GYNECOLOGY Flashcards
Menstrual physiology:
amenorrea dx algo
BREAST + UTERUS +
BREAST + UTERUS -
Differentiate because pubic and axilary hair are absent
breast - uterus +
A) Gonadal Dysgenesis (Turner syndrome) 45,X0 (missing x on 23 par)
Short stature ,ovarian insufficiency
Instead of developing ovaries they have streak gonads.
**Fsh levels elevated because of ** no feedback inhibition from estrogen to the pituitary.
Treatment: Estrogen and progesterone replacement.
B)Hypothalamic –Pituitary Failure :Kallman Syndrome: Inability of Hypothalamus to produce Gnrh and also anosmia because the defect is close to olfactory area.
FSH levels are low
Treatment: Estrogen and progesterone replacement for secondary sexual characteristics. *(also known as hypothalamic hypogonadism, familial hypogonadism with anosmia, or hypogonadotropic hypogonadism)
kallman = inherited condition, meaning it ispassed on from parents to their children. Mothers can passon the gene to their daughters and sons, but fathers can usually only pass it onto their daughters. The condition is five times more common in boys (one boy in every 10,000) than in girls.
Secondary amenorrhea:
3 main causes:
Secondary amenorreah managment ?
1.First Step is to rule out Pregnancy through **Beta Hcg **.
Next step:??
2.Thyrotropin TSH:Hypothyroidism can lead to amenorrhea by elevating TRH that in turns elevates prolactin.Treatment:Thyroid replacement
3.Prolactin Level:Elevated prolactin level leads to amenorrhea through Gnrh.
- Medications:Anti psychotics and anti depressants have anti dopamine effect.
- Tumor: Pituitary Tumor and idiopathic.
- Hint:Dopamineand prolactin are inversely related
4 .** Progesterone Challenge** Test: PCT:
Administer a single dose of I/M progesterone or 7 days of oral medroxy-progesterone acetate.(MPA)
-Positive PCT: Withdrawl bleeding is diagnostic of anovulation.
-Negative PCT:reasons may be inadequate Estrogen or outflow tract obstruction.
5. Estrogen-Progesterone Challenge test: EPCT: **
- 21 days of oral estrogen followed by 7 days of MPA> Positive EPCT:
- Withdrawal bleed positive means inadequate estrogen.
- Etiology ?
- FSH?
- ●Low** FSH = CNS Pathology
- ●High FSH = Ovarian Failure .There can be two causes of Premature Ovarian failure:
- 1. X Chromosome Mosaicism:Premature ovarian failure (POF, OMIM 311360) is defined as the cessation of ovarian function before the age of 40, associated with elevated gonadotropins serum levels **(FSH ≥ 40 UI/l) **and affects at least 1%–3% of women of reproductive age,X chromosome can have multiple kind of defects during ageing in these people like deletions,tranlocations etc…
2.Savage Syndrome:
-1.Ovaries have follicles are present but don’t response to GNRH impulses
-2.Resistant ovary syndrome isone of the disease lead to ovarian failure and secondary amenorrhea. Diagnosis of this disease is based on having a normal 46, XX karyotype, normal secondary sexual characteristics, elevated follicle-stimulating and luteinizing hormone, and normal anti-Müllerian hormone.
————
Negative EPCT:
Absence of withdrawl bleeding
Cause could be outflow tract obstruction
-Asherman Syndrome: Result of extensive Curettage and infection induces Adhesions.
Next Step? Hysterosalpingogram.
Treatment:Hysterscopic adhenolysis followed by estrogen stimulation an inflatable stent is then placed to prevent readhesions**
HEAVY MENSTRUAL BLEEDING
AND
DYSMENO
HMB causes:
- most common sigle cause is DYSFUNCTIONAL UTERINE BLEEDING ( DUB)
- 2 types :
HMB causes:
DUB investigations
uterine causes:
HMB causes:
systemic causes:
HMB causes:
HMB TREATMENT :
- non hormonal (nsaids or tranexamic acid)
- hormonal (levonnogestrel mirena)
emergency menorrhagia
Uterine fibroids (leiomyoma):
Fibroids are benign tumours of smooth muscle of the myometrium. They are classified according to their location: subserosal, intramural, subendometrial or intra-uterine. They are oestrogen-dependent and shrink with the onset of menopause.
CLINICAL FEATURES:
Lifetime incidence of 60–70% in Caucasian women
Only 1 in 800 develop malignancy
Usually asymptomatic
SYMPTOMS:
Often asymptomatic if small
Menorrhagia
Dysmenorrhoea
Pelvic discomfort ±pain (pressure) including dyspareunia
Bladder dysfunction
Pain with torsion of pedunculatedfibroid
Pain with ‘red degeneration’—only in pregnancy (pain, fever, local tenderness)
Infertility (acts like IUCD if submucosal)
Calcification
MANAGEMENT:
Medical management the same as for DUB :
-Levonorgestrel IUD has now largely taken over as the Preferred option for reduction of bleeding.
-GnRH analogues—especially if >42 years can shrink fibroids (maximum 6 months)—use only immediately pre-operative
●Surgical options:
–myomectomy (remove fibroids only, esp. child-bearing years)
–hysteroscopic resection/endometrial ablation
–hysterectomy
●Other option: uterine embolisation
Premenstrual Syndrome:
Premenstrual syndrome (PMS) is defined as a disorder of non-specific somatic, psychological or behavioral symptoms occurring during the late luteal phase of the menstrual cycle.The symptoms of PMS decrease in severity just before and during menstruation. Premenstrual Syndrome:
The most common psychological symptoms are depression and irritability, while headache, bloating and breast tenderness are the most common physical symptoms.
CLASSIFICATION:
It is convenient to classify PMS in terms of severity of symptoms.
