gynaecology Flashcards

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1
Q

Pregnancy advice after previous puerperium DVT

A
  • increased risk of 20% for DVT in next pregnancy
  • avoid oral contraception
  • subsequent pregnancies should be managed in consultation with haematologist / specialist physician and obstetrician
  • SCREEN for clotting propensity (thrombophilia screen) prior to next pregnancy: anticardiolipin antibody, lupus anticoagulant, protein S, protein C, anti-thrombin 3, factor V Leiden,
  • if thrombophilia screen positive anticoagulants throughout pregnancy and puerperium.
  • if no thrombophilia and no longer on anticoagulants can choose for only anticoagulants in puerperium ( until 4-6 weeks postpartum) or start in gestation week 14
  • choose heparin or enoxaparin BD, followed by warfarin postpartum
  • no warfarin as 5% teratogenic in 1e trimester and increased miscarriage rate, feral and maternal haemorrhage, neurological problems and stillbirth.
  • avoid immobilisation, consider compression stockings,
  • deliver in controlled manner at 38- 39 weeks, hold morning dose and start induction, restart after delivery.
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2
Q

Fundus greater than date

A
  • multiple pregnancy
  • macrosomic (maternal diabetes, maternal obesity, excessive weight gain)
  • uterine fibroids
  • polyhydramnios (fetal malformation CNS, GI, abdo wall, elsewhere; infection with CMV or toxo) (chorioangioma placenta)
  • Can lead to malpresentation, PROM, premature labour, placental abruptio)
  • see specialist in few days
  • warn to present if thinks in labour even if early,
  • speculum so see cervix may be indicated
  • consider profylactic steroids for resp distress
  • rule out diabetes even if glucose challange was negative
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3
Q

Post partum heamorrhage causes

A
  • 80% uterine atony
  • retained placenta
  • abnormal placenta attachment
  • coagulopathy
  • genital tract laceration (vagina, cervix, uterine rupture)
  • inversion uterus during (traction) placental delivery
  • ‘HELLP’
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4
Q

Post partum heamorrhage work-up

A
  • iv canula
  • cross match
  • LFT’s (HELLP), coags, EUC/creat/lactate consider for severe shock
  • speculum examination
  • US +/- CT after initial treatment
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5
Q

Post Partum heamorrhage management

A
ABC FIRST 
- iv line, cross match see work-up
- N saline rapid infussion
- O2
TONE:
- massage fundus
- ergometrine/oxytocin
- urine urethral catheter to empty bladder
- manually remove cloths / tissue
LACERATION: 
- speculum examination
- suture or pack
Coagulopathy:
- FFP, thrombo's CALL HEAMATO
If ongoing bleeding --> theatre inspection under general
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6
Q

Alcohol abuse in pregnancy, complications

A

ALCHOHOL:

  • miscarriage
  • intra uterine growth restriction
  • Fetal alcohol syndrome (: growth restriction, facial skeletal and cardiovascular defects, neurological dysfunctions (intellectual, behavioral, emotional, failure to thrive resulting in death)
  • premature birth

–> refer to obstetrician, counsel, support etc, ensure every drink less is no further harm.

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7
Q

smoking in pregnancy, complications

A

one of worst correctable risk factors for adverse pregnancy outcomes nicotine and tar –> hypoxia, vasoconstriction, increased thickness villous membrane, decreased intervillous perfusion, carboxyhaemoglobin formation

  • miscarriage (2x normal)
  • Intra Uterine Growth Restiction
  • placenta previa
  • abruptio placentae
  • PROM
  • preterm birth
  • chorioamnionitis
  • still birth
  • perinatal morbidity and mortality
  • baby: anencephaly, congenital heart defects, orofacial clefts, SIDS, growth and intelect deficiencies, behavioural problems, respiratory (like pneumonia and asthma), ear infections

Avoid nicotine patches as toxic for fetus! Invole partner, counsel, support, inform etc. Every cigarette not smoked is no furhter harm, refer to obstetrician

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8
Q

Trophic vaginitis invx and management

A

vaginal dryness due to thinning or shrinking of mucosal tissue and decreased lubrication leading to chronic inflammation susceptible for infection, can have discharge or even blood stained discharge.

