gynae Flashcards
(223 cards)
1
Q
What is abnormal uterine bleeding defined as?
A
Any bleeding that is either:
- Abnormal in volume (excessive duration or heavy),
- Irregularity, timing (delayed or frequent), or
- Non-menstrual bleeding: intermenstrual (IMB), post-coital (PCB) or post-menopausal (PMB) bleeding
This definition covers the whole spectrum of menstrual bleeding disorders.
2
Q
What is the normal range of a menstrual cycle?
A
25-32 days
3
Q
Definition of heavy menstrual bleeding?
A
heavy menstrual bleeding (HMB)
Menstrual blood loss that is considered to be excessive by the woman and interferes with her physical, emotional, social and marital quality of life. It can occur alone or in combination with other symptoms
4
Q
what is the acronym to remember the different causes of abnormal uterine bleeding? 9 (4 structural, 5 non-structural)
also which women is this acronym relevant for?
A
PALM COEIN
PALM = structural causes
- POLYPS (endometrial / cervical)
- ADENOMYOSIS (ectopic endometrium in the muscle)
- LEIOMYOMA (fibroids)
- MALIGNANCY of genital tract, also pre-malignant endometrial hyperplasia
COIEN = non-structural causes
- COAGULOPATHY (systemic, eg thrombocytopenia, von willebrands)
- OVULATORY FUNCTION DISORDER (eg PCOS, hypothyroidism)
- ENDOMETRIAL DISORDERS (eg endometriosis, chronic endometritis - can be secondary to PID)
- IATROGENIC (exogenous hormones, eg COCP, also copper IUD, warfarin + other blood thinners)
- NOT YET CLASSIFIED (rare, eg AV malformations, sex steroid secreting ovarian neoplasm)
LEARN THESE REALLY WELL!
relevant to NON-GRAVID (ie not pregnant) women of REPRODUCTIVE AGE (ie not post-menopausal)
5
Q
When someone is presenting with heavy menstrual bleeding (HMB), what systemic complication should you always ask if they’re experiencing symptoms of?
symptoms? 5
clinical signs? 6
blood test to always do with HMB?
A
anaemia
- feeling faint (esp when standing)
- tired / lack of energy
- palpitations
- SOB / poor exercise tolerance
- pale skin
= pallor
= palmar creases
= conjunctival pallor
= angular stomatis
= glossitis
= nail spooning (koilonychia)
may also have orthostatic hypotension
ALWAYS DO A FBC!
6
Q
What are the three main types of leiomyoma (fibroid)? and where are they located in the uterus?
what are symptoms likely to be of each?
A
SUBSEROUSAL
= located under the peritoneum on the external aspect of the uterus
- no bleeding but may be pressure / heaviness / pain or frequency of bladder if large and sitting on that
INTRAMURAL
= within the myometrium
- likely to bleed heavily
SUBMUCOUSAL
= in the myometrium but also in the endometrium, they grow into the cavity of the womb
- often bleed heavily
nb can also have pedunculated submucosal
7
Q
Symptoms of fibroids (leimyoma)? 7
How common are symptoms in fibroids?
A
- heavy periods (ie HMB, bleeding alines with cycle)
- painful periods
- abdo pain
- lower back pain
- pain or discomfort during sex (dyspareunia)
- frequency
- constipation
(also bloating)
only 1 in 3 women with fibroids have symptoms
- nb only tend to treat symptomatic fibroids
fibroids can very rarely lead to problems conceiving (eg if fibroid if pushing on fallopian tube or large mass in cavity)
nb fibroids more common in black ethnicity and overweight
they tend to shrink and disappear post-menopausally
8
Q
examinations done if suspect fibroids? 3
- what expect to find on these?
A
- abdo
- speculum
- bimanual
bulky asymetrical uterus on bimanual (nb this may not be found in small fibroids or if woman is overweight)
9
Q
First line investigation for fibroids?
2nd investigation if concerned that could be cancer?
A
ultrasound
(think this is abdominal not PV?*)
can do hysteroscopy with biopsy
10
Q
management options for fibroids:
- first line if small and not distorting the cavity? 1
- medications to help with bleeding? 3
- medication to help with pain during period? 1
- more invasive management options? 4
- medication given to shrink fibroids before surgery? 1
A
- IUS (mirena) is first line if possible
- COCP
- POP
- tranexamic acid (take during period)
- mefanamic acid (or other nsaid)
nb just try one hormonal method at a time initially
- uterine artery embolisation (only if family finished)
- endometrial ablation
- myomectomy
- hysterectomy (only if fam finished)
OFTEN GIVE GNRH AGONISTS TO DHRINK FIBROIDS PRIOR TO SURGERY
need specialist / advanced management if really large, dyspareunia, uterine or bowel symptoms or problems with fertility etc
11
Q
What’s the difference between adenomyosis and leiomyoma (fibroids)?
A
Because the symptoms are so similar, adenomyosis is often misdiagnosed as uterine fibroids. However, the two conditions are not the same. While fibroids are benign tumors growing in or on the uterine wall, adenomyosis is less of a defined mass of cells within the uterine wall
12
Q
what sort of abnormal uterine bleeding does polyps normal present with?
A
light (sometimes heavy) bleeding which is unrelated to cycle
- can be IMB or PCB
13
Q
How will adenomyosis tend to present?
A
- heavy bleeding
- vague abdo / pelvic pain
bulky symmetrical uterus
(as opposed to asymmetrical in fibroids - though this is not always the case)
14
Q
what is the most worrying cause of post-coital bleeding?
A
cervical cancer
15
Q
What are the two different groups of causes of amenorrhoea? give some common examples for each?
A
PRIMARY AMENORRHOEA (never had menarche)
- turner’s syndrome
- congenital adrenal hyperplasia
- congenital malformations of genital tract
SECONDARY AMENORRHOEA (had periods but then stopped)
- Hypothalmic amenorrhoea (stress, excessive exercise, low weight - can be primary too)
- sheehan’s (PPH -> ischaemia of pituatory)
- hyperprolactinaemia
- hyper or hypothyroid
- PCOS
- premature ovarian failure
- asherman’s syndrome (intrauterine adhesions)
16
Q
What is dysmenorrhoea?
what are the two groups of causes? and how to differentiate between these?
A
dysmenorrhoea
= excessive pain during menses
PRIMARY
- no underlying pelvic pathology
- 50% of women
- 1-2 years after menarche
- excessive endometrial prostaglandin
SECONDARY
- result of underlying pathology
- pain starts 3-4 days before period!! (always ask when pain starts)
- eg endometriosis, adenomyosis, fibroids, PID, copper IUD
17
Q
How do you manage primary dysmenorrhoea 1st and 2nd line?
How do you manage (what appears to be) secondary dysmenorrhoea?
A
primary dysmenorrhoea
- 1st: NSAIDs (mefanamic acid or ibuprofen)
- 2nd: COCP
secondary dysmenorrhoea
- refer to gynae
18
Q
Management options for heavy bleeding (once excluded cancer):
- conservative?
- medical?
- surgical?
A
can reassure women that it’s okay (this is all some people need)
- mefenamic acid (also helps with pain)
- TXA (will give clots)
- mirena IUS (also oral contraceptives)
- endometrial ablation
- hysterectomy
also polyp removal or myomectomy if polyp / fibroid
(also if thyroid
19
Q
What two non-sex hormonal issues do you need to rule out for abnormal uterine bleeding?
- questions in hx?
- blood tests? 2
A
HYPO (or HYPER) THYROID
- ask about thyroid symptoms and do thyroid exam
- do TFT if any thyroid signs
PROLACTINAEMIA
- ask if any discharge from nipple
- do prolactin blood test if there is discharge
20
Q
POST-MENOPAUSAL BLEEDING
- Commonest cause? (and how is this treated?)
- what you must rule out?
- 1st line investigation? (and findings)
A
Commonest cause of PMB
= atrophic vagina
- treat with oestrogen cream topically on vagina
must rule out endometrial cancer
(refer PMB on 2WW)
trans-vaginal USS looking for massess and endometrial thickness
- should be <4mm if not on HRT
- should be <5mm if on continuous HRT
- should be <8mm if not cyclical HRT
21
Q
PREMENSTRUAL SYNDROME
What is it?
Common symptoms of PMS? 8
what % of women will experience severe PMS at some point?
A
cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms may extend into the first few days of menses
- abdominal bloating (very common - 90%)
- fatigue (v common)
- labile mood (ie mood swings - 80%)
- depressed mood and irritability (70%)
- increased appetite (70%)
- forgetfulness / difficulty concentrating (50%)
- breast tenderness (50%)
- headaches (50%)
(may also get change in bowel habits, insomnia, hot flushes and palpitations)
make sure this is just before (and start) of their periods, and not all the time - as this may indicate depression is constant
22
Q
pre-menstrual syndrome
- 1st line management? 7
- 2nd line management options? 3
A
1ST LINE
- regular exercise
- healthy, balanced diet
- reduce stress (yoga, meditation)
- stop smoking
- reduce alcohol
- OTC analgesia
- symptom diary of 2-3 cycles
2ND LINE
- hormonal contraceptives (eg COCP)
- CBT
- antidepressants
if none of these work, refer to gynae
23
Q
Polycystic ovarian syndrome (PCOS)
- syndrome it is linked to?
- secondary causes? 5
A
linked to metabolic syndrome (ie obesity, insulin resistance, hyperlipidaemia)
secondary causes
- androgen secreting neoplasms
- cushing’s syndrome
- thyroid dysfunction
- congenital adrenal hyperplasia (would have primary amenorrhoea)
- hyperprolactinaemia
be aware of secondary causes - but most cases are primary
24
Q
polycystic ovarian syndrome:
- name and three features of criteria for diagnosis?
- other symptoms and signs that support diagnosis? 3
- investigations to do? 1
A
ROTTERDAM CRITERIA
(need 2 out of 3 for diagnosis)
- oligomenorrhoea
- hyperandrogenism (either clinical - acne, hirsuitism - or raised serum testosterone)
- polyscystic ovaries on TV USS (>9 cysts, each <9mm - pearl necklace)
other symptoms / signs
- obesity
- infertility
- acanthosis nigracans
most symptoms / signs are picked up in hx + exam then do TV USS (exclude ovarian tumour) see ‘string of pearls’
Very common! 5% of women of reproductive age
- big cause of infertility
25
What happens to LH, FSH and testosterone levels in PCOS?
chronically high LH
chronically low FSH
(bear in mind, bar ovulation, in normal menstrual cycle, FSH is norm higher than LH)
high testosterone
26
Management for PCOS if NOT trying to conceive:
- lifestyle? 1
- screen for? 4
- if less than one period every 3 months? 2
weight loss
explain that this will:
- Reduce hyperinsulinism and hyperandrogenism.
- Reduce the risk of DM + CVD.
- Result in menstrual regularity.
- Improve the chance of future pregnancy (if it is desired).
screen for:
- diabetes
- CVD risk factors
- obstructive sleep apnoea (daytime somnolence, snoring)
- depression / anxiety
if less than one period every 3 months:
- provera (synthetic progesterone) to induce a withdrawal bleed
- TV USS to see endometrial thickness
if thick or unusual appearance -> need endometrial sampling to exclude hyperplasia
if normal, have options:
- give provera for 2wks every 1 to 3 months
- COCP
- IUS mirena
nb regular USS required to keep checking thickness
basically: you need a bleed every 3 months with PCOS (or mirena)
27
PCOS management IF TRYING to conceive:
- what to test for?
- what medications to stop?
- where to refer?
- do OGTT for diabetes (and repeat again in early pregnancy)
- stop any hormones (eg COCP / provera)
also continue lifestyle of reducing weight
fertility clinic - to assess if ovulation occuring or not and then go from there
28
What are the four things you need for a viable pregnancy (3 mother, 1 father)?
functioning menstrual cycle
- ovulation
- endometrial thickening
- healthy fallopian tubes
- healthy sperm
29
Where in the female genital tract does ovulation normally occur?
ampulla
30
What % of couples will get pregnant from having unprotected sex 2-3 times a week:
- for a year?
- for 2 years?
What age does fertility really drop off in women?
what is subfertility?
1 year = 84%
2 years = 92%
fertility drops off fast after 35
subfertility = 1 year of regular sex with no conception
- refer to specialist at this point
nb if women 35-40 then refer after 6 months (if older than 40 or have conditions likely to affect fertility then refer sooner
31
Four main groups of causes of subfertility? (roughly what % for each)
- male factor (35%)
- disorders of ovulation (30%)
- pelvic pathology (30%)
- unexplained (15%)
if unexplained cause then only treatment is IVF
32
What is primary and secondary subfertility?
primary subfertility = female partner has never conceived
Secondary = she has previously conceived (eg in a prev relationship)
33
pre-conceptional health advice:
- for woman? 6 (incl 2 vitamins)
- for man? 4
WOMAN
- stop smoking (also cannabis)
- no alcohol intake
- BMI 19-30
- low caffeine
- vit D
- folic acid
MAN
- stop smoking (also canabis and anabolic steroids)
- 3-4 units alcohol a week
- BMI <30
- optimise scrotal temp (reduce tight fitting clothing maybe)
34
What is the best test to confirm ovulation?
what day of the cycle should it be done?
