Gynaecology Flashcards
Definition of endometriosis
Presence of endometrial tissue outside the uterus
What is a chocolate cyst
ovarian endometrioma
frequency of endometriosis
5-10% women
Relative proportion types of cervical cancer
Squamous cell 80%
Adenocarcinoma 20%
Features of cervical cancer
Detected during screening
Abnormal vaginal bleeding:postcoital, intermenstrual or postmenopausal
Vaginal discharge
Risk factors for cervical cancwe
HPV , esp 16, 18 & 33
Smoking
HIV
Early first intervourse, many sexual partners
High parity
Low socioeconomic status
COCP
How does HPV cause cervical cancer
HPV 16 produces E6 oncogene inhibiting p53 tumour suppressor gene
HPV 18 produces E7 oncogene inhibiting Rb suppressor gene
Risks for endometrial cancer
Obesity
Nulliparity
Early menarche
Late menopause
Unopposed oestrogen
Diabetes mellitus
Tamoxifen
PCOS
Hereditary non-polyposis colorectal carcinoma
Features of endometrial cancer
postmenopausal blesding is classic. Usually initially slight and intermittent, then more heavy
Premenopausal bleeding = change in intermenstrual bleeding
Pain is not common
Vaginal discharge is unusual
Investigations for endometrial cancer
women >55 presenting with postmenopausal bleeding should be referred on suspectedcancer pathway
First line investigation is transvaginal ultrasound, if endometrial thickness <4mm then has high negative predictive value
Hysteroscopy with endometrial biopsy
Mmagement of endometrial cancer
localized disease is treated with total abdominal hysterectomy with bilateral salpingooopherectomy. If high risk may have post op radiotherapy
Progestogen therapy sometimes in frail elderly women not suitable for surgery
Risks for ovarian cancer
Family history: Mutations of BRCA1 or 2
Many ovulations: Early menarche, late menopause, nulliparity
Clinical features of ovarian cancer
abdominal distension and bloating
Abdominal and pelvic pain
Urinary symptoms, eg. urgency
Early satiety
Diarrhoea
investigations for ovarian cancer
ca125 (altho may be raised in endometriosis, menstruation, benign ovarian cysrs and other cinditions)
If raised, then urgent USS abdo and pelvis
Not for asymptomatic
Ultimately need diagnostic laparotomy
Ovarian cancer management and prognosis
Combo of surgery and platinum based chemo
85% have advanced disease at presentation
All stage 5 yr survival is 46%
Differential diagnosis for abnormal uterine bleed
(PALM CODEIN)
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulation disorder
Ovulatory dysfunction
Endometrial
Infection/iatrogenic
Not yet known
Features of adenomyosis
Multiparous women at end of reproductive years
Dysmenorrhoea
Menorrhagia
Enlarged boggy uterus
Management of adenomyosis
GnRH agonists
Hysterectomy
Causes of primary amenorrhoea
Gonadal dysgenesis (eg Turner’s syndrome)
Testicular feminisation
Congenital malformations of genital tract
Functional hypothalmic amenorrhoea (eg 2ndary to anorexia)
Secondary causes of amenorrhoea
hypothalamic amenorrhoea (eg secondary stress, excessive exercise)
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
Sheehan’s syndrome
Asherman’s syndrome
Risk factors for STIs
Multiple partners (>2 in 6 months )
Recent partner change (last 3 months)
Non use of barrier contraceptives
STI or symptoms in partner
Other or previous STI
<25 and even more if <20
Urban area
Low socio economic status
Routine STI Ix in men
first pass urine for chlamydia and gonorrhoea
Syphilis serology
HIV test (with consent)
Additional STI Ix in Men if discharge/dysuria
gram stained urethral smear with or without culture for gonorrhoea
Additional STI Ix for MSM
Pharyngeal swab for gonorrhoea (NAAT)
Rectal sample (if appropriate) for chlamydia and gonorhoeA
Hep B screening if not vaccinated
Hep C screening according to risk
STI ix in women
posterior vaginal swab for trichomoniasis
Endocervical sample for chlamydia and gonorrhoea NAAT
Syphilis serology
HIV test with consent
Additional STI Ix if symptomatic
wet prep of vaginal secretions for trichomoniasis
Gram stain for candida and BV
culture of genital secretions for candida
Perinatal transmission of chlamydia
Leads to neonatal conjunctivitis in 30-50% of exposed babies, usually in 2nd week of life.