●Mild:symptoms signal onset of menstruation. No medical advice sought or needed.
●Moderate:symptoms annoying but insufficient to interfere with function at home or work. Medical advice sought in about one-third.
●Severe:symptoms are such that functions at work or home are disrupted. Medical advice is usually sought. This disruptive form is labelled **PMDD **
Diagnosis:
Thorough history—including diet, exercise habits, psychosocial background, emotional influences and family history
Menstrual calendar—for 3 months, showing timing of the three main symptoms
Physical examination to exclude gynecological, endocrine or other systemic disease; and also include:–breast examination (if breast tenderness)–cervical screening test
Investigations (to exclude other causes):
●–thyroid function tests
●–full blood count
●–electrolytes and creatinine
●–FSH and oestradiol—if perimenopause suspected
●–serum androgens—if oligomenorrhoea present
**MANAGEMENT **
**Explanation, reassurance and insight
**Cognitive-based therapy , which has been shown to have a positive effect in several RCTs,is very Helpful.
●Keeping a diary
●Advise the patient to keep a daily diary of all her symptoms and when they occur over a 2–3 month period. This information should help her to plan around her symptoms: for example, avoid too many social events and demanding business appointments at the time when PMS symptoms are worst.
Dietary advice
1:Advise the patient to eat regularly and sensibly; eat small, frequent meals and aim for ideal weight.Increase amount of low-GI complex carbohydrates, leafy green vegetables and legumes.
Decrease or avoid: refined sugar, salt, alcohol, caffeine (tea, coffee, chocolate), tobacco, red meat and excessive fluid intake during premenstrual phase.
Decrease total protein to 1 g/kg/day; decrease fats.
Exercise
Recommend a program of regular exercise such as swimming, aerobics, jogging or tennis. Such exercise has been proven to decrease depression, anxiety and fluid retention premenstrually
Relaxation
Advise patients to plan activities that they find relaxing and enjoyable at the appropriate time. Consider stress reduction therapy, including meditation, yoga, relaxation techniques and appropriate counselling.Appropriate dress:loosedressing
●Medication:
●Pharmaceutical agents that have been used with success in some patients and little or no relief in others include diuretics (e.g. spironolactone), vitamins and minerals (e.g. pyridoxine and evening primrose oil), simple anti-inflammatories (e.g. aspirin, mefenamic acid) and hormonal preparations such as the **OCP. A combination of agents may have to be used.
SUPPLEMENTS:Women often enquire about the use of vitamins, minerals and herbal remedies for PMS. The evidence base for symptom relief so far is as follows:
pyridoxine/vitamin B6 up to 100 mg daily (evidence limited, beware nerve damage to hands/feet with higher doses)elemental calcium, 1200 mg to 1500 mg daily (two randomisedcontrolled trials have shown significant benefit)elemental magnesium** up to 400 mg daily (minimal evidence)evening primrose oil 500 mg daily (no benefit over placebo)Agnuscastus(Premular®) is an extract of the berries from the chaste tree (several small randomisedcontrolled trials have indicated some benefit over placebo)
ORAL CONTRACEPTION:It is appropriate to use a COC-containing ethinyloestradiol and drospirenone since a meta-analysis of drospirenone, which is a progestogenderivative of spironolactone, concluded that it was effective in reducing the severe symptoms of PMDD.
Moderate to severe PMDD:fluoxetine20 mg (o) or sertraline50 mg (o) daily in morning for 14 days before anticipated onset of menstruation and through to the first full day of menses of each cycle
Atrophic vaginitis:
In the absence of oestrogen stimulation, the vaginal and vulval tissues begin to shrink and become thin and dry in old age in post menopausal women. This renders the vagina more susceptible to bacterial attack because of the loss of vaginal acidity. Rarely, a severe attack can occur with a very haemorrhagicvagina and heavy discharge:
●yellowish, non-offensive discharge
●tenderness and dyspareunia
●spotting or bleeding with coitus
●the vagina may be reddened with superficial haemorrhagicareas
TX
Oestrogen cream or pessary(e.g. Ovestin, Vagifem) daily at bedtime for 2–3 weeks, then once or twice weekly
●or
●zinc and castor oil soothing cream
●Note:perform a careful speculum examination.
VULVOVAGINAL CANDIDIASIS:
clinic
- Usually in the presence of estrogen.
- CLINICAL
- ●Intense vaginal and vulval pruritus
-●Vulval soreness
●Vulval fissures
●Vulvo vaginal erythema(brick red)
●Vaginal excoriation and oedema
●White, curd-like discharge
●Superficial dyspareunia
●Dysuria
VULVOVAGINAL CANDIDIASIS:
factors predisponing
ENDOGENOUS
●Diabetes mellitus●Pregnancy●Immune deficiency, e.g. HIV
EXOGENOUS
●Oral contraceptives (but cessation of the OCP does not usually improve candidiasis)
●MHT or topical oestrogen
●Antibiotics
●Corticosteroid therapy
●Immunosuppressants
●Orogenital/anogenitalintercourse
●IUCD
●Tight-fitting jeans
●Nylon underwear
●Wet bathing suit
vaginal candidiasis
tx ?
chronic vulvovaginal candidiasis tx?
resistan infection, candida
tx
Trichomonas vaginalis:
clinic
tx
Flagellated protozoan Transmitted via sexual intercourse.
In Australia, trichomonasis more common in older women and women from regional and remote areas, especially Aboriginal and Torres Strait Islander
——————-
Profuse, thin discharge (grey to yellow–green in colour) **
●Small bubbles may be seen in 20–30%
●Vulval itch
●Malodorous discharge
●Dyspareunia
●Diffuse erythemaof cervix and vaginal walls
●Characteristic punctate appearance on cervix
.