Day 21 progesterone test is most reliable
Actually you want the midpoint of the luteal phase - so if, eg, cycle is 21 days then want day 14 - basically want 7 days before period
35
What are the WHO classifications of different types of anovulatory infertility? 3
Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
FSH and LH
Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
Group III: ovarian failure.
36
What is AMH a test of?
What do oestrogen, FSH and AMH do with each different WHO classification of anovulation? (ie normal, high, low)
What two other blood tests should you always do if you suspect ovulation problems?
Anti-mullerian hormone (AMH)
= a test of roughly how many follicles a woman has left in her ovaries
Group I
- oestrogen = low
- FSH = low or normal
- AMH = normal
Group II
- oestrogen = normal
- FSH = normal
- AMH = high
Group III
- oestrogen = low
- FSH = high
- AMH = low
nb this makes sense as PCOS is commonest cause of group II so AMH high, whereas ovarian failure would cause low AMH
ALWAYS DO
- TFTs
- prolactin
37
What are the common causes of Group I ovulation disorders? 3
what is the management for these? 3
Hypothalamic pituitary failure
---> hypothalamic hypogonadism –> reduction in GnRH release.
- stress
- intense exercise
- low BMI, low bone mass (eg anorexia)
(can also get Kallmann’s syndrome – GnRH secreting neurones fail to develop)
- increase BMI to >19
- reduce exercise
- treat with gonadotrophins (for ovulation induction)
38
What is the female athlete triad?
get in female athletes but also low BMI
- Low energy availability / eating disorder
- Low bone mass
- Menstrual disturbance
need to increase BMI and periods will norm start again, may need gonadotrophins as well though
39
What are the common causes of Group II ovulation disorders? 3
Management options for these? 3
Dysfunction of Hypothalamic-pituitary -ovarian axis
- PCOS
- hyperprolactinaemia
- Sheehan's syndrome (PPH -> necrosis of pituatory)
- if overweight, loose weight
- if BMI normal, Clomiphene Citrate or Letrozole
2nd line = gonadotrophins or CC + metformin or laprascopic ovarian drilling
test for diabetes, if have, treat
40
What is the commonest cause of Group III ovulation disorders?
diagnostic criteria for this?
Management for conceiving? 1
management to preserve women's health? 1
Premature ovarian insufficiency (POI) (ie super early menopause)
POI Diagnostic criteria:
1) Oligo/amenorrhea for at least 4 months
2) An elevated FSH level >25 IU/l on two occasions >4 weeks apart
- IVF with donor egg
- give HRT for CV and osteoporosis risk
nb this runs in families
nb remember FSH and LH rise in menopause (as no neg feedback from ovaries / endometrium)
41
What are the age cut offs for:
- premature ovarian insufficiency (POI)?
- Early menopause?
POI = <40
early menopause = 40-45
nb both run in families
42
What are the four commonest causes of pelvic pathology (as causes of subfertility)?
- Pelvic inflammatory disease (norm dt chlamydia)
- endometriosis
- past abdominal / pelvic infection or surgery
- tubal disease (-> hydro-salpinges - remove before IVF as contains cytokine which can damage pregnancy)
43
Three methods for investigating possible pelvic pathology (in context of subfertility)?
Hysterosalpingography
- Appropriate for low risk women
- xray with dye being squirted into cavity
Hysterosalpingo-contrast-ultrasonography
- Alternative to HSG with no radiation exposure
- same dye but look with USS instead of x-ray
Laparoscopy
- The gold standard BUT need GA with all those risks etc
44
What first line investigation is done to investigate male fertility?
What are the three main things that are measured in this test?
What are the proper names for each of these?
semen analysis
- fresh sample from masturbation (abstinence 3-5 days prior)
oligozooapermia
= low sperm count
asthenozoospermia
= low motility
teratozoosperma
= poor morphology
(also have azoospermia - so no sperm)
45
Male factor infertility:
- most common cause?
- other causes? 7
commonest cause
= idiopathic
- hypogonadism (only one can treat)
- genetic causes (need to be excluded before ICSI)
- cryptorchidism
- Testicular trauma / surgery
- obstructive (surgery - vasectomy / infection)
- anabolic steroid induced (not always reversible)
- previous chemo / radiation
46
When investigating the woman in a couple for infertility, what things are looked for on examination? 4
- BMI
- hirsutism, acne, acanthosis
- hyper / hypothyroid
- galactorrhoea
47
What are the first line investigations for a subfertile woman with no known health conditions:
- blood tests? 5
- blood test that can be added on by paying? 1
- other blood tests that can be done if clinical suspicion on hx / exam? 4
- imaging? 1
day 1-5 of cycle:
- FSH
- LH
- Oestrogen
- chlamydia antibodies
- rubella immunity
- can add AMH on (£70)
if clinical suspision:
- testosterone
- SHBG
- prolactin
- TFTs
all women get TV USS
Can also do antral follicle count! (?on USS)
48
Management options in fertility treatment and who most appropriate for:
- lifestyle? 1
- medication? 2
- surgery? 2
- procedural? 3
- other options (which don't use both native sperm and egg)? 3
loose / gain weight
- women BMI >30 or <19
- PCOS
letrozole or clomiphene (stimulate ovulation)
- decent ovarian reserves
- eg in PCOS after weight loss
gonadotrophins
- hypogonadism in men
salpingectomy
- significant tubal disease
laproscopy and ablation
- significant endometriosis
IVF
- unexplained infertility
- other methods failed
ICSI (with IVF)
- low sperm quality or number
IUI
- physical disability
- Psychosexual issues (eg vaginismus)
- Donor sperm (especially in WSW)
- moderate sperm quality / number
Sperm donation
- WSW
- azoospermia
egg donation
- Premature ovarian failure
adoption
- anyone or all other methods failed / run out of money
49
What is the most serious complication of IVF?
Symptoms of mild, moderate and severe disease
Ovarian hyperstimulation syndrome
mild
- abdo bloating
- mild abdo pain
- ovarian size <8cm
moderate
- moderate abdo pain
- nausea / vomiting
- USS evidence ascites
- ovaries 8-12 cm
severe / critical
- clinical ascites
- oliguria
- hyponatraemia
- hyperkalaemia
- hypoproteinaemia
- ovaries >12cm
critical = hydrothorax, ARDS, VTE
50
OVARIAN CYSTS:
- possible symptoms? 6
- three exams to do? 3
- 1st line investigation? 1
nb pelvic cysts can be malignant or benign
- pelvic pain (normally dull)
- dysparenuia
- bloating
- difficulty emptying bowels
- urinary frequency
- changes to menstrual cycle (heavier, lighter, irregular)
- abdo
- speculum
- bimanual
TV USS
51
OVARIAN CYSTS:
- two complications?
- symptoms to tell women to look out for? 2
- cyst rupture
- ovarian torsion
- sudden onset sharp pain in iliac fossa (can radiate to loin, groin or back)
- nausea and vomiting (esp torsion)
52
OVARIAN CYSTS:
- three management options?
- which option is normally taken, based on cyst appearance and age of woman?
conservative (watch and rescan - if growing, consider surgery)
- premenopausal: <10cm, simple, mobile, unilateral, no ascites
- simple cysts post-menopause
periodic drainage
- for benign cysts causing mass symptoms where surgery not an option
surgical excision
- premenopausal: >10cm, solid or complex, fixed, bilateral, ascites
- complex cysts post-menopause
nb most pre-menopausal simple cysts self-resolve
53
Menopause:
- definition?
- average age?
- what happens to FSH, LH and oestrogen levels?
amenorrhoea for 12 months (diagnosed in retrospect)
nb perimenopause is before menopause
average age is 51
- oestrogen drops
- FSH and LH rise
(nb this is because ovary stops producing oestrogen and so FSH and LH increase to try and stimulate it, but to no avail...)
54
Perimenopausal symptoms:
- early symptoms? 7
- medium term? 5
- long term risks? 2
- how long do symptoms last?
EARLY
- irregular menstrual cycle (10% stop abruptly, may be heavy or light)
- hot flushes
- night sweats
^known as vasomotor symptoms
- irritability and mood swings
- mild memory impairment
- insomnia
- fat redistribution (abdo weight gain)
MEDIUM TERM
- vaginal dryness / itching
- dyspareunia
- bladder frequency
- urgency
- frequent UTIs (dt dryness)
LONG TERM RISKS
- osteoporosis
- cardiovascular disease
symptoms last 4-8 years
55
Management of menopause:
- non-pharm? 6
- vitamins?
- exercise
- yoga
- stop smoking
- reduce alcohol
- sleep in cooler room
- vit D and calcium
can also try acupuncture, hypnotherapy, reflexology etc - no evidence but helps some people
56
Management of menopause:
- different types of HRT? 5 (and their effects)
- topical treatment?
1) OESTROGEN ONLY
- With absent uterus only!
COMBINED HRT (OESTROGEN + PRGESTERONE)
2) Continuous combined
- Every day
- No bleeding
- Only give if >54 years old or >1yr amenorrhoea
3) Sequential combined cyclical
- Oestrogen daily, progesterone for last 10-14 days of cycle
- Withdrawal bleed every month
4) Sequential long cyclical
- Oestrogen for 3 months every day, progesterone for second half of third month
- Withdrawal every 3 months
TIBOLONE (*look this up)
- Synthetic steroids w estrogenic, androgenic and progestational activity
- No withdrawal bleed
TOPICAL OESTROGEN
- for vaginal symptoms
- can have in addition to oral HRT
57
MISCARRIAGE:
- definition?
- what % of pregnancies miscarry?
- recurrent miscarriage definition?
- commonest reason for miscarriage?
miscarriage
= loss of pregnancy before 24 weeks
20% of known pregnancies miscarry (but actual no may be higher)
Recurrent miscarriage
= loss of 3+ consecutive pregnancies (ie no babies in between) with the same partner
foetal abnormality is commonest reason for miscarriage
58
On a TV USS, at what gestation should you be able to:
- see gestation sac?
- see foetal pole and heart beat?
gestation sac
= 5 weeks
foetal pole AND heart beat
= 6 weeks
59
MISCARRIAGE
| - symptoms? 3
- bilateral abdo cramping / pain
- bleeding / expulsion of clots
- regression of pregnancy symptoms (N+V, breast tenderness)
nb can have no symptoms - esp if missed
60
MISCARRIAGE
- blood tests? 3
- imaging?
- HCG (get serum so can compare in 48 hours if need to)
- FBC (anaemia)
- group + save (rhesus status)
TV USS (abdo if later)
61
What are the five different types of miscarriage?
incl if os is opened or closed
- which two need no treatment?
THREATENED MISCARRIAGE
- Bleeding +/- pain, but pregnancy continues
- On examination the os is closed
- Uterine size correct for dates
- Cause unknown
- No long-term harm to baby/ implications for pregnancy
= no treatment needed
```
INEVITABLE MISCARRIAGE
- Presents in process of miscarriage
- Nothing can be done to save pregnancy
- Vaginal bleeding
Cervical os is open
```
COMPLETE MISCARRIAGE
- Process completed without intervention
- Present with bleeding, but will have lessened on completion
- Uterus returned to near normal size
- Cervix closed
- Bleeding + pain + empty uterus on scan = confirmation. However, ensure no ectopic. (check HCG levels)
= no treatment needed
INCOMPLETE MISCARRIAGE
- Not all products of conception have been expelled
- Continued bleeding
- Cervical os open (?or closed)
- Scan shows mixed debris in uterus
- Medical or surgical treatment offered to complete the miscarriage
MISSED (OR DELAYED) MISCARRIAGE
- Entire gestation sac is retained within the uterus
- Pregnancy has stopped growing
- No foetal heart beat
- Minimal bleeding
- Cervical os closed
- Uterus/ foetus smaller than gestational age
- Found on routine scan.
62
Four options of management for incomplete or missed miscarriage? (describe each)
what test should be done following any miscarriage? how long after?
EXPECTANT / CONSERVATIVE
- allow body to do it by itself
- can take up to 14 days
MEDICAL MANAGEMENT
- PO mifeprostone (anti-progesterone)
- then PV misoprolol (prostaglandins) 48 hours later
- can -> heavy bleeding and moderate pain
- 5% risk of retained product
SURGICAL MANAGEMENT (SMM)
1) Under GA
2) Under LA - Manual vacuum aspiration (MVA)
- complications of retained products, damage to cervix, trauma, haemorrhage for both
Do pregnancy test (urine) 3wks after miscarriage - should be negative
63
recurrent miscarriage:
- what % are unknown cause?
