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Protocol > Gynae Protocol > Flashcards

Gynae Protocol Flashcards

1
Q

Miscarriage management

A

Expectant
Medical
Surgical

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2
Q

Expectant management miscarriage

A
  • wait and watch for 7-14 days for the expulsion to occur naturally

Consider other management if
- woman has coagulopathy or no blood transfusion available
- history of still birth, missed miscarriage
- risk of haemorrhage (late 1st tri)
- risk of infection
- less than 6weeks of preg with bleeding but no pain, advise for preg test after 7 days

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3
Q

Medical management miscarriage

A

Misoprostol (cytotec)
1tab is 200mg

  • Missed- 800mg pv 2doses 6hrs apart
  • incomplete 600mg oral 1dose
  • induced (13-22wks)- 400 mg pv 3hrly
  • IUD
    200 if 13- 17 wks pv 6hrly
    100 if 18- 26 wks pv 6hrly
    25-50 if more than 26wk pv 4hrly
  • induction of Labour 25mg pv or 50mg orally 4hrly

-pph prophylaxis- 800mg perrectal
-pph treatment- 1000mg perrectal

-cervical ripening- 400mg pv 3hrs before op

Reduce dose if c-sec scar present

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4
Q

Surgical management miscarriage

A

1- MVA AND DNE
2- Surgical uterine evacuation for excessive vaginal bleeding, hemodynamic instability, evidence of infected retained tissue and suspected gestational trophoblastic disease
3- misoprostol 3hr before
4- send products of conception for histo path
5- 1gram azithromycin I/v or oral + metronidazole 500mg iv before procedure
6- grief councelling

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5
Q

Labs for miscarriage

A

1 cbc
2 tvs (pelvis)
3 blood group rh factor (give 250iu antiD if more than 12 weeks and -ve)
4 coagulation profile
5 hepBsag and hep C
6 seria BhcG weekly until negative

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6
Q

Recurrent miscarriage history

A

3 or more miscarriages. 1% incidence
History
- prev miscarriage history number and age
- hx of prev cervical surgery
- history of painless cervical dilatation
- was fetal heartbeat confirmed at the time of miscarriage
- congenital uterine malformations
-APLA
- thyroid disorders
- thrombophelia
- vaginal Infections
- PCOS

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7
Q

MCC of recurrent miscarriages

A

6-8 wks chromosomal abnormalities
8-12 IUD APLA thrombocytopenia
12-24 cervical weakness, (anatomical defects) vag infections, uterine abnormalities

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8
Q

Labs for recurrent miscarriages

A

1- cbc
2- blood group th factor
3- tvs
4- anti phospholipid antibodies
5- rubella serology ig
6- HVS for c/s
7- day 2 LH FSH
8- laparoscopy hysteroscopy
9- screaming for APLA, factor 5 Leiden deff, thrombophilia, protein S
10- paternal peripheral karyotyping for both parents
11- histo path of products of conception of 3rd miscarriage.

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9
Q

Management for recurrent miscarriages

A

1 reassurance and councelling
2 folic acid 400ug 3 months before conception
3 low dose aspirin and LMWH for APLA and thrombophilia
4 clinical geneticist for karyotypical abnormalities
5 cervical cerclage offered for cervical incompetence

60-70 percent chance after 3
45 percent chance after 6

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10
Q

Ectopic pregnancy

A

It is defined as an implantation of a fetus outside the normal uterine cavity

11.1/1000 pregnancies)

Fallopian tubes 95%, Ovaries 3%, and Peritoneal cavity 1%

RISK FACTORS:
Previous ectopic pregnancy
Pelvic infections especially chlamydia infection (40%)
Pelvic inflammatory disease
Previous tubal surgery
Subfertility
Use of assisted reproductive techniques

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11
Q

Ectopic cp

A

Unruptured ectopic —- lower abdominal pain, mild vaginal bleeding, May be asymptomatic

Ruptured ectopic— severe lower abdominal pain, shoulder tip pain, epigastric pain or shock Common

Symptoms:
 abdominal or pelvic pain
 amenorrhoea or missed period
 vaginal bleeding with or without clots
More common signs:
 pelvictenderness
 adnexaltenderness
 abdominaltenderness

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12
Q

Labs for ectopic

A

1 cbc
2 rbs
3 serial bhcg
4 tvs
5 urine dr
6 hep c Hbsag

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13
Q

Ectopic ultrasound for fallopian tube

A

1- Adenexal mass moving separate from ovary with gestational sac containing a yolk sac - sliding sign

2- adnexal mass moving separately form ovary with empty gestational sac - bagal sign

3- empty uterus
4- collection of fluid in uterine cavity

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14
Q

Expectant management for ectopic done in?

