Gynaecology Flashcards
What is used in the medical management of miscarriage?
Vaginal misoprostol
Bleeding should start within 24 hours
NOTE: also give antiemetics and analgesia for the symptoms
What is the surgical management option for miscarriage?
Manual vacuum aspiration
NOTE: surgical management of miscarriage requires anti-D in RhD-negative patients
Which tests should be requested in a patient with recurrent miscarriage?
Antiphospholipid antibodies (anticardiolipin and lupus anticoagulant)
Cytogenetics (products of conceptions or both partners)
Ultrasound scan for structural anomalies
Screen for thrombophilia (e.g. factor V Leiden)
How is antiphospholipid syndrome in pregnancy treated to reduce risk of miscarriage?
Low-dose aspirin + LMWH
What conditions need to be fulfilled for expectant management of ectopic pregnancy?
Size < 30 mm Asymptomatic No foetal heartbeat Serum hCG < 200 IU/L and declining Expectant management involves taking serial serum hCG measurements until the levels are undetectable
What is the medical management of ectopic pregnancy and what conditions need to be fulfilled for this option?
IM Methotrexate
• No significant pain
• Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
• Serum -hCG < 1500 iU/L
• No intrauterine pregnancy (confirmed by USS)
How should a patient be followed-up after medical management of ectopic pregnancy?
2 serum hCG measurements on days 4 and 7
1 serum hCG measurement every week until negative
Don’t have sex during treatment
Don’t conceive for 3 months after treatment
Avoid alcohol and prolonged sun exposure
What conditions need to be fulfilled to consider surgical management of ectopic pregnancy?
- Significant pain
- Adnexal mass > 35 mm
- Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
- Serum b-HCG > 5000 iU/L
Describe the follow-up after salpingectomy and salpingotomy.
Salpingectomy - urine pregnancy test at 3 weeks
Salpingotomy - 1 serum hCG per week until negative
Is anti-D required after ectopic pregnancy or miscarriage?
Only if they were managed surgically
NOTE: also required for all cases of molar pregnancy
What is the first line management option for molar pregnancy?
Suction curettage
NOTE: methotrexate may be used as chemotherapy
What advice should be given to women who have had a molar pregnancy?
If receiving chemotherapy, do not get pregnant for 1 year
Do not conceive until follow-up is complete
COCP and IUD can be used once hCG has normalised
Which investigations should be used in secondary amenorrhoea?
o Urinary or serum hCG (exclude pregnancy)
o Gonadotrophins (low indicates hypothalamic cause, high indicates ovarian cause)
o Prolactin
o Androgen (high in PCOS)
o Oestradiol
o TFTs
What are the Rotterdam criteria for PCOS?
Oligo/anovulation
Clinical or biochemical hyperandrogenism
Polycystic ovaries on ultrasound
How should PMS be investigated?
Symptom diary for 2 cycles
What are some medical management options for PMS?
COCP
Transdermal oestrogen
GnRH analogues (if severe)
SSRI (if severe)
Conservative: stress reduction, alcohol and caffeine reduction, exercise
Which investigation should be performed in all women with heavy menstrual bleeding?
FBC
What are the management options for menorrhagia of no known cause or menorrhagia caused by < 3 cm fibroids or adenomyosis?
1st line: LNG-IUS 2nd line non-hormonal: • Tranexamic acid • NSAIDs (e.g. mefenamic acid) 2nd line hormonal: • COCP • Cyclical oral progestogens Surgical: • Endometrial ablation • Hysterectomy
What are some medical management options for menorrhagia caused by fibroids > 3 cm?
Non-Hormonal: tranexamic acid, NSAIDs
Hormonal: Ulipristal acetate, LNG-IUS, COCP and cyclical oral progestogens
NOTE: ulipristal acetate carries a risk of liver injury
What are some surgical management options for fibroids > 3 cm?
Transcervical resection of fibroid (for submucosal)
Myomectomy
Uterine artery embolisation
Hysterectomy
What are the 1st and 2nd line management options for dysmenorrhoea?