- known causes? 4
- possible causes? 6
50% are unknown cause
KNOWN
- antiphospholipid syndrome
- inherited thrombophilias (factor V leiden etc)
- cervical incompetence (cause of late miscarriages)
- chromosomal abnormalities in parents (eg translocation)
POSSIBLE
- abnormal shape uterus
- PCOS
- infection
- immune problems
- uncontrolled diabetes
- untreated thyroid disease
nb don't worry too much about knowing this!
64
What is it called when person has a positive pregnancy test but foetus can't be visualised on scan?
what are the three possible reasons behind this?
investigation (and results) to find out which one it is?
PREGNANCY OF UNKNOWN LOCATION (PUL)
do serum HCG testing 48 hours apart and see if rise or fall
1) ectopic
= HCG stays same or rises or falls a bit
2) complete miscarriage
= HCG falls a lot
3) v. early foetus (<5wks)
= HCG rises a lot
- rescan in 2 weeks
65
Symptoms of ectopic pregnancy? 2
- additional symptoms in ruptured ectopic? 5
- additional signs in ruptures ectopic? 4
what % of pregnancies are ectopics
- constant lower abdo pain (normally on R or L)
- PV bleeding (usually less than a normal period)
norm get pain at 6-8 weeks as this is when foetus starts stretching tube
may have no symptoms! (esp if early)
RUPTURED ECTOPIC
- shoulder tip pain
- nausea + vomiting
- diarrhoea
- pain on defecation / urination (also urge to defecate)
- collapse
- high HR, low BP
- lower abdo guarding
- cervical motion tenderness
- unilateral adnexal tenderness
1% of pregnancies are ectopic (and 90% of ectopics are tubal)
nb ectopic and miscarriage can be clinically quite difficult to differentiate
66
Investigations for ectopic pregnancy:
- first line blood?
- imaging?
- 2nd line blood?
- definitive / emergency investigation?
1) pregnancy test (if negative, excludes ectopic)
TV USS
- purpose to confirm intrauterine pregnancy
- if PUL, do:
2) serum HCG and repeat after 48 hours
- if plateau or slightly rising or falling = ectopic (if high rise = intrauterine, if steep fall = miscarriage)
laparoscopy if any doubt
- or need for emergency treatment anyway
67
Four management options for ectopic pregnancy?
when is each done?
EXPECTANT / CONSERVATIVE
- ie watch and monitor hcg (rare to do)
- If hCG level is static or low (<1000) then consider doing this (also obs normal)
MEDICAL
- methotrexate
- If hCG is 1000-5000 (also obs normal) then woman’s choice between medical or surgical
- Medical is a long process (have to monitor hCG levels and that they’re falling - take a few weeks) - 5% need surgical anyway
- also need contraception for 3 months to protect future pregnancies from methotrexate
SURGICAL
1) Salpingectomy
- if first ectopic
- if ruptured
2) salpingtomy
- if already had one tube removed
- increases risk of future ectopic though but if have both tube removed then can only conceive with IVF
68
DDx for lower abdo pain in early pregnancy? 5
- threatened miscarriage
- miscarriage
- ectopic pregnancy
- appendicitis
- UTI
69
DDx for abdominal pain in late pregnancy? 7
where is pain in each
- labour (cramping)
- placental abruption (constant pain and shock - disproportionate to visible blood loss)
- symphisis pubis dyfunction (Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs)
- pre-eclampsia / HELLP syndrome (epigastric or RUQ)
- uterine rupture (shock and abdo pain)
- appendicitis (RIF)
- UTI
70
What is Gestational Trophoblastic Disease?
What is a hydatidiform mole? how common? two different types?
Gestational Trophoblastic Disease = spectrum of histologically distinct diseases originating from placenta:
- Partial and complete Hydatidiform mole
- Choriocarcinoma
- Placental – Site trophoblastic tumour.
Molar pregnancy aka hydatiform mole
- 1 in 600 pregnancies
COMPLETE hydatiform mole
- no foetal tissue
- Correct number of chromosomes – 46,XX
- All nuclear genetic material from father = androgenetic in origin
PARTIAL hydatiform mole
- non-viable foetus
- 69 chromosomes, 23 from mother + 46 from father --> where 2 sperm enter the ovum.
71
Possible symptoms of molar pregnancy? 3
- hyperemesis (dt high HCG levels)
- PV bleeding
- uterus large for gestational age
(may also have enlarged ovaries on USS, dt very high hcg)
(may also have abdo pain)
nb always scan women with hyperemesis to see if molar
often undetected, especially partial, until have 12 week dating scan
72
investigations if suspect molar pregnancy:
- bloods? 2
- imaging? 1
(and findings)
management of molar pregnancy? (2 components)
HCG
- will be very high
group and save
- rhesus status (see if need anti-D)
TV USS
- snow-storm appearance of the uterine cavity and absence of foetal parts (complete molar); or a small placenta with partial foetal development (partial molar).
Surgical management!
- need to continually check HCG levels afterwards until undetectable - if not falling enough or start rising, may need chemo for choriocarcinoma
- can't conceive until hcg levels back down to zero (need contraception)
(nb can do hysterectomy if sterility desired)
73
What test is does following any miscarriage? why?
histological examination of miscarriage tissue
to see if was a molar pregnancy - as need to monitor hcg levels if it is!
74
What are the indications for giving anti-D to a rhesus -ve mother? 6
- any surgical procedure (SMM, MVA, surgical TOP)
- medical TOP (though not med management of miscarriage)
- any PV bleeding after 12 wks
- chorionic villus sampling or amniocentesis
- following abdo trauma in preg
- normal pregnancy (at 28-30wks - and again after birth if baby is rh +ve)
REMEMBER ONLY NEED TO GIVE IF MOTHER RH -VE!
nb anti-D only works for about 2 weeks - so if repeated bleeding, may need repeated doses
75
Questions to ask in urogynae history:
- urinary symptoms? 9
- sys review? 5
- gynae / obs hx? 4
- PMHx? 1
- DHx? 4
- SHx? 6
- frequency (anything >5 a day is bad)
- nocturia (once okay but more or change is not)
- dysuria
- haematuria
- urgency /urge incontinence
- stress incontinence (leak when laughing, coughing, exercising, lifting)
- difficulty initiating urination
- incomplete emptying
IF BOTH, which of urge or stress AFFECTS you the most?
SYS REVIEW
- neuro problems? (cauda equina)
- chronic cough (stress incontinence)
- constipation (ie bowel symptoms)
- Prolapse symptoms (something dragging, woman can push back in)
- problems with intercourse (ask if sexually active first)
OBGYN HX
- pre / post menopausal?
- smear tests up to date?
- how many babies? (parity really important) delivery method?
- any abdo / pelvic surgery (incl hysterectomy)?
PMHx
- diabetes? controlled?
DHx
- allergies
- diuretics
- laxatives (show may already be constipated)
- tried any medication for urinary symptoms already (what? help? side effects?)
SHx - ASD OhA Dot
- alcohol
- smoking
- drugs (esp ketamine)
- occupation (heavy lifting?)
- ADLs (how affecting life)
- Diet (caffeine, carbonated drinks)
76
Examination in urogynae:
- exams to do? 3
- extra thing to do during exam? 1
- what looking for in exams?
- bedside investigations? 2
1) ABDO
- BMI - need to loose weight
- any masses?
2) SPECULUM
- get to COUGH (any leakage - do before speculum in)
- assess for prolapse
- opportunistic smear (if needed)
3) BIMANUAL
- feel for fibroid uterus (can cause urge)
- assess vaginal atrophy
- urine dipstick
- MSU
can also use sims speculum to assess for prolapse
77
Main investigation for either type of incontinence?
What does it tell you?
urodynamics
fill up bladder with a catheter and, if pressure also increases in probe in vagina or rectum (ie in abdo) then is stress incontinence - if not, is urge incontinence
basically just tells you if the problem is mainly urge or stress incontinence
- as these have different management
you do this investigation AFTER you have tried lifestyle, physio and medical management for the type which you think, from hx, is most likely - this is just to confirm the type before you do any procedures or surgery
78
Management for urge incontinence:
- lifestyle? 6
- physio? 1
- medical? 1
- procedural options? 2
- reduce / stop caffeine
- reduce / stop fizzy drinks
- reduce / stop alcohol
- loose weight
- stop smoking
- bladder diary (incl intake and output) and the training, increasing time between voiding
- pelvic floor exercises with physio
- oxybutynin (1st line anticholinergics - try a different one if this not tolerated)
- cystoscopy and botox (every 6 months)
- percutaneous sacral nerve stimulation
nb urge incontinence is due to detrusor muscle overactivity (smooth muscle in wall of bladder)
nb other procedures can do further down the line but v specialist and don't need to know
79
Management for stress incontinence:
- lifestyle? 5
- other issues to fix if relevant? 2
- physio? 1
- medical options? 2
- surgery? 1
- reduce / stop caffeine
- reduce / stop fizzy drinks
- reduce / stop alcohol
- loose weight
- stop smoking
- manage chronic cough
- manage chronic constipation (laxatives)
- pelvic floor exercises with physio (for 6 months)
- duloxetine (actually a SNRI anti-depressant, but useful)
- topical vaginal oestrogen (strengthens muscle)
surgery (eg tension-free vagiinal tape - TVT)
nb stress incontinence is due to weak pelvic floor muscles
nb can also inject bulking agents (bulkamid) to semi-obstruct bladder neck
80
What are the three different groups of pelvic prolapse? (and the 2 subtypes for first two and 2 subtypes for last one)
VERTICAL
- uterovaginal prolapse
- vault prolapse (if had TAH)
ANTERIOR
- lower 1/3 = cystocele
- upper 2/3 = urethrocele
POSTERIOR
- lower 1/3 = deficient perineum
- middle 1/3 = rectocele
- upper 1/3 = enterocele
81
What are the different grades of prolapse?
what is this system called?
BADEN-WALKER SYSTEM
0 - Normal position for each respective site
1 - Descent halfway to the hymen
2 - Descent to the hymen
3 - Descent halfway past the hymen
4 - Maximum possible descent. Procidentia.
look up pictures!!
82
How do patients describe pelvic prolapse?
What do patients say
Feels like something’s coming down
- Worse on lifting/walking/at the end of the day
Usually not painful just uncomfortable
Can see a bulge vaginally/has to push it back in
- Do you have to push it back to have to poo - posterior wall
- Do you have to push it back to have to wee - anterior wall
Generalised lower backache
Discomfort during intercourse (always ask this!)
83
Management options for pelvic prolapse:
- lifestyle changes? 3
- other issues to fix if relevant? 2
- minor procedure? (2 types - when each used)
- surgical options? 3
- weight loss
- avoid heavy lifting
- pelvic floor exercises
- manage chronic cough
- manage chronic constipation (laxatives)
PESSARY (change every 6 months)
- ring pessary (if sexually active)
- gell horn pessary (if not sexually active or no womb)
SURGERY
- anterior / posterior vaginal wall repair
- hysterectomy
- slings (abdo/laproscopic, not vaginal)
EXAMINE FOR PROLAPSE USING SIMS SPECULUM
nb other types of pessary too, but these main two ones
84
What is the NEW cervical smear process? incl recall details?
exactly the same swab is taken
1) all swabs are tested for high risk HPV strains (hrHPV)
- If negative, normal + go back to normal recall
- if positive, look at cytology on same sample
2) cytology for hrHPV +ve samples
- if cytology normal, recall in a year to check HPV infection cleared
- if cytology abnormal (shows dysplasia) go for colposcopy!
at colposcopy, see affected area using acetic acid
85
CERVICAL SMEARS
- age range done in?
- frequency done in each age range?
- who gets recalled every year (regardless of prev results)? 2
aged 25-49
- every 3 years
aged 50-64
- every 5 years
people who get recalled every year:
- HIV positive
- long term immunosuppression (eg following organ transplant)
nb trans men who have a cervix should get normal recall! - but often aren't due to automatic nature - so always ask!!
86
HPV Vaccination
- current vaccine offered?
- which strains are covered? 4
- who mainly offered it?
- other high-risk group offered?