Less commonly, pneumonitis between 4 and 12 weeks of age
Symptoms of chlamydia (F)
up to 80% asymptomatic
Menstrual irregularities (IMB, PCB)
Dysuria or pelvic pain
Vaginal discharfe
Symptoms of chlamydia M
> 50% asymptomatic
Dysuria and or urethral discharge
Signs of chlamydia F
normal
Cervictitis, mucopurulent discharge, contact bleeding
Auto inoculation (lol) may result in chlamydial conjunctivitis
Signs of chlamydia in M
normal
Meatitis
Urethral discharge
Auto innoc causing chlamydial conjunctivitis
complications of chlamydiA F
bartholinitis
Ascending infection leasing to endometritis, salpingitis, tubal damage, ectopic preg, chronic pelvic pain and infertility possible
Reiter’s syndrome
Perihepatitis (FitzHughCurtis Syndrome)
Complications of chlamydia M
epididymitis
Reiter’s syndrome
Rarely subfertility
Chlamydia diagnosis
NAAT testing, ideally female endocervical and male urine samples
Treatment of chlamydia (normal)
doxycycline 100mg bd for 7 days
Treatment chlamydia if pregnant or breastfeeding
possinle pregnancy or breast feeding: Erythromycin 500mg bd for 14 days
In pregnancy: Azithromycin 1g stat
Symptomatic vs asymptomatic gonorrhoea
85% of men w. Urethral infection develop symptoms within 10 days
Rectal infection usually asymptomatic
Pharyngeal infection usually asymptomatic
Cervical infection asymptomatic in about 70% of episodes
Signs of gonorrhoea in urethra
discharge mucoid, purulent
Meatitis
Signs of gonorrhoea in rectum
discharge
Proctitis
Signs of gonorrhoea in cervix
Cervicitis
Discharge mucoid purulent
Cervical excitation
Signs of upper genital tract infection
Signs of gonorrhoea in pharynx
exudate
Pharyngitis
Treatment of gonorrhoea
limited due to big resistance patterns, usually third Gen cephalosporin, eg ceftriaxone IM, plus second Abx eg azithromycin or doxycycline
Symptoms of gonorrhea F
Up to 50-70% asymptomatic
Pelvic pain, discharge, dysuria, dyspareunia
Symptoms of gonorrhoea M
urethral discharge in 80%
Dysuria in 50%
With or without rectal discharge or discomfort
Complications of gonorrhoea F
Ascending infection, endometritis, salpingitis, tube damage, PID
Peri hepatitis
Sexually acquired reactive arthritis
Disseminated infection: Skin, skeletL, hepatitis, meningitis, encephalitis
Complications of gonorrhoea M
epididymo orchitis
Sexually acquired reactive arthritis
Disseminated infection: Skin, skeletL, hepatitis, meningitis, encephalitis
Causes of altered vaginal discharge
candida
Bacterial vaginosis
Chlamydia and gonorrhoea (uncommon)
Trichomonal vaginalis (uncommon in UK)
Physiological or normal
Foreign body
Classic symptoms of bacterial vaginosis
discharge with malodour, no itch or vulval soreness
Treatment for bacterial vaginosis
metronidazole
Symptoms of trichomonas vaginalis
discharge with malodour, no itch or vulval soreness
Treatment of trichomonas vaginalis
metronidazole
Incubation period of HSV
7-21 days
But can be months or years post infection
Genital ulcers in HSV
Multiple painful ulcers with painful lymphadenopathy which mat be bilateral or unilateral
Takes 10-21 days to heal if untreated
HSV symptoms
Ulcers
Dysuria, urinary frequency and fenital neuropathic pain
Diagnosis of HSV
HSV PCR from lesion
Treatment of HSV
acyclovir 400mg PO TDS for 5 days
Syphilis Incubation period
9-90 days
Syphilis symptoms
solitary papule lesion, not painful.