1st line: NSAIDs
2nd line: COCP
What are the three forms of emergency contraception and what is the window for taking them after UPSI?
Levonorgestral (Levonelle) - 72 hours
Ulipristal Acetate (EllaOne) - 120 hours
Copper IUD - 120 hours
NOTE: levonorgestrel and ulipristal should NOT be taken together, but both can be used more than once in a single cycle
How long after taking emergency contraception must it be repeated if the patient vomits?
2 hours
What are the main side-effects and risks of the COCP?
Side-Effects: headache, nausea, breast tenderness
Risks: VTE, breast and cervical cancer, stroke, ischaemic heart disease
How do periods tend to change with the COCP?
Usually makes periods regular, lighter and less painful
How long before an elective operation should the COCP be stopped?
4 weeks
How should a patient on the COCP who has missed 1 pill be counselled?
Take last pill
How should a patient on the COCP who has missed 2 pills be managed?
- Use condoms until pill has been taken correctly for 7 days in a row
- 2 Missed in Week 1: consider emergency contraception
- 2 Missed in Week 2: no need for emergency contraception
- 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break
Aside from emergency contraception, what else should be offered to women coming in asking for emergency contraception?
STI screen
Long-acting contraception
NOTE: this should be discussed with all TOP patients as well
Describe how progesterone-only pills should be taken.
1 pill at the same time every day with no pill-free week
Which POP has longer leeway with regards to taking the next dose?
Cerazette (desorgestrel) - 12 hours
How should you advice a patient who is >12 hours late to take her cerazette?
Take the missed pill ASAP and continue with the rest of the pack
Use extra precautions (condoms) until pill taking has been re-established for 48 hours
What is the main side-effect associated with POPs?
Irregular menstrual bleeding
Describe how the combined hormonal transdermal patch should be used?
Apply patch for 3 weeks (replacing at the end of every week)
Take 1 week off (withdrawal bleed)
What benefit does the transdermal patch have over the COCP?
No increased risk of clots
Describe how the combined hormonal ring is used.
Worn vaginally for 21 days followed by a 7-day hormone-free period
How long does the mirena last?
3 or 5 years
How do periods tend to change with mirena?
They become lighter and less painful
List some side-effects of mirena.
Acne
Breast tenderness
Mood disturbance
Headache
What is Jaydess?
Smaller form of LNG-IUS that is effective for contraception but not for treating heavy periods
Lasts 2 years
Easier to put in
How long does nexplanon last?
3 years
How long does depo-provera last?
12 weeks
What are some important side-effects of depo-provera?
Weight gain (only form of contraception with proven link) May take up to 6-12 months for fertility to return
How long does the copper coil last?
5 or 10 years
What are some side-effects of the copper coil?
Heavy, painful periods
Expulsion
Infection
How long do all LARCs take to be effective?
1 week
Except copper coil
How is female sterilisation performed at laparoscopy?
Occlude Fallopian tubes with Filshie clips
What advice should be given to women who have had a laparoscopic sterilisation?
Additional contraception should be used until the first period after the procedure
What is hysteroscopic sterilisation?
Insert expanding springs into the tubal ostia via a hysteroscope
This induces fibrosis over 3 months
Additional contraception should be used during this time
Which drugs are used in the medical termination of pregnancy?
Mifepristone
Misoprostol (after 48 hours)
NOTE: pain relief should also be provided
Where should medical TOP take place?
< 9 weeks = can be done at home if easy access to follow-up, perform urine pregnancy test after 3 weeks
> 9 weeks = done in clinical setting (higher risk of bleeding/discomfort), repeated misoprostol may be needed every 3 hours
What extra treatment may be required in TOP over 21 weeks?
Intracardiac KCl injection (feticide)
What are the surgical management options for TOP?
Vacuum aspiration (< 15 weeks) Dilatation and Evacuation (D&E) > 15 weeks
What additional management should you discuss with all TOP patients?