```
GARDASIL (quadravalent)
- 6
- 11
- 16
- 18
(6+11 warts, 16+18 cancer)
```
female AND male year 8 students (then 6-12months later)
also can give to MSM in SH clinic who are too old to have been covered
87
When doing a cervical smear, how many times do you turn it in the os?
turn it 5 times (all one direction) in the os
88
CERVICAL CANCER
- possible initial symptoms? 4
- possible later symptoms? 3
- differential diagnoses? 4
- PCB (post-coital)
- IMB (inter-menstrual)
- PMB (post-menopausal)
- persistent, offensive blood-stained discharge
later:
- pain in late disease
- swollen leg (thrombosis in pelvis)
- renal failure
DDx
- STI (chlamydia, gonorrhoea)
- ectropian (esp in pregnancy)
- cervical polyp
- other abnormal uterine bleeding (eg fibroids)
89
CERVICAL CANCER
- examinations required? 4
- initial investigations? 1
- abdo (feel for fibroids)
- speculum
- bimanual
- digital rectal (check for local spread, not norm at first presentation)
needs colposcopy
- with cervical biopsy
then do MRI/CT for staging before any management plan
90
CERVICAL CANCER
- management options? 6
- what does it normally depend on? 2
- LLETZ (large loop excision of transformation zone)
- Hysterectomy
- Radical hysterectomy – stage 1b
Trachelectomy – removal of the cervix and a stitch placed to give support to the cervix in case of further pregnancy (ie fertility sparing)
- Radiotherapy
- Chemotherapy
management depends on:
- spread of disease
- future fertility desired
91
endometrial / uterine cancer
| - risk factors? 12
- Obesity (unopposed oestrogens from aromatisation of adrenal androgens in fat tissue)
- increased age
- Diabetes (higher even if normal BMI)
- PCOS (unopposed oestrogenic stimulus and lack of endometrial shedding)
- Early menarche (before age 12)
- Late menopause (after age 52)
- Nulliparity
- Unopposed oestrogen therapy (wrong HRT given)
- Tamoxifen use
- Family history of breast, ovary or colon cancer (HNPCC)
- Prior pelvic irradiation
- Oestrogen-secreting ovarian tumours
(don't worry too much about knowing these off by heart - just more oestrogen = bad for uterus!)
nb cocp, pregnancy, ius are protective
92
endometrial / uterine cancer:
- two main presentations?
- differential diagnoses? 6
- post-menopausal bleeding (after 1 year of amenorrhoea)
- changes in bleeding pre or peri-menopausally (esp if more heavy, more irregular, IMB etc)
DDx
- STI
- other vaginal infection (eg BV)
- vaginal atrophy (commonest cause of PMB)
- endometrial polyps (rarely fibroids, as these shrink during menopause)
- cervical pathology
- urological causes (eg stones, bladder or kidney ca)
93
uterine / endometrial cancer:
- examinations to do? 2
- first line investigation?
- subsequent diagnostic investigations?
- investigations for staging / management planning?
- speculum (exclude cervical and vulval/vaginal pathology)
- bimanual (fixed uterus is bad sign)
TV USS (to measure endometrial thickness)
- only helpful in post-menopausal women
SHOULD BE
= <4mm if no HRT
= <5mm if HRT (though <8mm for one type but too in detail)
diagnostic:
- pipelle biopsy (norm in colposcopy)
- hysteroscopy with biopsy
staging / management planning:
- MRI
- CT scan
94
uterine / endometrial cancer:
- ideal management? 1
- management options if lymph node spread? 2
- palliative management to slow spread? 1
Ideally
= TAH BSO - with washing and nodes sampling
additional if spread:
- radiotherapy (is inserted into uterus/vagina)
- chemo
palliative / slow spread
- high dose progestins (+/- mirena coil)
95
OVARIAN CANCER:
- Symptoms? 5
- signs? 3
- differential diagnosis? 6
- bloating / abdo distension (ascites)
- early satiety (anorexia)
- nausea
- diarrhoea / constipation
- pelvic pain
- shifting dullness (ascites)
- cachexia
- irregular abdominal mass
DDx
- ascites from liver disease (alcohol or fatty)
- IBS
- IBD
- diverticular disease
- endometriosis
- benign ovarian cyst
nb new onset IBS symptoms in older women should always make you suspicious
nb can also get PMB but rare
most people present late so may also have symptoms of mets
96
OVARIAN CANCER
- risk factors? 8
- protective factors? 2
basically the more ovulations you have, the greater your risk
- early menarche
- late menopause
- nulliparity
- smoking
- increased age
- endometriosis
- BRCA1 + 2 (5-10% of cases have this)
- HNPCC (lynch syndrome)
protective factors:
- COCP
- pregnancy
97
OVARIAN CANCER
- examinations to do? 3
- blood test?
- what also raises this blood test? 3
- 1st line imaging? 1
- test if have ascites?
- imaging for staging?
- abdo
- speculum
- bimanual
Ca-125
also raised in:
- premenopausal women (dt ovulation)
- endometriosis
- some benign cysts
nb can also test for Ca19.9 (pancreas) and CEA (bowel) to see if tumours are actually mets from elsewhere
TV USS
do paracentesis of ascites, if present
then do CT abdo pelvis for staging
98
OVARIAN CANCER
- 1st line management? 1
- additional management if needed? 1
- palliative surgery? 1
TAH, BSO, omentectomy, lymph node sampling and peritoneal biopsies with peritoneal washings or ascitic fluid obtained for cytology
adjuvant chemo with platinum based compounds
can do 'debulking' surgery to improve symptoms for palliative care
nb 75% of ovarian cancers present at stage 3 or 4 - ie mets in abdo or mets further away
99
VULVAL CANCER
- possible symptoms? 4
- possible examination findings? 4
- differential diagnoses? 5
some have no symptoms!
- pruritis / soreness
- bleeding (post-menopausal)
- discharge
- ulcer or mass
- skin often thicker and lighter or darker than skin around it (VIN - vulval intraepithelial neoplasia)
- raised mass (red/pink/white)
- ulcerated mass
- warty mass
DDx
- VIN (vulval intraepithelial neoplasia - pre cancerous condition)
- pagets disease of vulva
- lichen sclerosis
- genital warts
- bartholin's cyst
nb VIN is precancerous and lichen sclerosis and pagets can both become cancer too
100
VULVAL CANCER
- examinations? 4
- investigation for diagnosis?
- investigation for staging?
- speculum
- bimanual
- PR (to assess spread)
- palpate inguinal lymph nodes (to assess spread)
- biopsy lesion
- MRI for staging
101
VULVAL CANCER
- management options? 5
(depending on spread)
- Wide local excision of the suspicious area
- Vulvectomy
- Ipsilateral/ bilateral lymphadenectomy
- Radiotherapy
- chemotherapy
102
ENDOMETRIOSIS:
- What is it?
- describe the pain?
- main other symptom? 1
- other possible symptoms? 5
- possible sites? 6
ectopic endometrial tissue in the pelvis where it shouldn't be
= dysmenorhhoea (also pain starts BEFORE period)
= deep dyspareunia
- chronic and cyclical pelvic pain (dt adhesions)
- Menorrhagia
- painful defecation (dyschezia)
- sacral backache with menses
- subfertility
POSSIBLE SITES
- Peritoneum
- Pouch of Douglas
- Ovary/ tubes (chocolate cysts)
- Ligaments
- Bladder
- Myometrium (Adenomyosis)
nb 30-40% of women with endometriosis end up infertile
103
ENDOMETRIOSIS:
- gynae? 5
- other? 4
- adenomyosis
- fibroids
- pelvic inflammatory disease
- ovarian cyst
- ectopic pregnancy (always do a PT)
- neuropathic pain
- fibromyalgia
- painful bladder syndrome (aka interstitial cystitis)
- IBS
104
ENDOMETRIOSIS
- examinations? 3
- possible findings on exam? 3
- abdo
- speculum
- bimanual
- Fixed, retroverted uterus (should be mobile). Fixed indicates scar tissue – adhesions between large bowel and adnexa lead to subfertility and pain.
- Nodularity of the uterosacral ligament
- Enlarged, tender adnexa
105
ENDOMETRIOSIS:
- norm first line imaging?
- other imaging can do?
- gold standard?
- TV USS (can see endometriomas and if really extensive disease)
- MRI (may be able to visualise)
- laparotomy and visualisation is gold-standard (but only do if going to treat at the same time)
nb there is no correlation between extent of disease and symptoms - always treat the symptoms
106
Management of endometriosis:
- analgesia? 1
- other medical? 3
- medical before surgery? 1
- surgery option if want to preserve fertility? 1
- surgery option if finished family? 1 (what else do you have to prescribe if do this surgery? 1)
- NSAIDs
contraceptives to suppress ovaries:
- COCP (take pills back to back)
- Mirena IUS
- POP
GnRH analogues
- can only take for 6 months
To retain fertility:
- laparoscopic excision/ ablation of endometrial tissue – where larger ovarian endometrioma >4cm suspected
No desire for further children:
- TAHBSO
- must prescribe combined continuous HRT afterwards up until age 50 (then woman can decide whether to continue)
nb don't use oestrogen-only HRT as may have endometrial ca from ectopic endometrium
- also not cyclical as this may cause symptoms
107
Pelvic inflammatory disease:
- % that are asymptomatic?
- description of pain?
- other possible symptoms? 5
60% asymptomatic
generally symptoms will be short term (<30 days)
- Lower abdominal pain – bilateral – in PID often initially starts after menses, when mucosal barrier weaker
- Deep dyspareunia
- IMB
- PCB
- Menorrhagia
- Abnormal vaginal or cervical discharge (offensive, say: change in smell)
108
Differential diagnoses for PID:
- gynae? 3
- other? 4
- ectopic pregnancy
- ovarian cyst complications (rupture, torsion)
- endometriosis
- appendicitis (don't forget!!)
- IBS
- UTI
- functional pain (eg ovulation)
nb symptoms often shorter term - endometriosis norm longer term
109
Pelvic inflammatory disease:
- examinations to do?
- possible findings on exam? 4
- swabs to take during exam? 3
- abdo
- speculum
- bimanual
- lower abdo tenderness, usually bilateral
- offensive discharge
on bimanual:
- cervical motion tenderness
- adnexal tenderness
(can see fever if severe disease)
1) Vulvo-vaginal swab (VVS) ---> Chlamydia and gonorrhoea (NAAT)
2) High vaginal swab (HVS) ---> BV, TV and candida
3) Endocervical swab (EC) --> gonorrhoea culture
Nb only test for TV if symptomatic
110
investigations for pelvic inflammatory disease:
- swabs taken during speculum exam? 3
- urine test for all? 1
- other bedside tests if urinary symptoms? 2
- bloods for all? 2
- bloods if unwell? 4
- organism to test for if recurrent or not responding to treatment? 1
1) Vulvo-vaginal swab (VVS) ---> Chlamydia and gonorrhoea (NAAT)
2) High vaginal swab (HVS) ---> BV, TV and candida
3) Endocervical swab (EC) --> gonorrhoea culture
Nb only test for TV if symptomatic
PREGNANCY TEST for all
if urinary symptoms:
- dipstick
- MSU
For all:
- HIV
- syphilis
nb if had syphilis in the past then blood test will always be positive
if unwell:
- FBC
- U+E
- LFTs
- ESR
test for Mycoplasma Genitalium (causes about 15% of PID) if recrrent / not responding to treatment
111
Risk factors for pelvic inflammatory disease? 7
- < 25yrs (75%)
- Multiple partners
- Unprotected sex
- Vaginal douching
- IUD insertion
- Previous PID
- TOP
112
how would you describe PID to a patient?
PID is where a woman’s reproductive organs become inflamed. The womb, fallopian tubes, ovaries and tissues surrounding these organs.
In about 25% of women PID is caused by an STI
- Absence of STI does not exclude PID
It is easy to treat, but important to do so asap as it can cause problems such as infertility but most women can go on to become pregnant
Cannot have sex until cause is found, and partner has been fully treated.
113
Management of PID:
- for all? 1
- if unknown cause / before test results come back? 3
- if known cause? 1
- abx to cover mycoplasma genitalium?
- abx for chlamydia in pregnancy?
- management if systemically unwell?
- Other management to stop the spread? 2
give analgesia to all
try and find organism on microscopy on site if possible
treat empirically as an STI (even though other causes, such as BV)
if unknown cause, give all 3 , to cover for chlamydia, gonorrhoea + anaerobes:
1) Chlamydia = Doxycycline 100mg BD PO 14 days
2) Gonorrhoea = Ceftriaxone 500mg IM stat
3) Metronidazole 400mg bd po 7-14 days
If known cause, just treat that one
mycoplasma genitalium: moxifloxacin 400mg od 14 days
chlamydia in pregnancy
= azithromycin (doxycycline is teratogenic)
admit for IV abx +/- fluids if systemically unwell (eg fever)
1) PARTNER NOTIFICATION (clinic can do this anonymously)
2) NO SEX until pt AND partner have completed treatment
nb have a low threshold for treating PID with abx!!
114
What is the name for pain on ovulation
mittelschmerz
nb this is unilateral lower abdo pain (as only one ovary releases an egg each month)
115
Complications for PID? 5
What % of pts with PID get complications?
complications in 25% of pts with PID
- Ectopic pregnancy
- Tubal factor infertility from scarring
(1 episode = 10%, 2 = 20%, 3 = 40%)
- Chronic dyspareunia and pelvic pain
- Fitz Hugh Curtis Syndrome (perihepatitis)
(Especially in pts with Chlamydia)
- Tubo-ovarian abscess (Systemically unwell, palpable mass)
Nb in women <30 years, RUQ pain is highly suggestive of perihepatitis, rather than cholecystitis!