Lymphadenopathy bibilateral and painleas
Syphilis diagnosis
serology
Multiplex PCR from lesion
Treatment syphilis
benzathine penicillin 2.4mU IM STAT
What does aciclovir actually do
symptomatic not curative’reduces viral shedding, helps ulcers heal faster and reduces duration of symptoms
Does not eradicate infection
Nine main causes of abnormal uterine bleeding
PALM COEIN
Polyps
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovarian probs eg PCOS
Endometrosis
Iatrogenic
Not yet specified
Risk factors for endometrial cancer in younger women
obesity, diabetes, nulliparity, history of PCOS, family history hereditary non polyosis colorectal cancer
When to do an endometrial biopsy
age >40
Heavy menstrual bleeding + intermenstrual bleeding
Risk fCtors for endometrial cancer
Heavy menstrual bleeding unresponsive to medical therapy (IUS or TXA)
U,trasound suggests polyp or focal endometrial thickening
If bleeding has resulted in admission
Sheehan’s syndrome
severe postpartum haemorrhage results in pituitary necrosis and can then be follow by hypopituitarism
Primary causes of amenorrhoea
constitutional delay
Anorexia nervosa
Hyperprolactinaemia
Hypo/hyperthyroidism
Adrenal tumours
Adrenal hyperplasia
PCOS
POI
Turner’s syndrome
Androgen insensitivity
Imperforate hymen
Causes of secondary amenorrhoea
non pathological: Pregnancy, lactation, menopause, drugs
Secondary:
Anorexia nervosa
Hyperprolactinaemia
Hypothyrodism
Adrenal tumours
PCOS
POI
Asherman’s syndrome
Cervical stenosis
Differentials for postcoital bleeding
cervical carcinoma
Cervical ectropion
Cervical polyps
Cervictitis
Vaginitis
Cervical ectropion
columnar epithelium of endocervix is visible around os of surface of cervix
Common finding in younger women, partic those pregnant of on COCP
Normally asymptomatic, but can occasionally cause vaginal discharge of postcoital bleeding
Can be treated with cryotherapy, but need smear first
CIN definitions
presence of atypical cells within squamous epithelium
CIN I: Atypical cells only in lower third of epithelium
CIN II: Atypical cells in lower two thirds of epithelium
CIN iii: Atypical cells full thickness of epithelium. Carcinoma in situ as no invasion through basement membrane
CIN progression
if untreated approx 1/3 with CIN ii/iii will develop cervical cancer in the next 10 years.
Colposcopy what is
cervix inspected via speculum using microscope with 10-20x magnification. Stain with 5% acetic acid, grades of CIN then have characteristic appearances
Cut off value for Ca125
35IU/ml
What to do if Ca125 is raised
Arrange pelvic and abdo ultrasound
If reveals ascites and /or peoviv or abdominal mass, refer urgently to secondary care
Surgery for ovarian cancer
total abdominal hysterectomy and bilateral salpingoopherectomy performed
If stage 1, sample retroperitoneal lymph nodes, if stage 2 then remove with block dissection
In advanced tumours,prognosis relates to success of debulking procedure, so may have more radical resection ef of bowel, spleen and peritoneal stripping.
Tissue samples also obtained to guide chemotherapy
Chemotherapy in ovarian cancer
if very early (1a or 1b), may avoid chemotherapy
1c : 6 cycles of carboplatin
Stages 2-4: Carboplatin used alone or with paclitaxel
2/3 of women whose tumours initially respond to first line Chemo relapse withiin 2 years of completion.
Palliation with gynae cancer
considering high stage at presentation prtoc for ovarian, this frequently becomes important.
MDT work
Pain control with Co analgesics eg antidepressants, steroids and cytotoxics
Nausea and vomiting affects 60% with advanced carcinoma
May have heavy vaginal bleeding in cervical/endometrial cancer. High dose progestogens may be helpful, or radiotherapy
Ascites and bowel obstruction partic frequent of advanced ovarian cancer. Drain ascites and manage obstruction at home.