TX
Oral Metronidazole 2 g as a single dose (preferable) or 400 mg bdfor 5 days (if relapse)
●or
●tinidazole 2 g as a single dose
” Sexual PARTNERS must be treated simultaneously “ ●No sexual contact is advised for 7 days after treatment for patient and partner
Bacterial vaginosis:
●A white or grey, homogenous discharge
●Malodorous
●No obvious vulvitisor vaginitis
●Liberates an amine-like, fishy odouron admixture of 10% KOH (the amine whiff test)
●Clue cells on wet preparation
●±Dyspareunia and dysuria
●±Pruritus (uncommon)
METRONIDAZOLE OR CLINDAMICINA
Lichen Planus:
clinic
dx
tx
Lichen planus (LP) is a chronic, inflammatory, puriticskin disorder, typically found on the limbs (especially flexor surfaces), mucous membranes (often in the mouth) and genitals –including inside the vagina
Lichen sclerosis:lichen sclerosus et atrophicus
Complications: if untreated:
●Vulvalatrophy and labial (even clitoral hood) fusion, introitalstenosis
●Lifetime risk of SCC 2–6%
Uterovaginal prolapse: 4 of - uterine prolapse are: -
Treatment:Medical:Kegelexercises,Pessaries,Estrogen replacement.
Surgical:anteriorand posterior vaginal wall repair or colporapphy
For uterine prolapse:Sacrohysteropexy
cervix
types:
factor risk
-fourth most common cause of cancer
- The most common is squamous cell carcinoma (SCC) 80% of cases. Adenocarcinoma is less common and more difficult to diagnose because it starts higher in the cervix.
- Cervical cancer almost exclusively occurs in women who have been sexually active, due to exposure to human papillomavirus(HPV). Other risk factors include smoking, use of combined oral contraception >5 years, immunosuppressionand exposure to diethylstilboestrol in utero.
- HPV 16 and 18
-
cervix
Who should be screened?
Women are invited to commence cervical screening at 25 years (or two years after first sexual intercourse, whichever is later).
●Both HPV-vaccinated and non-vaccinated women should be screened.
●An exit test can be performed at age 70–74 years.
●Women aged 75 years or older may request screening.
●Screening applies only to asymptomatic women. Women with postcoitalor persistent intermenstrual bleeding require a co-test (both HPV test and diagnostic LBC), and referral for an appropriate investigation to exclude malignancy should be considered.10
●For women who experienced first sexual activity at a young age (<14 years) and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis
cervix
special groups
hysterectomy
pregnancy
postmeno
inmunodeficient
DES
CIN comparison of nomeclature
Algorithm for management of low-grade squamous
INFERTILITY
female factors
ovulation disorders:
Tubal disease:
uterine and cervical anormalites:
INFERTILITY
male factors
physical examination nad investigation
man
infertility:
physical examination woman infertility:
and investigations first ovulation status:
fertility awareness:
chance of fertilization is best during:
endometriosis
endometriosis
symptoms:
dx endometriosis
most acurate test
laparoscopy and biopsy
endometriosis
tx
ocp
nsaid
first line investigation
basal body temperature and cervical mucus dairy
semen analisis
serum progesterona
transvaginal us
rubella inmune status
male infertility investigation
most important endocrine test?
female investigation in infertilty
infertility tx options
Poor nutrition and weight ovulation disorders
DX CRITERIA (ROTTERDAM)
LH - TECA- ANDROGENOS + PROGESTERONA
FSH - GRANULOSA - ESTROGENOS
EXCLUDE OTHERS:
Hipotiroidismo
hiperprolactinemia
= GnRH DOWN
= fsh y lh down
PCOS SYMPTOMS
PCOS
investigations
riesgo cancer endometrial
managment PCOS
Premature Ovarian Failure
Clinical Features:
Investigations
Investigations
tanner staging
Klienfelter’s Syndrome –XXY:
next step would be pelvic examination if she is a virgin (or US trasnvaginal)
imperforate hymen
hyperprolactinemia
STOP METROTEXATE BUT CONTINUE HYDROXICLOROQUINE
ULTRASOUND
- remember the best is hysterosalpingogram
BREAST
TRIPLE TEST :
INVESTIGATION X RAY MAMMOGRAPHY
MOST EFFECTIVE TOOL FOR BREAST CANCER
SCREENING 50 YEARS -
BREAST ULTRASOUND
Breast imaging for palpable lumps
According to age:
<35
35-50
50>
NEEDLE ASPIRATION AND BIOPSY TECHNIQUES
Fibrocystic Disease:
clinical features:
- fluctuate with periods!
- pain tender and swelling
reassure that is no cancer
FIBROADENOMA
REASSURANCE
breast cyst
Localized Nodularity:
Lactation Cysts
Phyllodes Tumor
FAT NECROSIS
Breast
Most accurate test : biopsy
reassurance and triple test
Duct Papillomas:
breast
mammary duct ectasia:
Red Flag Pointers for Breast Lumps
*Hard and irregular lump
*Skin dimpling and puckering
*Skin oedema (‘peau d’orange’)
*Nipple discharge
*Nipple distortion
*Nipple eczema
*Postmenopausal women
Diagnosis of Breast Cancer
dx:
TX BREAST CANCER
Adjuvant Therapy for breast cancer:
screening for breast cancer
RISK
1SLIGHTLY
2 MODERATE
3 HIGH
Lymphoedema of arm
Ductal Carcinoma in Situ
risks:
tx:
Paget disease of the nipple:
Lumps that require investigations and referral:
TX MASTALGIA
Mastitis carcinomatosa
breast abcess:
Breast Infections
MASTITIS
CLINICAL
candida symptoms?
tx?