116
History of pt with pelvic pain:
- HPC? 8
- associated symptoms to ask about? 8
- other 5 histories to do? (look each up in more detail)
SOCRATES
bleeding
- menorrhagia
- IMB
- PCB
- dyspareunia
- change in discharge, (amount, colour, smell)
- dysuria
- change in bowel habit
- fever
SEXUAL HX
- LSI?
- PSI? (in last 3 months)
- who with? (gender, casual / relationship)
- protection?
- type of sex?
MENSTRUAL HX
- LMP
- timing of pain related to menses?
OBGYN HX
- smear hx (if 25 or over)
- any children?
- ever been pregnant?
PMHX
- ever had STI before?
- other conditions?
DHX
- contraception?
- allergies?
- other meds?
117
What broad questions should you remember for any gynae hx? 6
Remember for any gynae:
- LMP (or menopause)
- smear (if >25)
- contraception
- any children? prev pregnancies?
- sexually active (or LSI, PSI)
- urinary or bowel symptoms?
118
Describe the relationship between the hypothalamus, pituitary and ovaries in the female menstrual cycle, including:
- which hormones secreted by each?
- from which part of the pituitary is something secreted?
- what are the negative feedback loops?
- what changes at menopause?
HYPOTHALAMUS
- secretes GnRH (this stimulates anterior pituitary)
ANTERIOR PITUITARY
- stimulated by GnRH
- secretes FSH and LH (stimulate ovaries)
OVARIES
- stimulated by FSH and LH
- secrete oestrogen and progesterone (have effects on endometrium)
in the 1st half of the cycle, these hormones have a positive feedback loop, in the 2nd half they have a negative feedback loop
(nb everything is from the anterior pituitary, expect ADH and oxytocin which are from posterior)
MENOPAUSE
- ovaries stop producing oestrogen and progesterone so anterior pituitary tries to stimulate them by secreting high levels of FSH and LH but doesn't work (but explains why you have high levels of FSH and LH at menopause
119
Describe the normal menstrual cycle, including:
- the first and second half and what these stages are called in reference to 1) the ovaries 2) the endometrium
- describe the fluctuation of oestrogen, progesterone, FSH and LH throughout this
- how do you calculate the date of ovulation in a woman's normal cycle?
menses begins on day 0
```
FIRST HALF (start of menses to ovulation)
= FOLLICULAR phase (ovaries)
- Developing the egg in follicle
- FSH predominates then surge of LH at ovulation
= PROLIFERATIVE phase (endometrium)
- oestrogen predominates (then levels suddenly drop off at ovulation as progesterone beginning to rise)
- endometrium is built up
```
LH surge gives ovulation
It produces the corpus luteum (lutenising hormone) - from what is left over of the follicle once the egg is released
- Corpus luteum produces progesterone
```
SECOND HALF (from ovulation to start of menses)
= LUTEAL phase (ovarian)
- Corpus luteum produces progesterone which maintains endometrium
- nb FSH and LH are low in this phase
= SECRETORY phase (endometrium)
- changes from proliferative to secretory endometrium (secretes nutrients)
- Progesterone changes endometrium into the decidua
```
progesterone and oestrogen drop off at the end of the luteal phase due to death of corpus luteum (when clear no sperm is coming) and this triggers menses
Ovulation is 14 days prior to the start of menses
- ie luteal phase is fixed at 14 days (as corpus luteum can only live for 14 days), it's the follicular phase which can vary in length
- eg in a 21 day cycle, ovulation is day 7, in a 28 day cycle, ovulation is day 14
120
How does emergency hormonal contraception work?
based on this, when will it work and when won't it in a menstrual cycle?
Morning after pill = massive dose of progesterone = ovulation inhibitor.
If you have ovulated, it will not work. Thus, need to work out cycle dates.
Ovulation always occurs 14 days before end of cycle. Thus, in 32-day cycle, ovulation must be on day 18. In 21-day cycle must be on day 7.
Sperm can live for 5 days – so sex during period, in shorter cycle can lead to conception.
---> If ovulation already occurred, emergency copper coil required.
121
Normal menstrual cycle:
- normal length of menses? (range and average)
- normal length of cycle? (range and average)
- normal age of menarche? (range and average)
- normal age of menopause? (range and average)
- what is it called when you have menopause early? what ages?
LENGTH OF MENSES
- 2-8 days
- 5 is average
CYCLE LENGTH
- 23-49 days
- 29 is average
MENARCHE
- 8-16 years
- 12 is average
nb if you don't start period by age 16 then this is primary amenorrhoea
MENOPAUSE
- 45-55 years
- 51 is average
early menopause
= 40-45
premature ovarian failure (POI)
= under 40
122
CONSENT AND LEGALITIES
- What is the legal age of consent in the UK? (what do you have to do if have person under this age in consultation? 3 things)
- at what age do you have to report it to the authorities?
Legal age is 16
- but no legal duty to report UNLESS at risk of harm aged 13-15
- legal duty to report if 12 and under (ie under 13)
UNDER 16 (ie 13-15)
- 3 Cs
= CONFIDENTIALITY
- inform that everything will be confidential unless there is a threat to their or another person's well being so have to disclose (but will always tell pt this)
= CONSENT
- risk assess to see if at risk (eg older partner, exploitation, if being coerced, paid etc - see other flashcard for what Qs to ask)
= COMPETENCE (FRASER)
- Must check fraser competence prior to prescribing any contraception (see other flashcard for this)
123
Who should you risk assess for exploitation etc:
| - two main groups?
anyone under the age of 18!
anyone else who you think may be at risk (eg if hint of domestic abuse etc then probe)
124
How do you assess Fraser competence? 5 (acronym)
Which ages do you have to assess this in?
UPSIS (Un-Protected Sex Is Silly)
1) Young person UNDERSTANDS the advice given
2) PARENTS involvement is encouraged by clinician
3) Young person likely to continue having SEXUAL intercourse
4) It is in the young person’s best INTEREST to supply her with contraceptive
5) Young person’s physical & mental health is likely to SUFFER without contraception
assess in age 13-15
(12 and under is totally illegal - report!)
125
PRESCRIBING CONTRACEPTION:
- What should be excluded before prescribing? 2
- What aspects of the 'history' need to be asked before prescribing? 4 (what sort of things asking about in each)
- Guidelines to read to ensure method not contraindicated? 1
- What to consider and discuss with patient when deciding type of contraception to use? 8
- What to emphasise that most methods don't protect against? 1
- what additional thing to do if child under 16? 1
- what additional thing to do if under 18? 1
- exclude pregnancy (any chance could be pregnant, LMP, do test if unsure)
- exclude current STI (symptoms, any unprotected sex?, test if unsure) (though can still prescribe most with an STI)
PMHx
- eg migraine w aura, VTE, epilepsy, menorrhagia, fibroids, obesity (weigh) etc
- any past pregnancies or STIs
DHx
- which contraceptives tried before?
- allergies
- concurrent meds that can interact: st johns wart, anti-epileptics, ARVs
FHx
- FHx of VTE
SHx
- smoking (incl how many)
- lifestyle - how will many if short-acting contraception
- who live with
UKMEC guidelines
- for contraindications AND table of efficacy of each method
TO CONSIDER / DISCUSS
- pts expectations (ie what they already know, think about diff methods - incl if tried any before)
- age of pt (<18, approaching menopause)
- regular partner or multiple / concurrent
- future plans for children
- logistics of each method (incl missed pill rules)
- understanding of efficacy (show ukmec table) for each method (emphasise benefits of LARCs)
- understanding of risks / possible side effects of methods
- how will be followed up (eg initial then annual review for pills)
EMPHASISE THAT MOST METHODS DON'T PROTECT AGAINST STIS!!
assess fraser competence
- "Un-Protected Sex Is Silly"
- understanding
- parents (persuade to tell)
- Sex (likely to continue regardless)
- Interest (in their interest to prescribe)
- Suffer (likely to suffer without it)
ALSO RISK ASSESS ANYONE UNDER 18!
126
UKMEC
- What two things are they really good at advising on?
- of one of these, what are the four categories and ways to remember these?
1) Shows perfect and typical efficacy of each method (show pts table)
2) Lists contraindications for each method
UKMEC GUIDELINES
Offers guidance to providers of contraception regarding who can use contraceptive methods safely
UKMEC 1
= A - Always usable
UKMEC 2
= B - Benefits outweigh risk
UKMEC 3
= C - Cautious use
UKMEC 4
= D - Do not use!
nb the abcd thing isn't used, that's just a way of remembering what all of the numbered categories mean in practise
127
What are the three methods of combined hormonal contraception (CHC)?
How is each method used? (nb for pill describe 3 possible ways of using)
COCP (PILL)
1) take 3 weeks on, one week off (or dummy pills)
2) take three packs back to back then have a week off (tricycling)
3) take packs always back to back (but if start bleeding, stop for 4-7 days then continue)
EVRA PATCH
= patch on the skin, replace every week for 3 weeks and then one week off (ie each patch lasts for a week)
NUVA RING
= ring inserted vaginally for 3 weeks then remove for a week before putting in a new one
nb can run all of these together - ie none need a break (though may get occasional withdrawal bleeds with all)
128
Mechanism of action of combined hormonal contraception?
Synthetic oestrogen and progestogen prevent pituitary release of FSH and LH (via negative feedback): hence prevent ovulation
Endometrial effects prevent implantation
Cervical mucus changes exclude sperm
Think about it like: First 7 pills inhibit ovulation
Next 14 pills maintain anovulation
nb withdrawal bleed occurs as a result of removal of hormonal stimulus on endometrium
129
Non-contraceptive potential benefits of combined hormonal contraception? 7
- most dangerous adverse effects of CHC? 2 (when is the risk the highest?)
- which cancers does it reduce the risk of? 3
- which cancers does it increase the risk of? 2
- cycle control (if irregular)
- management of PMS
- improves menorrhagia
- improves dysmenorrhoea
- management of acne (some make worse, others make better)
- improves endometriosis
- improves PCOS
(also fertility returns immediately after stopping)
dangerous adverse effects:
- VTE
- MI / Stroke
^these at greatest risk in first 4 months after starting then risk decreases (though still higher than background risk)
REDUCES risk of:
- ovarian cancer
- endometrial cancer
- colon cancer
INCREASES risk of:
- breast cancer
- cervical cancer
DOES NOT PROTECT AGAINST STIs!!
130
Which is the only non-permanent contraceptive method where fertility DOESN'T return immediately?
depo (progesterone) injection
| - can take up to a year for fertility to return to normal
131
Advantages (2) and disadvantages (3) of Evra patch? (compared to other CHCs)
efficacy of perfect and typical use?
advantages
- don't have to think about every day
- not affected by vomiting / diarrhoea
disadvantages
- have to change every week
- breakthrough bleeding / spotting may occur in first few months
- if patch comes off, have to replace with a new patch
perfect use = 0.3 in 100 women will get pregnant in a year
typical use = 9 in 100 women will get pregnant in a year
nb efficacy is the same for all CHCs
132
Which medications interact with every type of combined hormonal contraception? 5
(thus another method of contraception should be used instead)
- CPY450 enzyme inducers
- Some anti-epileptics e.g.phenytoin phenobarbitone & carbamazepine
- Rifampicin
- Some ARVs used in HIV eg ritonavir
- St John’s Wort
**look up specifics
133
Advantages (1) and disadvantages (3) of COCP? (compared to other CHCs)
efficacy of perfect and typical use?
advantages
- nothing in / on body (people generally more comfortable using it as they know people on it etc)
disadvantages
- have to remember to take pill every day
- breakthrough bleeding / spotting may occur in first few months
- diarrhoea and vomiting reduces efficacy (have to either repeat pill or use barrier if recurrent)
perfect use = 0.3 in 100 women will get pregnant in a year
typical use = 9 in 100 women will get pregnant in a year
nb efficacy is the same for all CHCs
134
Advantages (3) and disadvantages (3) of Nuva ring? (compared to other CHCs)
efficacy of perfect and typical use?
advantages
- no daily effort required
- not affected by diarrhoea or vomiting
- lower dose than pill/patch so may have fewer side effects
disadvantages
- woman has to be comfortable inserting and removing it
- if ring is out for > 3 hours then loose efficacy
- breakthrough bleeding / spotting may occur in first few months
perfect use = 0.3 in 100 women will get pregnant in a year
typical use = 9 in 100 women will get pregnant in a year
nb efficacy is the same for all CHCs
135
What is the time period for taking the COCP in a day? ie when is a pill 'missed'
What are the 'missed pill rules' for the COCP? (different for each of the 3 weeks)
Have 24 hours, so a COCP is missed if it is over 24 hours late (if <24hrs late then just take it and is fine and don't need to do anything)
IF PILL IS >24 HRS LATE (or missed >1 pill):
ALL weeks: condoms or abstain for 7 days
In addition:
In 1st week (and have had UPSI): take emergency contraception
In 2nd week: carry on
In 3rd week: run packs together
(ie for all weeks use condoms/abstain for 7 days and do the other things in addition)
REMEMBER: 1st 7 pills inhibit ovulation. Next 14 maintain anovulation.