Long-acting reversible contraception (copper IUD, mirena, nexplanon)
How many doctors need to sign a form to agree to TOP?
2
Which investigations should you request for subfertility?
Blood hormone profile (FSH, LH, oestrogen, AMH, mid-luteal progesterone) TFTs Prolactin Testosterone STI screen TVUSS (antral follicle count) Semen analysis (2 tests 3 months apart)
Which tests are used to assess ovarian reserve?
Anti-Mullerian hormone (AMH)
Antral follicle count (AFC)
How can tubal patency be assessed?
Hysterosalpingography (HSG) either by X-ray or ultrasound (HyCoSy)
Laparoscopy and dye (lap and dye)
List some medical management options for subfertility.
Ovarian induction (clomiphene)
Intrauterine insemination
Donor insemination
IVF
List some surgical management options for subfertility.
Treat anatomical disease (e.g. adhesions, endometriosis, cyst)
Myomectomy (if fibroids)
Tubal surgery
Laparoscopic ovarian drilling (PCOS)
What is cyclical HRT?
Either 1 monthly or 3 monthly
Take oestrogen every day
Take progesterone for last 14 days of time period (during which withdrawal bleed will happen)
What is continuous HRT?
Take oestrogen and progesterone every day
Which patient groups are cyclical and continuous HRT recommended for?
Cyclical - perimenopausal
Continuous - postmenopausal
What are the possible routes of administration of HRT?
Oral
Transdermal
Vaginal (if predominantly vaginal symptoms)
NOTE: transdermal HRT will avoid hepatic metabolism so isn’t associated with VTE/cardiovascular risks
What are the main benefits of HRT?
Improved vasomotor symptoms
Reduced risk of osteoporosis
Improved genital tract symptoms
What are the main side-effects and risks of HRT?
Side-Effects: breast tenderness, headaches, mood swings, fluid retention
Risks: breast cancer, cardiovascular disease, VTE
NOTE: cardiovascular risk is decreased in younger women and increased in older women
List some absolute contraindications for HRT.
Pregnancy Breast cancer Endometrial cancer Uncontrolled HTN Current VTE Thrombophilia
List some non-hormonal treatments for menopause.
Alpha agonists (clonidine)
Beta-blockers (propanolol)
SSRIs (fluoxetine)
Symptomatic: lubricants, osteoporosis treatments
What investigation is used to diagnose premature ovarian insufficiency?
2 x FSH results > 30 IU/L
How should the osteoporosis be managed in patients with premature ovarian insufficiency?
Regular DEXA scans every few years
All patients should be recommended HRT
Which lifestyle measures could help lessen the symptoms of menopause?
Regular exercise
Weight loss
Reduce stress
Sleep hygiene
How is bacterial vaginosis treated?
Metronidazole
Alternative: clindamycin
How is vulvovaginal candidiasis treated?
Intravaginal/pessary clotrimazole (canestan duo)
Alternative: oral antifungal (fluconazole)
Pregnancy: topical treatments ONLY
How is trichomonas vaginalis treated?
Metronidazole
IMPORTANT: male contacts will also need treatment as this is an STI
How is chlamydia managed?
Doxycycline or azithromycin
Contact tracing and treatment
How is gonorrhoea managed?
IM ceftriaxone 1 g
With single dose oral azithromycin and doxycycline
Which tests should be done in a patient with PID?
Test for chlamydia and gonorrhoea (swabs)
Which antibiotic regimen is recommended for PID?
Ceftriaxone 500 mg IM
Doxycycline 100 mg BD for 14 days
Metronidazole 400 mg BD for 14 days
Alternative: ofloxacin + metronidazole
How should sexual contacts of someone with PID be treated?
Single dose azithromycin 1 g
List some investigations that may be used in syphilis.
Dark field microscopy or PCR
Non-treponemal: rapid plasma reagin (RPR) or VDRL
Treponemal: EIA, treponema pallidum particle or haemagglutination assay (TPPA/TPHA)