If systemic symptoms develop:
*Antibiotics:resolution without progression to an abscess will usually be prevented by antibiotics:
*(di/(flu)cloxacillin 500 mg (o) 6 hourly for 10 days or (if hypersensitive to penicillin), cephalexin 500 mg (o) 6 hourly for 10 days)
*If severe cellulitis di/(flu)cloxacillin 2 g (IV) 6 hourly
*Therapeutic ultrasound (2 W/cm 2 for 6 minutes) daily for 2–3 days
*Ibuprofen or paracetamol for pain
.*For** Candida albicans** infection:(fluconazole 200–400 mg (o) daily for 2–4 weeks, second line—nystatin 500 000 U (o) tds
OSTEOPOROSIS
definition
common sites of fracture:
It is also defined by bone mineral density (BMD) as a T score of ≤–2.5.
gold standard of osteoporosis:
t score and z scorea
Risk factors for minimal-trauma fracture.
age when to review fracture risk? men and women
fall
women
menopause
age
osteoporosis identifyng risk :
average:
high:
average risk: clinical assement for risk factors
increase risk: DXA
**high risk: ** DXA (every 2 years)
prevention of osteoporosis:
fracture orevention
Calcium and osteoporosis
dosis
vitamin D
1300 mg osteoporosis
1300 mg women > 50 years < 1000 mg
1300 mg men > 70 years < 1000 mg
calcium carbonate first line
calcium citrato (if proton pump inhibitor)
*
*
*
remeber to consider the possibility of. a secondary cause
Management of osteoporosis following minimal-trauma fracture:
Management of osteoporosis in the absence of fracture:
Choice of drug therapy for osteoporosis
summary
Bisphosphonates
regimens:
inhibiting osteoclasts
Zoledronic acid
adverse effects:
Duration of bisphosphonate therapy
Bisphosphonates are retained in the skeleton after treatment withdrawal. The beneficial effects on BMD persist for several years after stopping alendronate and zoledronic acid.
●In contrast, BMD decreases within one year of stopping risedronate.
●Long-term bisphosphonate therapy has been linked to an increased risk of skeletal adverse effects such as osteonecrosis of the jaw and atypical fracture of the femur, although the absolute risk remains low. Limiting the duration of bisphosphonate therapy may reduce the incidence of these effects.
●Riserdonateis slightly safer option in patients with gastrointestinal irritation
denosumab
reducing osteoclast formation and differentiation and increasing osteoclast apoptosis.
Can cause **HYPOCALCEMIA **CHECK
VITAMINA D
CALCIO SERUM
CREATININE CLEAREANCE
Teriparatide
Teriparatide is also indicated to be used if the patient has a fracture while on therapy with osteoporosis
-
The maximum lifetime duration of teriparatide is 24 months.
-
DO NOT USE IN:
Romosozumab
Romosozumab’suse is limited by strict eligibility criteria for PBS subsidy—●therapy must be started by a specialist, the patient must have a T-score of –3 or less and they must have experienced at least one symptomatic new fracture after at least 12 months of therapy with an antiresorptive drug.
ESTROGEN THERAPY OSTEOPOROSIS
how to monitor patients with osteoporosis:
BMD
Skeletal adverse effects of drugs used for osteoporosis:
Glucocorticoid-induced osteoporosis
**The extent of bone loss is related to the dose and the duration of glucocorticoid therapy.
A prednis(ol)one dose of at least 7.5 mg per day, or an equivalent dose of another glucocorticoid is associated with the greatest risk.
effectiveness of contraceptive methods.
Classification of contraceptive methods
Contraceptive methods can be classified by their mechanism of action (hormonal versus non hormonal) or duration of action (long acting versus shorter acting).
** Long-acting reversible contraception(LARCs)**
➢intrauterine contraceptive devices (IUDs)—levonorgestrel-releasing and copper intrauterine IUDs ➢etonogestrelcontraceptive implant
**Shorter-acting hormonal contraception
**➢depot medroxyprogesterone injection
➢combined hormonal contraception—combined oral contraceptives (COCs) and the contraceptive➢vaginal ring
➢progestogen-only contraceptive pills
Hormonal contraception
Progestogen-only contraception :
uses:
women who are breastfeeding or have a contraindication to taking oestrogen
Progestogen-only contraception is contraindicated in women with active breast cancer within the past 5 years (MEC 4), but has relatively few other contraindications.
Etonogestrel implant (Implanon NXT)
3 years
inhibits ovulation
IRREGULAR BLEEDING MOST COMMON EFFECT
Depot medroxyprogesterone acetate:
dosis:
return of fertility?
adverse effect?
age?
(amenorrhoea rate 50–70% by 12 months), weight gain (average 2–6%), breast tenderness, mood changes and a delay in return of fertility (mean time 8 months).
Long-term use is associated with **accelerated bone loss. **
For this reason it is not recommended as a first-line contraceptive for women less than 18 and more than 45 years.
Progestogen-only contraceptive pill:
The POP (mini-pill) is most commonly prescribed for breastfeeding women for whom an oestrogen contraceptive was previously not recommended. POP is safe from 4 weeks after delivery
evonorgestrel 30 mcg/day
●norethisterone 350 mcg/day
uterine contraceptive devices
absolute contraindications:
including young and nulliparous women
All IUDs prevent pregnancy by inhibiting sperm migration and ovum transport and preventing implantation
The levonorgestrel IUD also causes endometrial suppression and cervical mucus thickening and may prevent ovulation.
-
copper IUDs: 99.5% perfect and typical use
-
Absolute contraindications
-active PID,
-undiagnosed abnormal genital tract bleeding
-current or past history of breast cancer for those considering levonorgestrel IUD (MEC 4)
uterine contraceptive devices
Side effects and complications of IUD use:
Pregnancy/ectopic pregnancy
- Early removal of the IUD is essential
- IF pregnancy occurs there is an increased risk of abortion and intra-uterine sepsis during the second trimester.