136
Vomiting / diarrhoea while on the COCP:
- what to do if single episode?
- what to do if repeated episodes?
single episode within 3 hours of taking pill, take another pill and continue as normal
if repeated episodes then continue to take pills (even if throw them up / don't fully absorption AND use condoms / abstain for entirety of illness AND 7 days after last episode of vomiting / diarrhoea
137
If an Evra patch falls off, what should you do?
- what's the time period which it's okay and when should you use additional contraception?
replace it with a NEW patch
If in 1st week after break:
- if off for any period, replace and use condoms / abstain for next 7 days in addition
If in 2nd or 3rd week:
- if off for <48 hours, just replace, no other action needed
- if off for >48 hours, replace and use condoms / abstain for next 7 days in addition
Also if off for >48 hours at any time and have had UPSI, consider emergency contraception
138
If an Nuva ring falls out, what should you do?
- what's the time period which it's okay and when should you use additional contraception?
If ring is out for more than 3 hours or more than once a cycle, contraceptive efficacy is lost
If ring free week is extended efficacy is lost
(in both of these scenarios, use condoms / abstain for 7 days and get EC if had UPSI)
Expelled or removed ring may be washed with tepid water and replaced (ie don't need a new ring if it comes out)
139
Starting combined hormonal contraceptives:
- when in cycle can have UPSI straight away? 1
- when have to wait (and for how long?) before having UPSI? 1
If started day 1-5 of natural period (or following TOP)
= no extra protection needed
If start at any other time in cycle
= need 7 days of condoms/abstinence
nb this is the same for COCP, patch or ring
140
Possible side effects of all combined hormonal contraceptives:
- common but not serious? 8
- rare, but serious? 5
What can try if experience the common ones and they are intolerable? 2
- nausea
- stomach ache
- weight gain (though just as many loose weight)
- breast tenderness (also increase in size)
- mood changes
- headaches
- skin changes
- spotting for first few months
= VTE (unilateral leg swelling, sudden shortness of breath)
= MI / STROKE
= Breast cancer (check them)
= Cervical cancer (go to smears)
= liver disease (pain in upper abdo, jaundice, itching)
If mild side effects can try:
- switching to another CHC (eg each pill has different concs of progesterone and oestrogen)
- switching to another type of contraception
141
What are the UKMEC contraindications for combined hormonal contraception:
- UKMEC 4? 8
- UKMEC 3? 7
UKMEC 4 (don't use)
- >35 years old and smoker of > 15 cigarettes per day
- migraine with aura
- PMHx VTE
- PMHx stroke or ischaemic heart disease
- Uncontrolled hypertension (sys >160)
- Breast cancer
- Recent major surgery with prolonged immobilisation
- Breast feeding and < 6 weeks
postpartum UKMEC 3 (cautious use)
- > 35 years old and smoker of < 15 cigarettes per day
- BMI > 35
- Migraine with no aura
- FHx of VTE in first degree relative < 45 years old
- Controlled hypertension
- Immobility e.g. Wheelchair use
- Breast feeding and 6 weeks to 6 months postpartum
Nb there are loads of other more in detailed caveats but just say you would check UKMEC to confirm
142
Combined hormonal contraceptives:
- how long before major surgery should these be stopped? and when can start again?
- what should you use instead?
- what should you do if emergency surgery?
Stop 4 weeks before major surgery
switch to progesterone-only pill
Restart 2 weeks after mobilisation
If emergency:
- still do surgery but stop CHC from earliest point
- have LMWH and TEDs until mobilising again (then can restart 2 weeks after mobilising again)
143
When prescribing a combined hormonal contraceptive (CHC), what should you tell the patient? 13
- efficacy with typical and perfect use
- how to use (make sure know if have dummy pills or not)
- how long it will take to work after starting it
- missed pill rules (see leaflet in packet)
- what to do if vomit or diarrhoea (COCP only)
- drug interactions (incl st johns wart)
- common side effects
- what to do if experience side effects
- follow up (norm 4 wks) then monitoring required (BP every year)
- signs of major side effects (VTE, MI, breast ca)
- doesn't protect against STIs (use condoms if multiple partners)
- need to attend smears when called
- check breasts
144
four examples of brand names of COCP?
- micregynon
- rigevidon
- yasmine
- cilest
nb some of these have versions with dummy pills and some are just 21 pill packets
145
Mechanism of action of progesterone only pills (POP)?
Prevents ovulation
Thicken cervical mucus
Reduces endometrial receptivity
146
What are the two different types of progesterone only pill? (brand examples of each)
how often do you have to take each?
What is the window for taking each one? (after which it is considered 'missed')
What to do if forget pill in respective 'window period'? (ie how long to take precautions for / when to take EC)
traditional POP
= levonorgestrel, norethisterone
- 3 hour window period to take
desogestrel only pill
= desogestrel (ie cerazette)
- 12 window period to take
- normally used 1st line now (as theoretically more effective)
TAKE BOTH EVERY DAY!!
if miss pill (ie outside of window period)
- use condoms/abstinence for 2 days (48 hours)
- if have UPSI in this time, consider emergency contraception
147
Vomiting / diarrhoea while on the POP:
- what to do if single episode?
- what to do if repeated episodes?
single episode within 3 hours of taking POP and still inside window (3 hours for traditional, 12 for cerazette), take another pill and continue as normal
if repeated episodes (or outside window) then continue to take pills (even if throw them up / don't fully absorption AND use condoms / abstain for entirety of illness AND 48 hours after last episode of vomiting / diarrhoea
148
If you are taking enzyme inducers (certain anti-epileptics, ARVs etc) what are the only three types of contraception you can safely use? (ie without it affecting absorption?)
- depo injection
- IUS
- IUD
(also condoms obvs)
ie CAN'T use:
- CHC (any form)
- POP
- implant
149
Starting combined hormonal contraceptives:
- when in cycle can have UPSI straight away? 1
- when have to wait (and for how long?) before having UPSI? 1
If started day 1-5 of natural period (or following TOP)
= no extra protection needed
If start at any other time in cycle
= need 48 hours of condoms/abstinence
150
Efficacy of progesterone only pill (both types) with perfect and typical use?
perfect use = 0.3 in 100 women will get pregnant in a year
typical use = 9 in 100 women will get pregnant in a year
nb this is the same as CHC
151
Contraindications for progesterone-only pills? 3
- following CVA
- Breast cancer in last 5 years
- severe cirrhosis
see UKMEC for other weird stuff - but basically it can be used by a lot more people the CHC can
152
progesterone-only pills:
- possible side effects? 6
- other disadvantages over other methods? 2
- advantages over other methods? 2
- main risk? 1
- irregular spotting (though normally settles)
- skin changes (incl spots)
- breast tenderness
- headaches
- mood changes
- weight changes
- have to remember to take every day
- no protection against STIs
- a much wider range of people can use it (CHC have a lot of contraindications), including can use while breastfeeding
- may help with PMS and dysmenorrhoea and menorrhagia
if do become pregnant, higher chance of it being ectopic
(nb contradictory data about links with breast cancer)
153
When prescribing a combined hormonal contraceptive (CHC), what should you tell the patient? 10
- efficacy with typical and perfect use
- how to use (every day at SAME time)
- how long it will take to work after starting it
- missed pill rules (see leaflet in packet)
- what to do if vomit or diarrhoea (COCP only)
- drug interactions (incl st johns wart)
- common side effects
- what to do if experience side effects
- follow up (norm 4 wks)
- doesn't protect against STIs (use condoms if multiple partners)
154
How many women will get pregnant in a year if not on any form of contraception?
85 in 100
155
Male condoms?
- perfect use and typical efficacy?
- advantages? 3
- disadvantages? 4
- what type of lube should you use with them?
women will get pregnant in a year:
- perfect = 2 in 100
- typical = 18 in 100
+ protects against STIs
+ easy to obtain
+ adverse effects are rare (main is latex allergy)
- requires forward planning and may interrupt sex
- participation, motivation and commitment of both partners
- loss of sensitivity during intercourse may occur
- can break or slip + require careful disposal
use water or silicone based lubes
156
Female condoms:
- efficacy with perfect and typical use?
- advantages? 4
- disadvantages? 4
women will get pregnant in a year:
- perfect = 5 in 100
- typical = 21 in 100
+ protects against STIs
+ can be inserted up to 8 hours before sex
+ latex free + no adverse effects known
+ less likely to tear than male condom
- can be noisy during intercourse
- participation, motivation and commitment of both partners
- requires careful insertion
- can be dislodged, or the penis can be inserted between the vaginal wall and the female condom
157
Diaphragm:
- two types?
- efficacy with perfect and typical use?
- advantages? 3
- disadvantages? 8
- traditional (has to be sized)
- caya (fits 80% of women)
women will get pregnant in a year:
- perfect = 6 in 100
- typical = 12 in 100
+ can be inserted hours before sex (as long as spermicide is applied at most 3 hours before sex)
+ Latex free
+ No adverse effects known
- Very user dependent ie. have to learn how to use, insert and remove it
- must reapply spermicide gel with every sex act (and must be left in place for at least 6 hours after sex)
- Doesn't provide reliable protection against STIs
- Can predispose to cystitis
- Weight gain and weight loss can alter size and fit
- Can't use if <6 weeks post-partum
- Can't use when menstruating
- don't use if history of toxic shock syndrome
158
IUD (copper coil) mechanism of action:
- primary? 3
- secondary? 3
Primary effect through copper ions:
- Direct toxic effect on sperm and ova
- Decreased sperm motility
- Decreased sperm survival
Secondary effect on endometrium:
- Impedes sperm transfer
- Sperm phagocytosis
- Impedes implantation
159
IUD:
- what tests required before fitting? 2
- how long does it take to be effective?
- perfect and typical use efficacy?
before fitting, need:
- pregnancy test (or be certain from hx that not pregnant)
- STI screen (or be certain no risk)
is effective IMMEDIATELY!
women will get pregnant in a year:
- perfect = 0.6 in 100
- typical = 0.8 in 100
160
IUD:
- how long does it last?
- how long fertility come back to normal?
lasts up to 10 years
- if fitted over age 40, can use until no longer required
fertility resumes immediately
161
IUD contraindications to fitting:
- UKMEC 4? 5
- UKMEC 3? 5
UKMEC 4
- any active pelvic infection (STI, post-puerpral sepsis etc)
- already pregnant (may cause an illegal abortion)
- unexplained vaginal bleeding
- endometrial or cervical cancer (pre-treatment)
- gestational trophoblastic neoplasia
UKMEC 3
- after radical treatment for cervical cancer
- abnormally shaped uterus
- asymptomatic chlamydia
- within 4 weeks of giving birth (although can give in first 48 hours after birth)
- long Q-T syndrome (as insertion can trigger vaso-vagal reaciton)
nb if have chlamydia or gonorrhoea while have IUD in place then is normally fine - just can't insert one while have active infection (nb if asymptomatic chlamydia then can insert one as long as initiate abx for chlamydia on the same day)
162
IUD:
- Advantages? 6
- disadvantages? 3
+ works as soon as it is put in
+ no user error, works for 5-10 years
+ not affected by other medications (and doesn't contain any hormones)
+ can be used during breastfeeding
+ can be used for emergency contraception
+ can be fitted immediately after miscarriage / TOP
- periods may be longer, heavier and more painful (may improve after a few months, also may spot initially too)
- doesn't protect you from STIs (+ if you do get an infection, may be more serious)
- need an internal exam when fitted, can be painful to fit (this may be intolerable to some pts)
163
What are the five scenarios which you can be sure that a woman is not pregnant before inserting and IUD or IUS
- Currently menstruating
- No sex since menstruation
- Using another reliable method
- No sex in last 3 weeks and PT negative
- earliest UPSI this cycle occurred <5 days ago (or ovulation was <5 days ago - *check this with EC notes!)
remember that a PT takes 3 weeks to go positive, hence why have to wait
164
What is one of the most common causes of failure in IUD/IUS?
- How common is this?
- When is it most likely to occur? 2
What is the biggest risk with IUD/IUS insertion?
- how common?
- who more common in?
- how manage?
```
Expulsion is common cause of failure
= 1 in 20
more common:
- first 3 months after fitting
- with heavy menstruation
(also if inserted soon post-partum)
```
Perforation of uterus
= 1 or 2 in 1000
- 6x more common in early post-natal period in lactating women
- surgery to remove
165
Pregnancy and IUD/S
- ectopic pregnancy risk? (numbers)
- if get pregnant, can you continue it?
1 in 20 IUD/S conceptions are ectopic, there is a reduction in the total number of ectopics
- can continue pregnancy, if uterine, but higher miscarriage rate
- remove device if threads can be seen (reduces risk of miscarriage)
166
Does IUS/D put you at higher risk of PID?
