH, Prolactin, Tesosterone + SHBG
2nd line: US
3rd line: Karyotyping
Primary amenorrhoea
By age 15 secondary sexual characteristics
By age 13 if no secondary sexual characteristics
Vulval cancer staging
Associations
Presentation
Treatment
1) Confined to vulva/perineum
2) Adjacent spread (lower urethra/vagina or anus) -ve nodes
3) +ve lymph nodes
4) Invasion of upper 2/3rds of urethra/vagina, rectum, bladder, bone or distant mets
Associations
- Lichen sclerosus
- Paget’s disease of the vulva
- CIN
- Smokng
- Immunosuppresion
Presentation
Pruritus, itching, mass/ulcer, hard/large inguinal node
SCC!!!
Rx
- Staging is surgical
1a: Wide local excision
If more - also groin lymphadectomy
Thin vulval epithelium
Name of condition
Managemebt
Lichen sclerosus = thin vulval epithelium with loss of collagen
Autoimmune - may co-exist with vitiligo and thyroid disease. Typically postmenopausal
Features
- Severe pruritus
- Scratching –> blled + trauma –> pain and dyspareunia - Koebner response
- Pink white shiny papules which coalesce to form parchment like thin wrinkled ski with fissures (affecting labias usually)
- Inflammatory adhesions –> fusion of labia and narrowing of the intaroitus
Dx = clinical
Management
C: Moisturisers. Avoid soap. Dry pat
M: Ultra potent steroid - topical clobetasol propionate 0.05%
S: Rarely to divide adhesiona
Grounds for TOP
Statutory grounds. 2 doctors to agree that 1 is met
A) Continuing pregnancy risks LIFE of woman more than if terminated
B) Termination necessary to prevent PERMANENT physical injury to the physical or mental health of the woman
C) Pregnancy not exceeded 24/40 AND continuing would involve risk greater than terminating of injury to the physical/mental health of the woman
D) Pregnancy not exceeded 24/40 AND continuing would involve risk greater than terminating of injury to the physical/mental health of the EXISTING CHILD(REN) OR FAMILY of the woman
E) SERIOUS risk that child born would suffer from physical/mental abnormalities that it wold be seriously handicapped
Also emergencies
F) To save life of teh pregnant woman
G) To prevent grave permanent injury to the physical/mental health of the woman
HPV vaccination strains and which are specific for cervical cancer
16, 18
but also
6, 11
Given to 12-13 yo girls
Cervical cancer staging
Presentation
Risk factors
Type of cancer
How to stage
How to manage
[1] Confined to cervix
[2] Upper 2/3 of vagina involved but NOT pelvic side wall
[3] Extension into lower vagina or pelvic wall
[4] Extension to bladder, rectal mucosa or beyond pelvis
PCB, Offensive blood stined discharge, IMB, PMB
Later: Uraemia, haematuria. rectal bleeding, pain
O/E: Ulcer may be present
Squamous cell
Risk factors
- Immunodeficiency
- Smoking
- COCP
- Many sexual partners
- Early first intercourse
Management - Stage on MRI
- > 4cm: Do NOT operate as relapse –> chemo/radio
- <4cm: Operate - Radical abdominal hysterectomy (Removal of parametrium, LN, upper 1/3 vagina too) = Wertheim’s hysterectomy
- <2cm: Option to remove cervix and LN = radical trachelectomy and pelvic lymphadenopathy. ONLY if still want children and would have to be C-sections.
How to manage CIN 1 after seeing on colposcopy
Colposcopy in 6-9 months
Back to NHSCSP after 2 -ves
If persists –> Tx
Follow up after LLETZ
Smear in 6 months + HPV test
- Negative –> discharge to NHSCSP
- Positive –> Re-colposcopy
For CIN2/3: Annual smears for 10y after
Cervical ectropion
Columnar epithelium of endocervix visible as read rea around the os on the surface of cervix
- Due to eversion - occurs with COCP and Pregnancy
Presentation
- Asymptomatic
- Can cause PCB, discharge
Management
- Cryotherapy
- Do smear and ideally colposcopy to exclude cancer
- > exposed columnar epithelium more prone to infection
Cervical polyps
Benign tumours of endocervical epithelium
Common in >40yo
Presentation
- Asymptomatic or PCB/PMB
Management
- Evulsion locally + histology
What is cervicitis
Associated with STI. Ulceration and infection in severe prolapse
Cn be chronic –> due to inflammation/infection
- Inflammatory smear
- Vaginal discharhe
Management
- Cryotherapy +/- antibiotics