Difference between lichen simplex and lichen planus
lichen simplex is a chronic inflammatory skin condition with a long history of pruritus, lichen sclerosis may also be itchy but without long past
Lichen simplex typically inflammed anid thickened, whereas sclerosis then skin is thin
Simplex: Hyper and hypopigmentation, sclerosus: Porcelain white, shiny papules, which can coalesce
Lichen simplex treated simply with enollients, moderately potent syeroids and antihistamines (to break scratcch itch cycle)
Lichen planus
common and can affect siin anywhere
Flat, popular, purplish lesions
In mouth and genital area can he erosive, and more commonly associated with pain than pruritus
Can affect all ages
Treatment w high potency steroid creams
Lichen sclerosus
possibly autoimmune basis (40% comorbid autoimmune fisease)
Severe pruritus which may be worse at night, uncontrollable scratching may cause trauma with skin bleeding and splitting
Present w discomfort, itch, pain and dyspareunia
appearance: Porcelain white papules which can coalesce and form fissures or inflammatory adhesions
Possible complications: Fusion of labia, narrowing of introitus, vulval carcinoma develop in 5%
May well need biopsy and treatment with very potent topical steroids
Vulvodynia
diagnosis of exclusion and particularly need to exclude vulval cancer and skin disease
Provoked or spontaneous vulval dysaesthesia which may be at a particular site or may be generalized
Associated with history of STIs, former use of OCP amd psychosexual disorders
Topical agents not that helpful and oral drugs eg amitriptyline and gabapentin mat be used
Vulval carcinoma
progression fromVIN, but rarely
Typically over 60s
95% squamous cell carcinomas
Present w bleeding, pruritus, discharge. Mass
Spread locally and through lymphatics (stage 3= positive nodes)
Treat: Tumour biopsy, possibly sentinel lymph node biopsy, then wide local excision with separate groin node excision, bilateral unless tumour >2cm from midline. Radio if nodes involved
>90% 5 year survival in stage 1, 40% in stages 3-4
Supportive structures for the pelvic viscera
Cervix and upper vagina supported by the cardinal and uterosacral ligaments, suspending uterus from pelvic side wall and sacrum
Mid portion of vagina attached ht endofascial condensation laterally to the pelvic side walls
Lower third if vagina supported by levator and muscles and perineal body
Cystocoele =
prolapse of upper anterior vaginal wall involving bladder, with associated prolapse of the urethra = cystourethrocoele
Apical prolapse
prolapse of uterus, cervix and upper vagina. If uterus has been removed, the vault of the vagina can itself prolapse
Rectocoele
prolapse of the lower posterior wall of the vagina involving the anterior wall of the rectum
Grading prolapse
Essentially done by extent to which leaves vaginal with and without straining.
Baden-Walker is one classification
Remember that it is incredibly frequent, but only 10-20% seek medical attention, and anatomical descent is not necessarily associated with symptom severity
Causes of prolapse
vaginal delivery (partic if multiple, large infants, prolonged second stage and instrumental delivery)
Pregnancy
Abnormal collagen eg Ehlers Danlos
Menopause
Increased intra abdominal pressire: Obesity, chronic cough, constipation, heavy lifting
Pelvic surgery
Prolapse history
often asymptomatic
Dragging sensation, or sensation of a lump - worse at the end of the day or after prolonged standing
Interference with intercourse, may have bleeding or discharge
Urinary frequency and incomplete bladder emptyng with cystocoele, stress incontinence
Rectocoele occaisonally causes difficulty with defecating
Sometimes patient finds that manually reducing the prolapse allows them to pass urine/etool
Examination for prolapse
Abdo examination to exclude pelvic mass
Smaller prolapse will need speculum exam - Sims speculum allows inspection of anterior and posterior vaginal walls, and patient Can be asked to bear down
Stress incontinence: Reduce prolapse and ask patient to cough
Conservative management for prolapse
pelvic floor exercises
Weight reduction
Treat chest problems incl dmoking (avoid cough)
Pessaries: Many shapes and sizes, changed every 6 months and probably with topical oestrogen to prevent vaginal ulceration. Can have sex with ring pessary in
Surgical treatment for prolapse
hysteropexy or vaginal hysterectomy for uterine prolapse
Repair anteriorly or posteriorly for cystocoele and tectocoele
Sacrospinous fixation or sacrocolpopexy for vault prolapse
Tension free taoe or transobturator taoe are procedures for stress incontinence
Urinary stress incontinence definition and fearures
involuntary leaking of urine on effort or exertion, or on sneezing or coughing
Confirmed on urodynamic testing
Aetiology: Childbirth and menopause, basically bladder neck slips below pelvic floor such that not compressed and leakage with “stress” of raised intrabdominal pressure
Urine diostick and diary also helpful
Frequently accompanied by prolapse
Urinary stress incontinence treatment options
weight loss and manage chronic cough (smoking)
Pelvic floor training for at least 3 months led by. Physio
Vaginal cones or sponges
Drugs: Duloxetine (SNRI), but SE of nausea, dyspepsia, dry mouth and insomnia
Surgery if conservative measures have failed, tension free vaginal tape is gold standard, good success rates but nit necessarily long term.
Overactive bladder definition
urgency with or without urge incontinence, usually with frequency or nocturri nd in the absence of a proven infection.
Symptoms suggest detrusor overactivity where contracts during bladder filling phase in urodynamic studies
Most commonly idiopathic, occasionally with underlying neurology eg MS or spinal cord injury
Urgency and leaking, spontaneously or with provocation
Investigation and management of overactive bladder
urinary diary show frequent passage of small volumes of urine, particularly at night
Cystometry may show detrusor contractions on filling or provocation, but fystometrt not generally done.