IUD/S does not cause pelvic infection
the risk of infection is higher only in the 3 weeks following insertion
167
What are the 6 things you need to remember to counsel a women about prior to IUD insertion? (acronym)
E and 5 Ps
- Expulsion
- Pregnancy (ie failure rate and ectopic)
- Perforation
- Periods
- PID
- Procedure
also that they need to check threads regularly
168
Two main brands of IUS on the market?
- difference in length of use?
- other difference?
Mirena
- 5 years
- also licensed for menorrhagia + for HRT, as well as contraception
Jaydess
- 3 years
- smaller and so supposedly more suitable for nulliparous women
169
IUS mechanism of action? 4
| - which hormones does it contain?
- Thickening of cervical mucus, inhibiting the passage of sperm
- Prevention of endometrial proliferation
- Prevention of ovulation in some women’s cycles
- Local effect of foreign body on uterus
contains progesterone only
170
IUS:
- what tests required before fitting? 2
- how long does it take to be effective?
- perfect and typical use efficacy?
- how long does it last?
- how long fertility come back to normal?
- pregnancy test (or be very assured that not already pregnant)
if fitted in first 5 days of period = effective immediately
if fitted any other time in cycle = effective after 7 days
women will get pregnant in a year:
- perfect = 0.2 in 100
- typical = 0.2 in 100
```
mirena = 5 years
jaydess = 3 years
```
fertility resumes immediately
171
IUS contraindications to fitting:
- UKMEC 4? 5
- UKMEC 3? 5
UKMEC 4
- any active pelvic infection (STI, post-puerpral sepsis etc)
- already pregnant (may cause an illegal abortion)
- unexplained vaginal bleeding
- endometrial or cervical cancer (pre-treatment)
- gestational trophoblastic neoplasia
- current breast cancer
UKMEC 3
- after radical treatment for cervical cancer
- abnormally shaped uterus
- asymptomatic chlamydia
- within 4 weeks of giving birth (although can give in first 48 hours after birth)
- long Q-T syndrome (as insertion can trigger vaso-vagal reaciton)
nb if have chlamydia or gonorrhoea while have IUD in place then is normally fine - just can't insert one while have active infection (nb if asymptomatic chlamydia then can insert one as long as initiate abx for chlamydia on the same day)
172
IUS:
- Advantages? 6
- disadvantages? 3
+ works as soon as it is put in
+ no user error, works for 3-5 years
+ not affected by other medications
+ can be used during breastfeeding
+ can be fitted immediately after miscarriage / TOP
+ periods become shorter, lighter + less painful (1st line treatment for menorrhagia + endometriosis)
- irregular bleeding or spotting common in first 6 months
- doesn't protect you from STIs (+ if you do get an infection, may be more serious)
- need an internal exam when fitted, can be painful to fit (this may be intolerable to some pts)
173
What are the 7 things you need to remember to counsel a women about prior to IUS insertion? (acronym)
E and 6 Ps
- Expulsion
- Pregnancy (ie failure rate and ectopic)
- Perforation
- Periods
- PID
- Procedure
- Possible progestogenic side effects
also that they need to check threads regularly
174
What is the most effective LARC?
The implant
175
contraceptive implant:
- mechanisms of action? 3
- where is it placed?
(aka nexplanon implant)
- contains etonogestrel (a progesterone)
- Prevents ovulation
- Thickens cervical mucus
- Reduced endometrial receptivity
Small, flexible rod placed under skin in the inside upper arm, just overlying tricep. Radiopaque.
176
contraceptive implant
- how long does it take to be effective?
- perfect and typical use efficacy?
- how long does it last?
- how long fertility come back to normal?
Inserted day 1-5 cycle = effective immediately
Inserted any other day of cycle = effective after 7 days
women will get pregnant in a year:
- perfect = 0.05 in 100
- typical = 0.05 in 100
lasts 3 years
fertility returns to normal on removal
nb when get changed can go back in same place - normally do this twice before switching arms
177
contraceptive implant contraindications:
- UKMEC 4? 1
- UKMEC 3? 5
(aka nexplanon implant)
UKMEC 4
- current breast cancer
UKMEC 3
- past breast cancer
- liver cirrhosis or cancer
- current use of enzyme inducers
- continuing use following a CVA
- unexplained vaginal bleeding
178
contraceptive implant:
- advantages? 6
- disadvantages? 5
```
+ lasts 3 years, no user error
+ fertility returns to normal after removal
+ not affected by vomiting / diarrhoea
+ may reduce heavy, painful periods
+ can use while breastfeeding
+ can put in immediately following birth
```
- can't use if on enzyme inhibitors
- invasive procedure to fit and leaves a scar
- progestogenic side effects (headaches, breast tenderness, mood changes)
- variable bleeding pattern (but this can be treated)
- doesn't protect against STIs
nb very slight risk of wound infection but incredibly rare - no real risks
179
What do you need to counsel women about before inserting contraceptive implant? 8
- procedure for fitting and removal
- how long it will take to work after starting it
- how long it lasts
- efficacy
- that it's affected by enzyme inducers
- progestogenic side effects (breast tenderness, headaches, mood swings)
- produces variable bleeding pattern (but this can be treated)
- doesn't protect against STIs
180
Contraceptive injection:
- two in current use? (incl route of injection and length effective for)
- mechanism of action?
Depo Provera
= 12 weeks
= IM injection
Sayana Press
= 13 weeks
= SC injection
nb both are effective up to 14 weeks
- Prevents ovulation
- Thickens cervical mucus
- Reduced endometrial receptivity
181
Contraceptive injection:
- how often do you have it? (ie how long does it last)
- how long to become effective?
- efficacy with perfect and typical use?
- how long till fertility comes back to normal?
Depo Provera (also Sayana Press)
- Lasts 12 or 13 weeks
If started days 1-5 = effective immediately
Started on other day of cycle = effective after 7 days
women will get pregnant in a year:
- perfect = 0.2 in 100
- typical = 6 in 100
fertility takes up to a year to return to normal
182
contraindications for contraceptive injections:
- UKMEC 4? 1
- UKMEC 3? 5
- who should you ideally not use it in? why?
UKMEC 4
- current breast cancer
UKMEC 3
- multiple risk factors for CVD
- vascular or IHD / stroke
- unexplained vaginal bleeding
- past breast cancer
- severe cirrhosis or liver cancer
ideally don't use injection in under 18 or over 45 due to its affect on bone mineral density (though this is regained once stopped)
183
contraceptive injection:
- advantages? 5
- disadvantages? 7
+ 70% of people have amenorrhoea by 1 year, though can be irregular initially (nb some people don't see this as an advantage)
+ Don't have to remember to take a pill once a month yet not that invasive
+ not affected by enzyme inducers
+ not affected by vomiting / diarrhoea
+ can use while breastfeeding
- have to remember to get injection every 3 months
- progestogenic side effects (headaches, breast tenderness, mood changes)
- Side effects cannot be reversed quickly as cannot be removed
- weight gain can occur (3kg by 2 years)
- Fertility and periods take time to return after stopping
- Affects bone mineral density (is regained when stopped – ideally not for young or menopausal)
- doesn't protect against STIs
184
What do you need to counsel women about before starting contraceptive injection? 7
- need to come back for repeated injection every 3 months (or may not be protected)
- how long it will take to work after starting it
- efficacy
- affects on periods (70% amenorrhoea by 1 year)
- progesterone side effects AND weight gain
- effect on fertility (1 year to regain)
- doesn't protect against STIs
185
Post-partum contraception, how long after birth is it safe to use each of these methods:
- combined hormonal (pill, patch, ring)?
- progesterone-only pill?
- contraceptive injection?
- contraceptive implant?
- IUS / IUD?
- female sterilisation?
- also how effective if lactational amenorrhoea method (LAM) as a method of contraception?
POST-PARTUM CONTRACEPTION
COMBINED HORMONAL (pill, patch, ring)
- if started in first 3wks then provides immediate protection, after than need to wait 7 days before protected
= if breastfeeding, contraindicated (UKMEC 4) for 6 weeks, then UKMEC 2 for breastfeeding 6 wks to 6 months (fine above 6 months)
= if not breastfeeding, but have other risk factors for VTE then UKMEC 4 for first 3 wks then UKMEC 3 for 3 wks to 6 wks (fine after 6 wks)
= if not breastfeeding and no other risk factors for VTE, UKMEC 3 for first 3 weeks then UKMEC 2 for 3 wks to 6 wks (fine after 6 wks)
PROGESTERONE-ONLY PILL
= can start any time post-partum
- if started in first 3wks then provides immediate protection, after than need to wait 2 days before protected
CONTRACEPTIVE INJECTION
= can start any time post-partum
- if started in first 3wks then provides immediate protection, after than need to wait 7 days before protected
- but if use within 6 wks post-birth then more likely to have heavy and irregular bleeding
CONTRACEPTIVE IMPLANT
= can start any time post-partum
- if started in first 3wks then provides immediate protection, after than need to wait 7 days before protected
IUS / IUD
= can be inserted within 48 hours of childbirth or after 4 weeks
- IUS effective after 7 days of insertions, IUD effective immediately
FEMALE STERILISATION
- can do at the same time as a c-section if woman wishes
LACTATIONAL AMENORRHOEA METHOD (LAM)
- is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
nb basically everyone is protected up to 3 weeks (21 days) post-partum)
nb in addition condoms can be used at any time, and wait 6 weeks to use a diaphragm or cap and check it still fits
nb an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age babies - ie important to discuss contraception with women post-partum
186
Vasectomy:
- two methods?
- anaesthesia used?
- failure rate of vasectomy to work?
Minimally Invasive (MIV) or No-Scalpel Vasectomy (NSV), involves puncture of the scrotal skin to access & occlude the vas
- Skin opening <10mm
- Dissection around vas is minimal
- No skin sutures
- local anaesthesia
1 in 2000 (nb female is 1 in 200)
187
Vasectomy:
- how long does it normally take to work?
- how do you know if it has worked?
- when is it considered to have failed?
- What to counsel patients about how long it takes to work?
Takes at least 12wks (3 months)
do first post-vasectomy semen analysis (PVSA) AT 12 WEEKS
- If azoospermia confirmed then no further samples needed (ie it worked)
- if still sperm, continue sampling until PVSA is free of sperm
- if motile sperm detected 7 months post-procedure, consider it a failure of vasectomy
NEED ADDITIONAL CONTRACEPTION UNTIL CLEAR PVSA
188
Vasectomy:
- potential intra-op complications? 3
- potential late complications? 2
- post-op advice to pt?
- need for further investigations if structural vas problems (eg absence, duplication etc)
- may need cautery or suture to maintain haemostasis
- bleeding, haematoma and infection rates are low
LATE
- failure of procedure
- pain (some may be ongoing, but rare!)
advice to pt
= rest and avoid strenuous activity post-op
189
female sterilisation:
- two types, what involved in which?
- which one normally done in UK?
- major risks to each type?
- failure rate for each?
TUBAL OCCLUSION
- by far most common
- Mechanical occlusion of fallopian tubes by Filshie clip is method of choice (though can also cauterise or tie tubes too)
- performed laparoscopically under GA
- major risks: injuries to bowel, bladder, ureter, blood vessels that require laparotomy
- 1 in 200 failure
HYSTEROSCOPIC STERILISATION
- transcervical route
- flexible micro-inserts passed through hysteroscope + inserted into proximal section of each fallopian tube
- norm no anaesthesia
- completely irreversible
- need post-procedure imaging to confirm placement (use contraception until this)
- low chance of risks: infection, expulsion of insert, uterine perforation
- 1 in 500 failure at 5 years (no longer term data)
190
What test should be done before female sterilisation?
How long does tubal occlusion take to work?
pregnancy test
- and also check that >3 weeks since last UPSI
Takes 7 days to work post-operation
- if have coil in place, keep in place until 7 days after sterilisation
191
male and female sterilisation:
- advantages? 2
- disadvantages? 7
advantages
- doesn't affect periods
- don't have to think about contraception again as is permanent
disadvantages
- requires a surgical procedure (GA if female)
- possible regret (especially if <30)
- there is a failure rate
- cannot be easily reversed (+ not funded on NHS)
- small risk of ectopic pregnancy if female sterilisation fails
- doesn't protect against STIs
- male sterilisation takes at least 12 weeks to work
192
male and female sterilisation:
| - what form of consent needs to be taken for both?
need written consent for both procedures and pts need to have been given written and verbal advice prior
if any doubt of patient's capacity to consent, need to seek legal advice!
193
male and female sterilisation:
| - pre-sterilisation things to discuss with patients? 8
- highlight irreversibility of procedure
- reversal is not available on the NHS
- LARCs are just as effective and are reversible (must go through all other contraceptive options before consider sterilisation)
- assess whether family is completed and discuss likelihhod of regret (assess individuals for known predictors of regret)
- failure rates (1 in 2000 for vasectomy, 1 in 200 for tubal occlusion)
- complications of procedure
- how long it will take to work (at least 12 wks for vasectomy, 7 days for tubal occlusion)
- will not protect against STIs
all of this information should be written and verbal!