invx;

  • pap smear
  • MC&S swab
  • transvaginal US to rule out endometrial cancer
  • endometrial curettage or biopsy (consider after above)
  • hormone levels to confirm menopause optional.

management:

  • local oestrogen (pessaries, rings, cream, tablet)
  • lubricants/moisurizing creams can work hours to one day
  • water suluble vaginal lubricant during intercourse (not oil or petroleum based as may damage condom or increase infection change)
  • avoid scented soaps, lotions or douches
  • consider HRT if other menopause symptoms but inform of risks
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9
Q

fetal intra-uterine death definition and causes

A
< 20 weeks: spontaneous abortion
> 20 weeks stillbirth
most common causes in Australia:
- unexplained 24%
- maternal disease 17% (infection, PROM, early labour, coagulopathy, poor controlled glycaemia, antibodies, TFT)
- major fetal anomaly 15%
- multiple pregnancy 11%
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10
Q

still birth management

A

EMPATHY!!!
Delivery:
- give women choise of delivery or await spontaneous labour (max 3 weeks for risk of consumptive coagulopathy, often adviced earlier for emotional trauma)
- 3th trimester: oxytocin iv with or without cervical ripening with misoprostol
- 2nd trimester: Prostaglandin (eg misoprostol) vaginally
- <18 weeks D &C (ideally only to 16 weeks)

refer for counseling or peer support, let them hold baby as long as they want, suggest foto’s or lock’s of hair

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11
Q

still birth investigations

A
  • photo’s of baby and placenta
  • cord blood testing
  • pathology and microbiology of placenta and cord
  • Autopsy (if consent)
  • Kleihauer test for meassuring fetomaternal haemorrhage
  • urine toxicology
  • FBE, LFT
  • Coags + coagulation screen
  • syphilis
  • fasting glucose
  • blood antibody screen
  • TFT
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12
Q

Gestational diabetes management and diagnosis

A

fasting suger > 5.5, 2 hour level >8.0

  • refer to (or consult with if remote) diabetiv physician
  • first try with diet to control BGL <7.0 during the day, if not possible add insulin.
  • 3-4 times/day BGL esp 2 hours after meal
  • US at 32-34 weeks and SC if macrosomnic
  • Weekly CTG, twice weekly if on insuline from 32-34 weeks (stillbirth risk)
  • deliver no later than due date
  • regular BGL during delivery
  • check GTT every 5 years
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13
Q

primary amenorrhoea causes

A

to be included

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13
Q

Gestational diabetes risks

A
  • DM later in live (counsel) (30%)
  • Macrosomia
  • fetal death in-utero
  • Hyaline membrane disease (steroid can help lung development but worsens GD)
  • pre-eclampsia
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14
Q

primary amenorrhoea investigation

A
  • vulval inspection (no speculum if not sexually active) and tanner stage of breast and hair growth
  • ultrasound: uterus and vagina
  • hormones: FSH, LH, prolactin, oestradiol

if all is normal, review again in 12 months according to AMC clinical guide (i would do 6 months)

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15
Q

Breech

A
  • no rotation when contractions have started
  • general recommendation is SC as it is associated with less risk for the baby, however a women should be allowed a trail delivery if: baby is normal size (2.5-4kg, normal pelvic proportions (us or previous uncomplicated delivery), complete breech (crossed legs) or breech with extended legs. Not for frank breech (legs streched in front of face) or incomplete breech (one leg frank, one leg complete) or with extended head
  • +/- 4% is breech
  • if vaginal CTG throughout delivery
  • deliver in hospital in controlled fasion
  • more change cord prolapse
  • even more care with co-morbodity
16
Q

threatened miscarriage (exam, invx, managmant)

A
# ask if regular, breast tenderness etc as signs of ongoing pregnancy, amount and duration blood loss, pain, fam hx, etc
# CVS including orthostatic hypotension and cap refill, pelvic exam (cervix, presence of blood), adnexa masses, tender/guarding abdomen.
# bed side pregnancy test, blood group plus resus status, urine test for infection, US to exclude ectopic, location of sac (placenta previa etc), viability of pregnancy, can do indirect coombs tests
# if US normal 90-95% proceed with normal pregnancy, before US results 50% proceed  with normal pregnancy, if abortion ANTI-D if rh negative!!!
17
Q