A

1- are able to return for follow up
2- bhcg less than 1000IU/L
3- adnexal mass less than 4cm
4- tubal ectopic less than 35mm w no heartbeat
5- haemodynamically stable pt
6- less than 100ml free fluid in pelvis

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15
Q

Expectant management in ectopic

A

hCG should be 50% less after 7 days

1- 2x weekly serial bHcG, then at 2,4,7 days. Reduce by 15%, then do weekly till less than 20IU/L
2- TVS weekly - adnexal mass reduction w/I 7 days
3- council for compliance
4- council for ectopic

If values don’t decrease seek consultation

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16
Q

Medical management for ectopic

A

Methotrexate - an anticancer anti folate agent.

Do LFT RFT CBC before

Single IM inj calculated from patients, body surface area as 50mg/m2. ( mostly will be between 75 mg and 90 mg or 1mg/kg.)

Criteria
1- bhcg less than 3000IU (can be 1500-5000)
2- mass less than 4cm
3- no contraindication for metho
4- unruptured ectopic
5- no fetal heartbeat
6- heamodynamically stable
7- pt compliance for follow up

17
Q

IN/CI for medical m in ectopic

A

INDICATION
 Cornual pregnancy,
 Persistent trophoblastic disease
 Patient with one fallopian tube and fertility is desired
 Patients who refuses surgery or in whom risk of surgery is too high
Cervical Ectopic pregnancy.

CONTRAINDICATION:
 Chronic liver, renal and haematological disorder
 Active infection
 Breast feeding
 Immunodeficiency

18
Q

Surgical management for ectopic

A

If Serum βhCG is >3000IU/L
Patient is symptomatic

1- Salpingotomy
Removal of conceptus with conservation of tubes done in women with diseased contra lateral tube and fertility desired.

In women with history of fertility reducing factor e.g.
 Previous Ectopic pregnancy
 Contra lateral tubal damage
 Previous abdominal surgery
 Previous (PID).

2- Salpingectomy
Removal of tube in the presence of healthy contra lateral tube can be done by two methods;

  • laptoscopic

 Haemodynamically stable patient
 No h/o previous surgeries
 Unruptured ectopic
 Adnexal mass<4cm

  • laprotomic

 Haemodynamically unstable
 Ruptured ectopic
 Previous surgeries
 Expertise for laparoscopy is not available

19
Q

Investigations for molar pregnancy

A

1- cbc
2- Blood group rh factor
3- Bhcg
4- TVS
5- Thyroid profile
6- Urea creatinine electrolytes
7- Chest X-ray

20
Q

Treatment of molar pregnancy

A
  • Suction curettage
  • Anti-D prophylaxis in Rh negative mother
  • Use of Oxytocin infusion prior the evacuation is not recommended.
  • Follow up with serial beta HCG
  • Provide written information about the condition.
21
Q

Follow up molar pregnancy

A

Complete mole-
BhcG tested (if reducing)
- weekly for first 4 weeks (28)
- fortnightly for next 4 weeks (56)
- monthly till 6 months complete

If HCG has not reverted to normal within 56 days then follow-up will be for 6 months from normalization of the HCG level.