194
female sterilisation
- when should it be performed post-abortion? (and what info to pts)
- when should consent be taken for it to be perfomed at c-section?
POST-ABORTION
- ideally wait an 'appropriate interval' before giving
- emphasise that increased rate of regret (and possible increased failure rate)
AT C-SECTION
- informed written consent should be obtained at least 2 weeks prior
195
What are the three forms of emergency contraception? (incl brand name)
what is the mechanism of action of each one?
Copper IUD
- prevents fertilisation and implantation (toxic to sperm and eggs)
```
Ulipristal Acetate (UPA)
= EllaOne
- selective progesterone receptor modulator -> inhibition / delay of ovulation
```
Levonorgestrel
= levonelle
- large dose of progesterone -> delays or inhibits ovulation
196
If someone comes to you asking for emergency contraception - what do you need to ask / establish in the history? 10 (split into 4 groups of Qs)
PERIODS
- cycle length (if irregular, assume the shortest length)
- first day of LMP
SEXUAL INTERCOURSE
- most recent UPSI
- all UPSI in the current cycle (ie since start of LMP)
- risk of current STI
DRUG HISTORY
- contraceptive use or not? when last used? (important if contains progesterone)
- any other medications (think enzyme inducers)
- allergies
OTHER
- sexual health understanding (educate on condom use etc)
- safeguarding (ALWAYS SCREEN IF UNDER 18)
nb if have missed period, unsure of when last one was - consider that she could already be pregnant - consider doing a PT
197
What are the main enzyme inducers which affect some contraceptives? 4
- st john's wart
- some anti-epileptics
- some anti-tubeculousis abx
- some anti-retrovirals
198
What are some of the different ways in which contraceptions can fail?
Condom accident
Missed pills
Depo/implant/IUCD expiry
Med interactions – antituberculous/antiretroviral/antiepileptic (St John’s Wort)
199
After what time period is emergency contraception indicated for for an UPSI after:
- childbirth?
- abortion, miscarriage or ectopic pregnancy?
What are the two other indications for EC?
UPSI from Day 21 after childbirth
UPSI from Day 5 after abortion, miscarriage, ectopic pregnancy
- UPSI that has taken place on any day of a natural menstrual cycle (ie w. no contraception)
- regular contraception has been compromised or used incorrectly
200
How long following UPSI is each type of emergency contraception effective for?
% effectiveness?
Copper IUD
- up to 5 days (though is a caveate to this - see other card)
- >99% effective
Ulipristal Acetate (UPA, EllaOne)
- up to 5 days (just as effective up to 5 days)
- 98% effective
Levonorgestrel (levonelle)
- up to 3 days (efficacy reduces the longer after UPSI it's taken)
- 95% effective in <24hrs
- 85% effective in 24-48hrs
- 58% effective in 48-72hrs
201
How long does it take after ovulation for implantation to occur?
How do you calculate the date of ovulation?
What are the two rules (A + B) about when you can insert an IUD after UPSI?
Why do these rules apply?
6-12 days
- therefore 5 days after ovulation is the latest can use IUD (if multiple UPSIs in cycle)
ovulation is 14 days before 1st day of period (so if cycle is 21 days then ovulation occurs 7 days after start of period)
RULE A
Has EARLIEST UPSI this cycle happened within 120hours (5 days)?
-> if yes, then can have copper IUD
If not, RULE B
RULE B
Has ovulation happened within 5 days?
-> if yes, can give IUD
If neither apply, (or poor historian - uncertain time of sex etc)
Don’t give copper coil, but can give EHC
eg, if someone had an UPSI on day 3 of a 28 day cycle then could have coil up to day 19 of cycle (ie 5 days after ovulation) - check this!!***
This is because, if already pregnant, an IUD can -> termination, whereas EHC do not affect a pregnancy if it's already implanted
nb if cycle is irregular, calculate cycle from shortest cycle length
nb if pt has to wait any time, even 30 mins in waiting room (as may leave) before having IUD fitted, give EHC (if not contraindicated) as well
202
Which is the only emergency contraceptive which can help with multiple UPSIs in a cycle?
IUD
| see rule A and rule B on another flashcard
203
After fitting an IUD for emergency contraception, how long does it have to stay in for to be sure that person doesn't become pregnant?
have to stay in at least until next period (ideally 4 weeks)
but strongly encourage people to keep it in, or at least switch to another LARC
204
Side effects / risks of emergency contraception:
- copper IUD? 6
- Ulipristal Acetate (UPA, EllaOne)? 4
- Levonorgestrel (levonelle)? 4
copper IUD
- Pain on insertion
- Infection (esp in 1st 20 days)
- Menorrhagia
- Perforation
- Vasovagal (common – 1/10)
- Expulsion (1 in 20)
Ulipristal Acetate (UPA, EllaOne)
- PV bleeding
- N&V
- Headache
- Breast/ pelvic pain
Levonorgestrel (levonelle)
- PV bleeding
- N&V
- Headache
- Breast/ pelvic pain
205
If patient vomits within how long of taking emergency hormonal contraceptives do you have to give them a second dose:
- Ulipristal Acetate (UPA, EllaOne)?
- Levonorgestrel (levonelle)?
and what else should you prescribe alongside?
```
Ulipristal Acetate (UPA, EllaOne)
- take 2nd dose if thrown up within 3 hours
```
Levonorgestrel (levonelle)
- take 2nd dose if thrown up within 2 hours
if throw up, prescribe anti-emetic alongside
206
Which methods of emergency contraception aren't effective after ovulation? 2
What should you do if need EC after ovulation?
neither pill is effective (ie UPA or levo)
- explain to pt and try to persuade them to have IUD
- if can't persuade, give EHC anyway as better than nothing and may still work!
207
If on enzyme inhibitors (st johns warts, some antiepileptics, anti-tuberculous + ARVs), which methods of emergency contraception can you use? and which can't you?
CAN HAVE
- copper coil
- levonelle BUT double dose!!
CAN'T HAVE
- UPA
208
When should you double the dose of Levonorgestrel (levonelle)?
- if pt is on enzyme inhibitors
- if pt has BMI >26
***look up if have to double does of UPA if high BMI too
209
Which emergency hormonal contraceptive can you not have if you've recently had a progesterone-containing contraceptive?
- how long before this EHC can't you have progesterone?
- how long after this EHC can't you have progesterone?
Ulipristal Acetate (UPA, EllaOne)
- can't have UPA if taken a progesterone-containing contraceptive in the last 7 days
- can't have progesterone in the 5 days following taking UPA
nb if you think about it, levo is just a large dose of progesterone so it obviously won't be affected by additional progesterone
nb also shouldn't breastfeed for 7 days after taking UPA
210
Can you use emergency hormonal contraception more than once in a cycle? if yes, how do you use it?
yes!! (though is off license!)
Already taken UPA
= can offer UPA again
- LNG should not be taken in next 5 days (as contains progesterone)
Already taken LNG
= can offer LNG again
- UPA theoretically less effective if taken in following 7 days (as LNG contains progesterone)
So basically have the SAME one as you've had previously in the cycle!
nb always try to persuade pt to have IUD if not contraindicated
211
What are the two main contraindications for using an IUD for emergency contraception?
- if can't be sure that pt is not already pregnant (see rule A + B)
- if have symptomatic STI
For emergency coil insertion:
- If symptomatic STI - ukmec 4
- --- No! Don’t give coil!
- If a positive test for asymptomatic STI - ukmec 3
- --- Maybe give coil but treat at same time and do test of cure
- If have UPSI and high risk for chlamydia
- --- Give coil but also give treatment for chlamydia and test of cure
- If have UPSI and low risk of chlamydia
- --- Give coil and do test for chlamydia but no treatment
ie ALWAYS do at least a NAAT test when inserting a coil for EC
212
What are the options for ongoing contraception following emergency contraception:
- IUD?
- UPA?
- levonelle (LNG)?
IUD
- effective ongoing contraception
- if want out, need to wait until at least next period
UPA
- wait 5 DAYS before starting hormonal contraception (abstain / condoms until this time)
LNG
- can start another form of contraception immediately (ie at same time as give LNG) - as long as sure not already pregnant
213
What should you tell patients about when giving them any type of emergency contraception? 3
- need to take a pregnancy test after 3 weeks (can't just rely on getting next period as this may be a withdrawal bleed)
- advice about what ongoing contraception options are available to them, when they can start them and where to get them from
- advice about STI protection, show how to put a condom on etc
214
What proportion of women will have at least one abortion by the time they're 45?
One third
215
What are the 5 reasons you can have an abortion in the UK?
- what is the most common reason?
- incl the timeframe for each of these?
- What form must two doctors sign before a pt can have an abortion?
A: the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
B: the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
C: the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
= MOST COMMON REASON (98%)
D: the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman
E: there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
TWO doctors must sign HSA1 form before a TOP can be performed
nb fraser guidelines apply to girls under 16, as they do with contraception
216
If a patient has an unwanted pregnancy, what are the three options she has and should be counselled about?
1) continue the pregnancy and become a parent
2) continue the pregnancy and pursue adoption
3) end the pregnancy by abortion
217
Pre-abortion management:
- what needs to be discussed with patient? 4
- what clinical tests need to be done? 5
- support with decision-making
- information about the different methods of abortion appropriate to gestation, potential adverse effects and complication
- contraception after abortion
- safeguarding (if relevant)
- confirmation of pregnancy (PT)
- determination of rhesus status (group + save)
- VTE risk assessment
- USS to confirm gestation + exclude ectopic
- STI screening (incl HIV)
218
What are the two methods of surgical TOP?
- describe process of each
- what gestation can you do each for?
- what pain relief / anaesthesia can be used? 4
VACUUM ASPIRATION
= up to 14 weeks
– use large-bore Cannulae and suction tubing
- <7 weeks requires examination of aspirate to confirm complete abortion
- Cervical preparation considered (Misoprostol 400 mcg given vaginally 3 hrs prior to surgery OR sublingually 2-3hrs before)
DILATION AND EVACUATION
= Over 14 weeks
- Preceded by cervical preparation (Misoprostol up to 18 weeks gestation the use osmotic dilators as superior to medical methods)
- Continuous US guidance to reduce risk of surgical complication
Pain relief:
- NSAIDs
(paracetamol not helpful)
Can have either procedure under:
- LA (cervical block)
- conscious sedation (fentanyl + midazolam)
- GA
219
Risks of surgical TOPs? 9
- retained products of conception (1 in 20)
- infection (1 in 10)
- unpredictable bleeding (v common)
- pain (v common)
- injury to the cervix (1 in 100)
- haemorrhage (1 in 1000)
- perforation (damage to the womb is 1 in 250)
- continuing pregnancy
- psychological problems
220
Medical TOP:
- medications used and route? (how do they work?)
- how far apart are medications taken?
- at what gestation does fetocide also need to be performed?
- what other medication should be given at the time?
1) PO mifepristone
2) PV or PO misoprostol taken 48 hours later
- the doses depend on the gestation (can also have additional doses of misoprostol if not fully successful / RPOC
mifepristone is an anti-progesterone steroid which effectively ends the pregnancy and sensitises myometrium to prostaglandin-induced contraction + ripens cervix
- misoprostol is a prostaglandin that stimulates contractions
Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth (can be done by intracardiac potassium chloride or intra-amniotic digoxin - check this!)
Give NSAIDs for pain relief (paracetamol not effective)
221
Risks of medical abortion? three commonest one and 8 others?
= pain (bad period pains)
= unpredictable bleeding, should lessen gradually over 2 weeks or so)
= Side effects of drugs such as nausea, vomiting, diarrhoea,
headache, dizziness, fever/chills (common)
- Unpredictable time to complete the procedure (variable)
- haemorrhage (2 in 1000, more common if late)
- RPOC (3 in 100)
- Infection (2 in 1,000)
- Undiagnosed ectopic pregnancy (1 in 7,000)
- Rupture of the uterus/womb (1 in 1000)
- Continuing pregnancy (1 in 100-150 )
- Psychological problems (variable)
nb if early abortion then can take 2nd pill as an outpatient but if later, take as an in-patient as risk of haemorrhage is higher
222
What medication should be considered for both medical and surgical TOPs? who given to?
What test should a woman do following an abortion?
anti-D injection
for women who are rhesus -ve
A pregnancy test after 3/4 weeks - should be negative by then , if not may have RPOC
223
What does the abortion act say about conscientious objection?
when does it not apply?
what does the act say doctors / nurses who conscientiously object do?
"If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You should make sure that information about alternative services is readily available to all patients. Children and young people in particular may have difficulty in making alternative arrangements themselves, so you must make sure that arrangements are made for another suitably qualified colleague to take over your role as quickly as possible."
- does NOT apply where it is necessary to save life or prevent grave permanent injury to the woman’s physical or mental health.
If have conscientious objection, you must:
- tell women about right to see another dr
- give them contact details / signpost about where to go