2nd amenorrhoea in OCP

A
  • likely progestagen induced, if no other symptoms in exam (and slow reduction of blood loss during perdiods)
  • reassure patient, fertility not affected
  • Pregnancy test to exclude pregnancy
  • switch to pill with higher oestrogen microgynon 50 eg, or triphasic pill. Can also use alternative method for a while and await return periods. If not returning further invx!
18
Q

GBS colonisation

A
  • 10-15 % pregnant women positive
  • 40-50% colonisation of baby following vaginal delivery
  • 1% of babies become infected, often very quick and severe
  • unable/hard to eliminate colonisation –> not recommended
  • Iv antibiotics on commencing labour or in ROM
  • optional to treat babies iv, if high risk (eg prolonged labour/ROM, other stress) than always treat!\
  • Use penicillin,if allergy erythromycin
  • routine screen at 34-36 weeks
19
Q

DM in pregnancy

A
  • Pre-pregnancy: screen for end-organ damage, HbA1c, keep track of sugars, refer to diabetes physician and opthalmologist, 24 hour urine for protein
  • in first trimester keep sugars 5-7 to reduce risk of fetal malformations
  • when pregnant referral to obstetrician
  • increased insulin requirement during pregnancy, returns to pre-pregnancy requirement in 24 hours of delivery
  • US at 12, 18 and 32 weeks (first two to screen for abnormalities, last for macrosomia)
  • risks: unexplained fetal death, macrosomia, pre-eclampsia, polyhydramnios, respiratory distress post delivery,
20
Q

Basic antenatal care: pre-conception

A
  • Folic acid at 3 months prior to conception (1 month miniamal), continue 12 weeks post post conception
  • cease alcohol and smoking, regular exercise, healthy diet
  • listeria infection: fetal mortality 30-50 %: avoid unpasteurised dairy products, soft cheeses, cold meats, raw seafood, chilled ready to eat food, take-away foods
  • general exam including CV, urine analysis and pap-smear
  • Rubella serology, if vaccination required do this 3 months prior to conception
  • ## other vaccinations to consider: DTP (boostrix), MMR, varicella, influenza
21
Q

Basic Antenatal care: First visit and subsequent invx

A
  • B-HCG blood and urine
  • menstrual and obstetric history
  • > 37 years: consider combined screening test
    # explain what test are to follow, when and how often to see GP
  • initial visit 8-10 weeks
  • up to 28 weeks every 4-6 weeks
  • up to 36 weeks every 2 weeks
  • > 36 weeks: weekly
  • in each visit check BP, urineanalysis, fundal height, weight, fetal heart, position, oedema
  • US at 18-20 weeks

blood test first visit:

  • FBE, ferritin
  • bloodgroup, Rh, and antibodies
  • Rubella antibody status,
  • PAP
  • HBC, HebB, HebC status, syphilis
  • discuss first trimester combined screening

Subsequent investigations

  • 28 weeks GTT if abnormal OGTT
  • 34 weeks: antiD immuogobulin for Rh-negative women
  • 36 weeks FBC & Group B streptococcus swab

weight gain: 3 kg in first half, than 0.5 kg per week until 36 weeks

22
Q

Antenatal screening for higher risk groups (previous malformations, older women etc)

A

First trimester combined screening

  • 9-13 weeks, ideally at 10 weeks
  • Serology: Free B-HG and PAPP-A
  • Nuchal translucency US

risk 30 yrs 1/626, 35 1/274, 40 1/68, 45 1/20
high risk =/> 1/250, offer amniocentesis or chorionic villus sampling
- amniocentesis: 1:200 miscarriage
- chorionic villus sampling 1:100 miscarriage

second trimester: 14-20 weeks

  • neural tube defect, abdominal wall defect, Down syndrome (but less accurate than in first trimester)
  • Serology: alpha-foetoprotein, oetriol, free B-HCG, inhibin A
  • US (part of normal screening protocol)