Partial mole- normal hcg on 2 samples 4weeks apart then stop

Notify for future pregnancy
Retake bhcg 6-8 weeks after next pregnancy

22
Q

Pregnancy after molar

A

No chemo- can after 6 months of bhcg being Norma
W chemo- after 1 year of treatment

Barrier method until Normal hcg levels
COCP after hcg levels are normal
NO iucd - risk of uterine perforation

23
Q

HMB history and exam

A

History-
Cycle, passage of clots, dysmenorrhea
Post coital bleeding, inter menstrual bleeding.
Signs and symptoms of thyroid, bruising and drug intake of anticoagulants.
Comorbidity and quality of life

Exam-
GPE- anemia bruising patechiae goiter
PA- mass
P/S- polyp fibroid cyst
P/V- uterine size and adnexa

24
Q

Labs for HMB

A

1- CBC
2- TVS
3- THYROID FT
4- Coagulation profile
5- Endometrial sampling (biopsy)
6- Hysteroscopy if u/s indecisive

Pipelle or DNC

Indications for a biopsy include
I. Persistent intermenstrual bleeding
II. Women aged 45 and over
III. Treatment failure or ineffective treatment

25
Q

Medical management for HMB

A

Hormonal- if contraception required
COCP-
- For 21 days started from day1, with seven days withdrawal. continue for next 3 months
- Norethisterone 15 mg
PROGESTERONE
- Fibroid 3 cm ˃ more indiameter.
- Norethisterone acetate 5mg three times a day for 21days for next 3 months
LNG-IUS
Uterine size is <12 cm or there is no organic pathology. 5yr contraception

Non hormonal fertility req

1- cap tranexemic acid 500mg 3 times a day during periods
or
Intravenous 1gm stat dose
2- Mefenamic acid 500mg 3times a day during periods
3- NSAIDS

26
Q

Surgical treatment for HMB

A

Endometrial ablation
Uterine artery embolisation
Myomectomy
Hysterectomy (types)

27
Q

SEVERE ACUTE HMB RX

A

May be a result of a coagulopathy
Initial management is based on haemodynamic stability

30μg ethinyloestradiol/ 0.3mg norgestrel

  • 4 times daily for 4 days then
  • 3 times daily for 3 days
  • 2 times daily for 2 days followed by
  • Once daily for 3 weeks
28
Q

Bacterial vaginosis Rx

A

Metronidazole 400mg twice daily for 5-7 days Or
Metronidazole 2 g single dose

ALTERNATIVE REGIMENS

  • Intravaginal metronidazole gel (0.75%) once daily for 5 days Or
  • Intravaginal clindamycin cream (2%) once daily for 7 days Or
  • Clindamycin 300 mg twice daily for 7 days Or
  • Tinidazole 2G single dose
29
Q

BV recurrence Rx

A

Suppressive therapy:

  • Metronidazole gel (0.75%) twice weekly for 4-6months to decrease symptoms
  • Metronidazole orally 400mg BD for 3 days at the start and the end of menstruation combined with
  • fluconazole 150mg as a single dose if there is also a history of candidiasis
30
Q

B rules for ovary

A

1- Unilocular Cysts

2- Presence of solid component where largest is < 7mm

3- Presence of acoustic shadowing

4- Smooth multilocular tumour with the largest diameter <100mm

5- no blood flow

31
Q

M rules for ovary

A

1- Irregular solid tumour

2- Irregular multilocular solid tumour where largest diameter > 100mm

3- Ascites

4- At least 4 papillary structures

5- Very strong blood flow

32
Q

Labs for ovarian mass

A
  • CBC
  • RBS
  • URINE D/R
  • HEPBSG, ANTI HCV
  • Blood group and save if plan of surgery
  • Urea, Creatinine, Electrolyte,
  • LFTs
  • Tumour markers: LDH, AFP and BhCG
  • CA 125

CA 125:
Less than 200- investigate if rapid increase
More than 200- referral to gynaecological oncologist

CA-125 can be increased is fibroid, endometriosis, adenomyosis and pelvic infection.

33
Q

Exam for ovarian mass

A

1- Inspection of Abdomen:
for distention, dilated veins

2- Palpation: if palpable assess mass, size, tenderness, mobility, nodularity, ascites (fluid thrill and shifting dullness).

3- Bimanual per vaginal examination: Assess size, mobility , texture (nodularity), consistency , tenderness or presence of nodules in POD

34
Q

Hx for ovarian mass

A

Persistent abdominal pain
Abdominal distention
Decreased appetite
Increase urinary urgency and frequency

35
Q

Surgical contraception

A

Laproscopic Sterilization
• Rings
• Clips
• Bipolar diathermy
• Lazer
Tubal Ligation
Vasectomy

36
Q

Hormonal contraception

A

Iucd
Merrier method
Ntural method
Spermicide

Protocol (2 decks)

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