- **risk is low **compared to non users
Pelvic inflammatory disease
- small increased risk of PID in the first 20 days post-insertion
Extrusion, perforation of uterus and translocation
- Factors that increase risk of perforation include breastfeeding, first 6 months postpartum and previous caesarean section.
- translocation of the IUD outside the uterus is proved by X-ray and pelvic ultrasound, referral for removal is mandatory
- woman should attend for a follow-up visit between 3–6 weeks after insertion specifically to exclude infection, perforation or expulsion
Combined hormonal contraception (CHC)
dose:
Combined hormonal contraceptives contain an oestrogen and progestogen, and their main mode of action is inhibition of hypothalamic and pituitary function leading to anovulation
COCs in Australia contain ethinyloestradiol(EE), oestradiol valerate (EV), oestradiol (E2) or mestranol and one of a range of progestogens.
-
**EE is the most commonly used oestrogen. The active oestrogen in the newer E2 and EV pills is structurally identical to the E2 produced by the ovaries. **
-
use a dose of 35 mcg EE or less.
-
Formulations containing 50 mcg EE are no longer recommended because there is no known additional benefit from their use and they are associated with an **increased risk of VTE. **
●Women starting on a 20 mcg EE pill are likely to have fewer hormonally related side effects such as headaches or mood swings, but have a higher chance of discontinuation due to breakthrough bleeding.
-
which progesterone ? image
combined oral contraceptive formulations in AUSTRALIA
Starting the pill: which COC to use?
past menstrual and medical history of the woman should be documented and contraindications excluded:
30 mcg or 35 mcg ethinyloestradiol (EE) with levonorgestrel or norethisterone (e.g. Nordette, Microgynon 30, Monofeme, LevlenED, Brevinor).
*Education and counselling are very important for the woman starting the pill. Suitable patient education should be given.
-
YOUNGS:
Contraception (excluding sterilisation) can be provided without parental consent to adolescents assessed as being able to consent to their own medical treatment.
●Clinicians should be aware of mandatory reporting requirements in their jurisdiction for young people assessed as being at risk of harm (non consensual sexual activity, significant age gap or power differential between the young person and the sexual partner)
first-line option in adolescence contraception?
Long-acting reversible contraception (LARC) (the etonogestrel implant and intrauterine contraceptive devices [IUDs]) is the first-line option in adolescence
Postpartum contraception
<6 weeks = progesterona
>6 weeks: estrogenos
-
The etonogestrelimplant can be inserted any time postpartum, including immediately before leaving hospital and during breastfeeding.
-
A levonorgestrel-releasing or copper intrauterine contraceptive device (IUD) can be inserted immediately postpartum (within 48 hours), (>considerar por especialista en otro tiempo)
-
4> semanas es safe DIU , (riks of perforation because of breastfeeding)
-
Depot medroxyprogesterone injection is safe to use immediately postpartum and during breastfeeding. It can be a useful option for those awaiting IUD insertion after delivery.
●Progestogen-only pills (POPs) are commonly prescribed for individuals who are breastfeeding because they do not increase the risk of VTE (unlike combined hormonal contraception). ●The POP can be started immediately after delivery.
- COP or vaginal ring = 6> semanas
Thromboembolic risk:
Migrane with aura:
migrane without aura:
smokers:
developmental disability:
>35 years:
liver enzyme inducing drugs:
All combined hormonal contraceptives (combined oral contraceptives [COCs] or the contraceptive vaginal ring) increase the relative risk of venous thromboembolism (VTE).
-Depot medroxyprogesterone is not associated with a clinically significant risk of VTE. Despite a small increase in VTE risk if started in the first week postpartum, it is considered safe to use immediately postpartum.
●Other progestogen-only contraceptives are not associated with an increased risk of VTE
.
Migrane with aura: Progestogen-only methods of contraception are safe to use for individuals with a current or past history of migraine with aura.
**migrane without aura: **Progestogen-only methods better than COPs
smokers: contraindicated in individuals 35 years or older who smoke 15 or more cigarettes per day;
developmental disability: assessed for their capacity to consent to treatment
>35 years:
*CHC use is safe for healthy non-smoking women until 50 years (MEC 2 for women over 40).
*CHC is not recommended if a woman is over 35 years and has cardiovascular risk factors, including obesity, smoking, diabetes and hypertension (MEC 3/4
liver enzyme inducing drugs:
DMPA and IUDs
antibiotics that interfere (The only exceptions are liver enzyme-inducing rifabutin and rifampicin.)
Other liver enzyme-inducing drugs include many of the older anti-epileptics (e.g. phenytoin, carbamazepine), St John’s wort and protease inhibitors. For women who still request the use of COC, an extended or tricycling regime of a higher dose pill (e.g. containing at least 50 mcg EE) may be effective.
ABSOLUTE AND RELATIVE CONTRAINDICATIONS OF COPS
Serious side effects of CHCs
MOST COMMON SIDE EFFECTS OF COC
Important advice for the patient
Important advice for the patient:If a woman vomits within 2 hours of taking an active pill, she should take an additional active pill
A missed pill is defined as one that is taken more than 24 hours late (>48 hours since last pill was taken).
<24 Horas tomar dos
Emergency contraception
>70kg or bmi >26 DOUBLE DOSE
vaginal ring
delaying a period
Lactational amenorrhoea method (LAM)
conditions
menopause
premature ovarian failure:
early menopause
menopause symptoms and tx
The classic vasomotor symptom of menopause is the hot flush. A hot flush lasts 1–2 minutes, begins in the chest and then spreads up over the face and body. There may be associated redness, sweats which can be drenching, panic attacks, palpitations and faintnes.