Simple advice: Reduce fluid intake, partic of caffeinated prodfuts and fizzy drinks,
Bladder training: Education, timed voiding with delay in voiding, positive reinforcement
Drugs: Anticholinergics to suppress detrusor overactivity, sympathomimetics (mirabegron) as antispasmodic, oestrogens often useful and finally Botox injection into detrusor muscle
Contributors to subfertility (by %)
ovulatory 30%
Male problems 25%
Tubal problems 28%
Coital problems 5%
Cervical problem <5%
Unexplained 30%
Definition of subfertile
couple not conceived after a year of regular unprotected intercourse
Normal semen analysis
volume >1.5ml
Sperm count >15million/ml
Progressive motility >32%
Investigations for detection of ovulation
Elevated progesterone 7 days before menstruation = indicative that ovulation has occurred
Ultrasound scans to serially monitor follicular growth and then fall in size of ccorpus outeum, but this is a bit too time consuming
Lutenising hormon based urine predictor kits can be bough over the counter
Investigations for anovulation
FSH (incr in ovarian failure, decr in hypothalamic disease, normal in PCOS)
AMH (anti mullerian hormone) (high in PCOS, low in ovarian failure)
Prolactin (exclude prolactinoma)
TSH
Serum testosterone levels (androgen secreting tumour or congenital adrenal hyperplasia if raised)
LH (often raised in PCOS but not diagnostic)
TVUSS for polycystic ovaries
Screen for diabetes and abnormal lipids if obese
Definition of PCOS
2 out of 3 of:
characteristic transvaginal appearance of 12+ follicles in an enlarged (>10ml) ovary
+ irregular periods (>35 days apart)
+ hirsutism, clinically (acne or excess body hair), and or biochemically (raised serum testosterone)
Symptoms which might present for PCOS
Obesity
Acne
Hirsutism
Oligo/amenorrhoea
More frequent miscarriage
Treatment for PCOS
Symptomatic generally
Weight loss and exercise
COCP will regulate menstruation and hirsutism (3-4 bleeds per year important to protect endometrium)
Antiandrogens for hirsutism: Cyproterone acetate or spironolactone )- but must avoid conception
Metformin: Effective for hirsutism and also effective at reinstating ovulation if BMI >30
Clomifene: Ovulation induction drug
Clomifene
first line drug for infuction of ovulation
Acts as anti oestrogen in hypothalamus and pituitary, so incr release of LH and FSH, initiating follicular maturation when given day 2-6 of cycle
Limited to 6 months use
70% ovulation success, but only 40% birth rate (potentially as causes thinning of endometrium)
Needs to be monitored with TVUSS to see if at effective dose.
Can be used in conjunction with metformin
laporoscopic ovarian diathermy
as effective as gonadotrophins and lowernmultiple pregnancy rate
Each ovary is monopolar diathermised at a few points for a few seconds, may then have much more regular ovulations
Risks: Periovarian adhesion formation, rarely ovarian failure
Gonadotrophin induction of ovulation
Used if first line treatments have failed, or in hypothalamic hypogonadism
Recombinant or purified urinary FSH +/-LH is given daily SC, to stimulate follicular growth
Given in low dose step up regime to keep multiple pregnancy rate to <10%
Follicular development monitored with USS, and once reached adequate size, ovulation can he artificuiaolt stimulated by injection of bHCG or recombinant LH
Side effects of ovulation induction
multiple pregnancy
Ovarian hyoerstimulation syndrome: Follicles can get very large and painful, esp if <35 and polycystic ovaries, and with IVF. Can be really severe
Ovarian and breast carcinoma - evidence so far reassuring about risk
Pelvic inflammatory disease and fertility
causes adhesion formation in fallopian tubes
12% will be infertile after one episode
Most women will have had no symptoms, but may have history of pelvic pain, abnormal discharge or abnormal menstruation
If peritubal adhesions or closed fimbrial ends but otherwise healthy then can do lap adhesiolysisnand salpingostomy
If tube damaged proximally to fimbrial emnds, suxcess rare poor and IVF likely indicated
Hormonal contraception with breast cancer
absolute contraindication
Time until progesterone only pill effective
48h
Restarting hormonal contracep after emergency contraception
can restart immediately with levonergestrel
Ulipristal acetate:wait 5 days
What is endometrial hyperplasia
Abnormal proliferation of endometrium excess to normal in menstrual cycle
Eg simple, complex, simple atypical, complex atypical
For example “incr gland to stroma ratio with some nuclear atypia”
Frequently presents with abnormal bleeding eg intermenstrual
Management of endometrial hyperplasia
Simple and without atypia -> high dose progestogens and repeat sampke in 3-4 months. Can use levonorgestrel IUS
Any atypia: Hysterectomy advised due to risk of malignant progression. If postmenopausal, should do bilateral salpingo-oopherectomy at the same rime due to risk of ovarian malignancy if not.
