ILA revision Flashcards
what does tender lt iliac fossa make you think..?
and what other symtpoms / features would make you suspect it … even more…
ectopic?
sexually active woman abdo pain fainting bleeding especially in early preganncy d&v (no guarding, no rebound tenderness, no masses)
how to differentiate between an ectopic and an intrauterine pregnancy
TVS + P-USS
bloods - (bHCG rasied in both - but prog <5 rules out intrauterine pregnancy- ie failing pregnancy)
(-ve serum B-hCG excludes ectopic 99%)
FBC, clotting, group and save
ectopic - OE - may be shocked / hupotensive / tachy / peritonitic
how to manage an ectopic:
(and when expectant…?)
what drug for medical
what surgical procedures…
2 large bore cannulae
fluids - crystalloids then colloids
may be suitable for expectant if:
- aSx / mild / hCG <3000 / <3cm / no haemoperitoneum
medical - MTX
surgical:
1. salpingectomy - removing the tube if the contralateral is healthy
2. salpingotomy - tubal incision to remove ectopic if the other tube is not healthy…. increases risk of another ectopic..
laparotomy if unstable..
Expectant Medical Surgical
Size <30mm Size <35mm Size >35mm
Unruptured Unruptured Can be ruptured
Asymptomatic No pain Severe pain
No fetal heartbeat Visible fetal heartbeat
Exp:B-hCG <200IU/L and declining
MedL: serum B-hCG <1500IU/L
Surg: serum B-hCG >1500IU/L
Not medical if another intrauterine pregnancy
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.
Surgical management can involve salpingectomy or salpingotomy
what is the finding of endometrioisis on bimanual palpation
fixed retroverterted uterus
what hormones are released from the ant and post pit
ant: GAF TPM GH ACTH (salt stress sex) FSH TSH Prolactin Melanocyte stimulating hormone
post: OA
oxytocin
adh
what do the following blood pictures make you think?
a. raised LH:FSH ration (3;1)
b. raised FSH (>40)
c. low fsh and low lh
a. PCOS
b. ovarian failure..
c. hypothalamic failure
what is it important to exclude in recurrent PCB?
cervical cancer
with or without IMB
what are some common causes of IMB?
define IMB
what is it important to exclude?
breakthrough bleeding with hormonal contraception
IMB - bleeding occuring between clearly defined cyclical and regular menses
EXCLUDE:
pregancy
infection ( esp chlamydia infection of cervix / vagina)
what is it important to exclude in PMB?
what are other causes?
uterine Ca
Ix: TVS - if endometrium <3mm then endometerial path unlikely
endometrial biopsy - diagnostic hysteroscopy
other causes:
- other GU tract tumours
- stimualtion of endometrium (exogenous oestrogen eg HRT / oestrogens from ovarian tumours)
-infection
-post meno atrophic vaginitis
list the structural and non-structural causes of abnormal uterine bleeding…
PALM-COEIN (polyp [5-10%]; adenomyosis5%; leiomyoma 20-30%; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified)
what investigations might you order in menorrhagia
EXCLUDE ANAEMIA / LOCAL CAUSES / MALIGNANCY / SYSTEMIC CAUSE
if PCB / IMB - investigate further
FBC - ?anaemia
TVS - ?structural abnormalities
TSH - ?hypo/hyperthyroid
endometrial biopsy if ?uterine malignancy
hysteroscopy if unresponsive to treatment
how would you manage / treat menorhagia?
- provide information on menorrhagia and its management** put this for lots of stuff….**
no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
if tryong to conceive:
Non-hormonal: tranexamic acid or a non steroidal anti-inflammatory drug (NSAID) eg. mefanamic acid..
if not trying to conceive:
- Mirena IUS is first line - may see changes in bleeding pattern
- then COCP
- cyclical oral progestogen (such as oral norethisterone - P-only contraception can suppress menstruation) / Depot-provera
other options (surgical):
Uterine artery embolization (UAE)
UAE involves cannulating the femoral artery and identifying the uterine arteries before injecting an embolic agent into them to impair the blood supply to the uterus and fibroids (if present).
Women should be informed that UAE may potentially allow them to retain their fertility.
Myomectomy
Women should be informed that myomectomy may potentially allow them to retain their fertility.
Myomectomy may increase pregnancy rates compared with UAE in women with fibroids who wish to retain fertility.
Hysterectomy
The route of hysterectomy can be vaginal, abdominal, or laparoscopic. It may include removal or preservation of the ovaries, and/or removal or preservation of the cervix.
Women should be informed:
About the increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present.
About the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy.