-
HT is the most effective method for relieving distressing symptoms such as hot flushes, urogenital symptoms, sleeplessness and joint symptoms.
-
strogen + progesterone = has UTERUS (hyperplasia and there is a 5–10 times increased risk of endometrial cancer if only estrogen.)
-
tibolone - no uterus
estrogenos transdermal (less VTE risk)
testosteron - for libido
-
perimenopausal -(12 m) - ** progesterone must be cyclical ** after it trasnfer to continuous
-
Women who are prescribed MHT should be reviewed at least annually
-first line therapy non hormonal lubricant in DRYNESS THEN TOPIC OESTROGEN VAGINAL
PRECONCEPTION CARE
folic acid dosis:
folic acid for women with risk:
supplementation preconception care
preconception restrictions:
pregnancy confirmation:
physical:
pregnancy differential:
complications:
HORMONAL CHANGES
Cardiovascular System Changes
Hematologic Changes
respiratory system changes
renal changes
inmune changes
gastrointestinal
increase estogen -> cholesterol secretion
increase progesterone -> decreased bile acid secretion and muscle relaxation
RISK CHOLELITHIASIS
ANTENATAL CARE
TIMING VISITS:
routine ANTENATAL SCREENING
ROUTINE LAB/DX STUDIES
RUBELLA
TSH
<3 CM FUNDUS ERROR REFER!
TIME OF MAJOR PRENATAL TESTS*
important
if the cDNA reveals high risk -> CVS = RISK 1-100 MISCARRIAGE
SCREENING TESTS again summary pregnancy
dx test pregnancy
vaccinations recomended in pregnancy
3
glucose challenge in pregnant
when ?
Vaginal bleeding in early pregnancy:
1-Trimester
- MISCARRIAGE
- ECTOPIC PREGNANCY
- MOLAR (rare)
20-40% pregnant women will BLEED 1 TRIMESTER
<6 semanas - hcg se eleva 66% cada 48 horas (sino ectopico)
- hCG > 1500 IU/L PEDIR TRASNV US ***
6-8 SEMANAS
- usar US
- repetir en una semana
> 8 semanas:
- normal US is reassuring
REST IS NOT NECESSARY FOR THREATHNED MISCARRIAGE
ANTI D - ONLY IN COMPLETE MISCARRIAGE
vaginal bleeding 1 trimester investigations:
- US TV
- hCG ( <50% 48 = no viable or ectopic)
- maternal blood group and antibody (determine Rhd inmunoglobuline)
shoulder tip pain sign
suspect:
Of the option, however, shoulder tip pain is the most important sign demanding urgent action. This sign is notcommon but if present in suspected EP, demands urgent surgical action because indicates** free blood in the peritoneum and peritoneal irritation**. The mechanism such pain is produced is thought to be irritation of the diaphragm and the phrenic nerve by the free blood in the peritoneal cavity. Then pain can radiate to the shouldertip especially on the right side
risk factors for ectopic pregnancy?
ectopic pregnancy most commonly location?
vaginal examination in ectopic pregnancy ?
->Ectopic Pregnancy
differentials
tx
- METROTEXATE
- ALL RH (D) NEGATIVES = ANTI D INMUNOGLOBULIN
INEVITABLE, INCOMPLETE, COMPLETE MISCARRIAGE
- inevitable - uterine bleeding, dilatation, contractions.
- complete
- incomplete
tx
HOSPITAL
analgesic
heavy bleeding (ergotamine)
vaginal examination and forceps removal
-
residual gestational tissue US
removal surgically by sponge forceps or medically misoprostol
ecotpic pregnancy diagnosis?
- b-hCG
- <5 not pregnant
+ -> US TV - 1000 = fetal heart beat
- ## no result in US => serial B hcg
SNOWSTORM = MOLAR
DEFINITIONS OF MISCARRIAGE
as recommended that a fetus be considered potentially viable when the gestation periodhas reached 22 weeks or more, or when the fetus weighs 500 g or more.
ABORTION TERM USED FOR DELIBERATELY TERMINATED
DEFINITIONS IN MISCARRIAGE
THREATNED MISCARRIAGE
- UTERINE BLEEDING (WITH OT WITHOUT PAIN)
- CERVIX CLOSED
- US
- IF subchorionic hematoma preganncy monitered closely
- NO BED REST
recurrent miscarriage
antiphospholipid syndrome dx and tx:
also cervical incompetence (do cerckage)
3 or more sucessive miscarriages
.
lupus anticoagulant
anticardiolipina
anti b2 glicoprotein
tx aspirin and unfractioned heparin
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law on abortion in NSW
abortion
epilepsy in pregnancy:
- no seizure in 6 months
complications epilepsy on pregnancy
Effect of pregnancy on epilepsy
*In most women seizures do not increase during pregnancy
*1-2% incidence of seizures during labour and in 24 hours post delivery
Effect of epilepsy on pregnancy Maternal
*Vaginal bleeding, abruptio placentae, PET, preterm labour Fetal
*Neural tube defects, I UG R, heart and skeletal defects, prematurity.
Newborn
Hemorrhagic disease of newborn***
care and investigations epilepsy pregnancy:
Antenatal Care
High risk pregnancy clinic-MDT with neurologist
Continue antiepileptic medication
*Screening for spina bifida: *by nuchal translucency scan for anencephaly, maternal alpha fetoprotein at 16-20 weeks, detailed U/S at 20 weeks which is most predictive for neural tube defects MCQ#########
Monitor anticonvulsant levels once in each trimester
**Oral Vitamin K **2omg/day during last 1 month of pregnancy.
Intrapartum and Postnatal care
Vaginal delivery at tertiary hospitalI/M 1mg vitamin K to newborn*Breastfeeding is not contraindicated despite the drugs crossing into the breast milk.