COCP and cancer
Increased risk of breast and cervical cancer
Protective against ovarian and endometrial cancer
Advantage s of COCP
effective contraception
Doesn’t interfere with sex
Reversible on stopping
Periods normally regular, lighter and less painful
Reduced risk of ovarian and endometrial cancer
Reduced risk colorectal fancer
may protect against PID
May reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of COCP
Must remember to take every day
No protection against STIs
Incr VTE risk
Incr risk breast and cervical cancwe
Incr risk stroke and ischaemic heart disease (especially in smokers)
Temporary headChe, nausea, breast tenderness
Expectant Management of ectopic pregnancy if,,,
Size <35mm
Unruptured
Asymptomatic
No fetal heartbeat
HCG <1000
Compatible if another intrauterine pregnancy
What is expectant management of ectopic pregnancy
closely monitor over 48h, and if B HCG levels rise again or become symptomatic then need to intervene
What is expectant management of ectopic pregnancy
closely monitor over 48h, and if B HCG levels rise again or become symptomatic then need to intervene
Medical management of ectopic preg
give methotrexate and follow up
When to do medical management of ectopic pregnancy
Size <35mm
Unruptured
No significant pain
No fetal heart beat
HCG <1500
Not if simultaneous intrauterine pregnancy
Surgical management of ectopic pregnancy options
Salpingectomy: For women with no other factors for infertility
Salpingotomy to be considered with risks eg contralateral tube damage. About 20% need further treatment (methotrexate and/or salpingotomy)
When to do surgical management of ectopic pregnancy
size >35mm
Can be ruptured
Pain
Visible fetal heartbeat
HCG >5000
Compatible with a other intrauterine pregnanct
Cyst appearances most likely malignant
irregular, solid tumour
Ascites
At least four papillary structures
Irregular multilocular solid tumour with largest diameter >100mm
Very strong blood flow
Expectant management of msicrriafe
wait 7-14 days for it to complete spontaneously
If not done at this point then mat need medical or surgical management
Not acceptable to managemiscarriage conservatively if..
increased risk of haemorrhage: Later first trimester , coagulopathies, unable to have blood transfusion
Previous adverse and or traumatic experience associated with pregnancy
Evidence of infection
Medical management of miscarriage
Vaginal misoprostol (prostaglandin analogue, stimulates myometrium to contract, expelling tissue)
Does not need to be accompanied by oral mifepristone
Contact Doc if bleeding not started in 24h
Also give some antiemetic and pain relief
Surgical management of miscarriage
vacuum aspiration under local anesthetic or surgical management in theater under general anesthetic
Legal proceedings around TOP
Two registered medical practitioners must sign a legal document (only one in an emergency)
And only registered medical practitioner can perform which must be in NHS hospital or licensed premise
Prior to 24 weeks , and that continuation if oregnancy would involve risk greater than if terminated and injury to physical or mental health of woman or any existing children
AntiD and TOP
antoD prophylaxis should be given to women who are resus D negative and having an abortion after 10+0 weeks gestation
Medical TOP options
mifepristone (an anti progesterone) can be given followed 48h later by prostaglandins (eg misoprostol) to stimulate uterine contractions = similar to mimicking a miscarriage
Takes hours to dats to complete and the timing may not be predictable
Pregnancy test in 2 weeks to detect reduced level of hCG (not just positive or negative)
Surgical TOP options
cervical priming with misoprostol +/- mifepristone is used before procedures
May have local anesthesia alone, sedation with local anaesthesia, deep sedation or general anesthesia
Options: Vacuum aspiration, electrical vacuum aspiration and dilation and evacuation
Following procedure, intrauterine contraceptive can be immediately inserted
Choice of procedure for TOP
can choose between medical or surgical jp to and including 23+6 weeks gestation
Patient decision aids given for informed decision making
After 9 weeks medical abortions less common, as msy see products of conception pass and decreased success rate
Before 10 weeks, medical are usually done at home