In all women who are considering hysterectomy, a full discussion should be had about the implications of surgery before a decision is made. The discussion should include:
Psychological impact.
Alternative surgery.
The woman’s expectations.
Treatment complications.
Need for further treatment.
Bladder function.
Impact on fertility.
Endometrial ablation
Endometrial ablation involves destroying the endometrium (lining) and the superficial myometrium (muscle) of the uterus.
Women should be informed to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation.
describe the differentiating features of placenta praevia and placental abruption..
PP:
painless, non-tender uterus, unstable lie, normal tone of uterus, BLOOD LOSS RELATES TO MATERNAL CONDITION
PA: constant pain / tender tense uterus / longitudinal lie / hypertonic uterus / blood loss incongruous with maternal condition
when should vasa praevia be diagnosed? (and when is this..)
colour USS at fetal anatomy scan
18-20 weeks
describe the risk factors for uterine rupture and its presentation
labour stops uterus hard blood fetal distress more likely with previous CS and grand MP women (obvs.. easier for it to split)
how would you investigate suspected APH in primary care>
full investigations:
- DO NOT DO A VAGINAL EXAMINATION IN PRIMARY CARE FOR SUSPECTED APH - WOMEN WITH PLACENTA PRAEVIA MAY HAEMORRHAGE
- stabilise if necessary
- transfer to a hospital maternity unit with facilities for resuscitation (such as anaesthetic support and blood transfusion resources) and performing emergency operative delivery.
Do BP + HR
O/E - abdominal palpation- tender/woody in abruption
no vaginal exam.
Speculum exam may be done as well - safe in placenta praevia
Rhesus D-negative
TV-USS - can Dx praevia BUT not exclude abruption
CTG monitoring begun
what are the DDxs for APH in primary care?
placental abruption
placenta praevia
vasa praevia
smaller - cervical ectropions etc..
what is the management of a primary PPH
Management:
A and B – assess airway and breathing
A high concentration of oxygen (10–15 litres/minute) via a facemask should be administered.
● C – evaluate circulation
Establish two 14-gauge intravenous lines; a 20 ml blood sample should be taken and sent for diagnostic tests,
including full blood count and assessment of FMH if RhD-negative, coagulation screen, urea and electrolytes
and cross match (4 units)
call for help - senior midwife, obstetrics registrar, anaesthetics registrar on call. alert blood transfusion labs and porters.
Push IV fluids, send blood for crossmatch and group and save
catheterise
deliver placenta, empty uterus, massage
Drugs to contract the uterus:
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost (up to 2 doses)
if medical options failure to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine Rusch balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
deifne 1y and 2y pph
define major 1y
when does 2y usually occur?
1y - blood loss of >500mls that may be primary or secondary
major - >1L
2y - occurs between 24 hours - 12 weeks**
due to retained placental tissue or endometritis
USUALLY 5-12 days post due to retained tissue or clot - often concurrent infection needing ABx tx
what are the causes of 1y pph (the 4ts)
tone (poor tone causes 90%)
tissue - retained products of conception
trauma - g tract trauma
thrombin - 3%
what is labour defined as?
4 criteria
- regular uterine contractions
- up to 2.5 mins each
- with 30s rest in between
- dilatation of cervix
how can you interpret a CTG?
describe the features of decelerations. which are reassuring, which are non-reassuring, which are abnormal
what are decelerations?
Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
How to read a CTG
To interpret a CTG you need a structured method of assessing its various characteristics.
The most popular structure can be remembered using the acronym DR C BRAVADO
DR – Define Risk
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression
early - fine - reassuring. physiological - foetus HR is dropping during the contraction
variable - usually seen in labour, usually caused by umbilical cord compression: ¹
Accelerations before and after a variable deceleration are known as the “shoulders of deceleration”.
Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow.
Late deceleration
Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends.
This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.
As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis.
Reduced uteroplacental blood flow can occur due to: ¹
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation
Prolonged deceleration
A prolonged deceleration is defined as a deceleration that lasts more than 3 minutes.
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as abnormal.
Sinusoidal - BAD
what is syntocinon?
what are the indications…
Syntocinon is a synthetic version of oxytocin that is used in the active management of third stage of labour. It stimulates the contraction of the uterus reducing the risk of postpartum haemorrhage. It is also used to induce labour.
what is ergometrine?
what is the mechanism?
what are the ADRs?
Ergometrine is an ergot alkaloid which is used as an alternative to oxytocin in the active management of third stage of labour. By constricting vascular smooth muscle of the uterus it can decrease blood loss.
Mechanism of action
stimulates alpha-adrenergic, dopaminergic and serotonergic receptors
Adverse effects
coronary artery spasm