DVT pregnancy
when is most risk?
tx?
The prevalence of VTE is equally distributed throughout pregnancy, but the day by day risk is greatest in the immediate puerperium. 6 weeks
The major risk factors include caesarean section, obesity, prolonged immobility, preeclampsia, current infection, previous VTE and familial thrombophilia.The preferred treatment of VTE during pregnancy is low molecular weight heparin (LMWH).
Compared withunfractionated heparin, as LMWH does not cross the placenta, there is a reduced risk of bleeding and no thrombocytopenia.
Incidence 1%
Symptoms: Pain, swelling in the leg usually unilateral and **on left leg (80%) **with redness, warmth.
Complication
*pulmonary embolism
Investigation of choice Compression Doppler US
-If U/S negative =clinical suspicion low, anticoagulation discontinued
- If clinical suspicion high = repeat doppler U/S, venography or magnetic resonant direct thrombus imaging.
PE in pregnancy
best initial investigation
TX-
UNFRACTIONED HEPARINE FOR MASIVE
LMWH FOR PROPHYLAXIS
TX DVT PREGNANCY OVER VIEW:
above the knee
distal DVT
LMWH anticoagulant of choice
warfarina contraindicated during pregnancy
Delivery
*Planned delivery preferably *Discontinue therapeutic LMWH 24 hours prior and give prophylactic LMWH until 12 hours prior induction or c-section
*If spontaneous delivery :
- Stop LMWH and send blood for cross match, group and hold.
If high risk of bleeding, unfractionated heparin **is preferred and is has shorter half life and can be completely reversed with **protamine sulphate**
**Unfractionated heparin also indicated in RENAL FAILURE.
Care during subsequent pregnancy:
*Screen for thrombophilia
*LMWH from 14 weeks to 4 to 6 week post partum
*Compression stocking and avoid immobilization
Gestational diabetes values:
DM vs GDM
(oh) * fasting glucose >5.1 mmol
*
(1h)* post 75 gr 1 hour > 10
*
* 2 hour> 8.5
all pregnant women should be screened at 24-28 weeks with 75 gr
unfractioned heparine indicated in pregnancy:
antidote:
- renal failure
- massive PTE with cardiovascular compromise
- high risk of bleeding (placenta previa)
risk factors for GDM:
gestational diabetes
uncertain values gdm
FASTING PLASMA GLUCOSE
<5 mmol/L = normal
5.1-5.9 mmol/L :uncertain. considere lifestyle. OGTT = 16-18 weeks
6.6.0-6.9 mml/L: lifestly advice. OGTT = 16-18 weeks. consider SMBG
RANDOM PLASMA GLUCOSE
9-11mmol/L : signficance unknown. further investigation - fasting or HbA1c.
GLYCATED HAEMOGLOBIN (HbA1c)
- 5,9-6,4 = reasonable predicting a dx of GDM . Lifestyle. consider SMBG
remember - >
OGTT:
1. Fasting(eight hours)
2. 75 g glucose administered orally
3. Blood is collected from a fasting venous sample and two-hour post-glucose challenge venous sample
managment of diabetes
screening and diagnosing type 2 diabetes
dx criteria type 2 diabetes adults
asymptomatic
GESTATIONAL DIABETES
RECOMENDATIONS
GESTATIONAL DIABETES
MANAGEMENT
GESTATIONAL DIABETES
follow up:
exams:
-
40% risk of subsequent GDM in pregnancy
GESTATIONAL DIABETES COMPLICATIONS
MATERNAL
FETAL
GESTATIONAL DAIBETES
DURING PREGNANCY
DURING LABOUR
FOLLOW UP?
PROM Premature Rupture of membranes:
risk factors
symptoms
**complications?
**
premature rupture of membranes (PROM) occurs when a patient at ≥ 37 weeks of gestation presents with rupture of membranes (ROM) prior to the start of uterine contractions
PPROM:preterm premature rupture of membranes (PPROM) describes PROM that occurs < 37 weeks of gestation
Chorioamnionitis
investigations
To prevent chorioamnionitis, it is recommended that all women with PROM more than 18 hours be started on parenteral antibiotic.
Management of PPROM:
Chorioamnionitis is an absolute contraindication to tocolysis
AB - **Chorioamnionitis is a feared feature of PROM of over 18 hours.
memorize this
PPROM
Fifty percent of women with PROM women will be in labor in12 hours, 86 % within 24 hours, and 94 % will be established in labor within 48-95 hours. 6% will not establish in labor within 96 hours of PROM.
Chorioamnionitis is a feared feature of PROM of over 18 hours. The most important risk factors for development of chorioamnionitis include: * Increasing numbers of digital vaginal examinations* Longer duration of active labor* Meconium staining of the amniotic fluid
To prevent chorioamnionitis, it is recommended that all women with PROM more than 18 hours be started on parenteral antibiotic.
PRETERM LABOUR
causes :
investigations:
PRETERM LABOUR
Fibronectintest
Fetal fibronectin (FFN) is an extracellular matrix glycoprotein localized at the maternal-fetal interface of the amniotic membranes, between chorion and decidua, where it is concentrated in this area between decidua and trophoblast. In normal conditions, FFN is found at very low levels in cervicovaginal secretions. Levels greater than or equal to 50 ng/mL at or after 22 weeks have been associated with an increased risk of spontaneous preterm birth. In fact, FFN is one of the best predictors of preterm birth.
Indications
**-Symptomatic women with threatened preterm labour: **
o Between 22+0 and 36+0 weeks gestation and
o Intact membranes and
o Cervical dilatation less than or equal to 3 cm
-OR Asymptomatic women, greater than 22 weeks gestation, with a history of:
o Cervical surgery/trauma or
o PTB in previous pregnancy or
o Late miscarriage in previous pregnancy.
Contraindications of FFN
* Cervical dilatation more than 3 cm
* Ruptured membranes
*Cervical cerclage in situ
* Presence of soaps, gels, lubricants or disinfectants
Relative contraindications*
Visual evidence of moderate or gross bleeding
* Within 24 hours of vaginal intercourse
* A negative fFNresult of less than 10 ng/mL is still valid:
o If a woman reports having intercourse in the previous 24 hours
o In the presence of moderate or gross vaginal bleeding
Preterm Labour
Management
Preterm Labour
Management
guidelines
Abnormal foetal presentations:
TRANSVERSE LIE
Abnormal foetal presentations:
BREECH PRESENTATIONS
breech presentation
management
occipito posterior?
face presentation?
shoulder dystocia
read basic
shoulder dystocia
management
CORD PROLAPSE
OBSTRUCTED LABOUR
Induction of labour –bishop score
Induction of labour –bishop score
GUIDELINES
Substance of abuse in pregnancy
medications
teratogenos
weeks 1-3 of gestation
●“ all-or-none” effects
●weeks ●3-8 of gestation embryonic period most susceptible time period due to organogenesis
●week 8 of gestation until birth growth and function of organs are affected
Substance of abuse in pregnancy
Heavy alcohol
Heavy alcohol consumption in pregnancy (>120 g, or 12 standard drinks a day) is associated with:
* 1-IUGR
* 2-Developmental delay and neurological complications in the baby
* 3 -Fetal alcohol syndrome (facial characteristics: low-set ears, elongated midface, small head and upturned nose, skeletal and cardiac malformations). The incidence of FAS is multifactorial and compounded by smoking and other drug abuse, poor diet and social deprivation.
A consumption of seven standard drinks in a week and no more than two in any 1 day spread over at least 2 hours does not appear to have any damaging effects on the fetus or mother. Nevertheless, a pregnant woman should be advised to limit her consumption of alcohol especially during the first trimester, as there is concern about the long-term effects on the neurodevelopment of the child, particularly with numerical problem solving and reading proficiency, which is dose dependent
Substance of abuse in pregnancy
Heroin
Substance of abuse in pregnancy
cocaine
Substance of abuse in pregnancy
Amphetamines
Substance of abuse in pregnancy
Cannabis
CTG interpretation
CTG
variabilidad
CTG interpretation
acelerations
CTG interpretation
decelerations
types
CTG interpretation
Overall impression
reassuring
non reasuring
abnormal:
JAUNDICE DURING PREGNANCY
ACUTE FATTY LIVER OF PREGNANCY
Systemic disease in pregnancy
Cholestasis of pregnancy
Systemic disease in pregnancy
HELLP syndrome
Systemic disease in pregnancy
THROMBOCYTOPENIA
Systemic disease in pregnancy
pulmonary embolism pregnancy daigram
Appendicitis
POSTPARTUM PSYCHIATRIC PROBLEMS
overview
INFECTIOUS DISEASES MEASELS
clinical features:
measles complication most common = OTITIS MEDIA
INFECTIOUS DISEASES MEASELS
prevention:
measles complication most common = OTITIS MEDIA
NOTE -Interpretation of CMV lgM results in pregnancy requires specialist opinion. Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/-fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage. Since this woman is 16 weeks pregnant, amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is perfomedin the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropraiteoption if it was an option.
round ligament pain
pregnancy
food to avoid during pregnancy
HEPTATITIS B
SCREENING
HEPTATITIS B
ANTENATAL MANAGEMENT
HEPTATITIS B
MAGAMENET POTENTIAL EXPOSURE DURING PREGNANCY
HEPTATITIS B
NEONATAL MAGAMENET
HEPATITIS C
ANTENATAL DIAGNOSIS
HEPATITIS C
ANTENATAL MANAGEMENT
HEPATITIS C
MANAGEMENT AND FOLLOW UP
DIAGNOSIS OF HIV INFECTION IN PREGNANT WOMEN
STRATEGTY TO MINIMISE HIV INFECTION IN PREGNANT WOMEN
MANAGEMENT OF INFANT RISK HIV
ANTI D PROPHYLAXIS
ANTI D PROPHYLAXIS
POSTPARTUM
HEMOLYTIC DISEASE OF NEW BORN
blood trasnfusion
a
GESTATIONAL THROPHOBLASTIC DISEASE
HYPERMESIS
VAGINAL BLEEDING
UTERUS LARGER THAN EXPECTED
HYPERTENSIVE DISEASE
MANAGEMENT HYPERTENSION PREGNANCY SUMMARY
preeclampsia:
preeclampsia
RISK FACTORS:
ECLAMPSIA
PREECLAMPSIA
ANTIHYPERTENSIVE MEDS
TIME O F BIRTH:
hemorrage antepartum > 20 weeks
Inmediate actions just read
PLACENTAE PREVIA
DX
SYMPTOMS
INVESTIGATIONS? Important ?
hemorrage antepartum > 20 weeks
PLACENTAE PREVIA
TX
risk factors memory ! mcq
PLANCETAE ACRETA, INCRETA, PERCRETA
VASA PREVIA
Abruptio placentae
UTERINE RUPTURE
BLEEDING>20 WEEKS
ANTEPARTUM BLEEDING SUMMARY
UTERINE RUPTURE
ABRUPTO PLACENTAE
PLACENTAE PREVIA
VASA PREVIA
ADHESIONS
Monthly COCP contents
28 pill pack:
* 21 hormonal pills and
*7 sugar pills.
PCOS Rotterdam Criteria
PCOS biochemical hyperandrogenism
