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Obs and Gynae osce > Knowledge notes > Flashcards

Knowledge notes Flashcards

1
Q

Antepartum haemorrhage - key things to ask?

A
  • Onset and timing (any trauma/trigger)
  • Has she had any episodes before
  • Colour (dark red in abruption, bright in preavia)
  • Any pain (praaevia is painless, abruption is painful)
  • Any abnormal bleeding prior to pregnancy
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2
Q

Antepartum haemorrhage - any other symptoms?

A
  • Pain
  • Foetal movements?
  • Contractions?
  • Symptoms of shock (sweaty, shaky, fast breathing)
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3
Q

Antepartum history - sections to ask?

A
  • History of this pregnancy - “low lying placenta”
  • Past obstetric history
  • Post gynae history (any abnormal bleeding prior to pregnancy, known fibroids or uterine abnormalities, any infections, smears up to date)
  • Past medical history (HTN, clotting problems)
  • Family history
  • DHx
  • Six - smoking
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4
Q

What is the definition of antepartum haemorrhage?

A

Bleeding PV after 24/40 gestation (but before the onset of labour)

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5
Q

What are the causes of an antepartum haemmorage?

A

In around 1/3, no underlying cause is found
In around 1/3, there is placenta praevia
In 1/3 there is placental abruption
In a small proportion bleeding may be from another source (e.g. cervical), or due to vasa praevia

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6
Q

How would you proceed from here? Antepartum haemorrhage

A
  • Placenta preavia and placental abruption are both obstetric emergencies
  • Admitted and obs checked, in particular looking for tachycardia suggestive of shock
  • Gain IV access, take blood for FBC, clotting and cross match
  • No vaginal examination until placenta preavia has been excluded, would feel abdomen for a woody hard uterus - indicative of abruption
  • Perform an urgent USS and CTG, Anti-D to Rh-Ve mothers and corticosteroids if baby less than 34 weeks
  • Urgent delivery by C section may be required
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7
Q

What is placenta praevia?

A

This is when the placenta implants over the cervical os, or in the lower segment of the uterus

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8
Q

Risk factors for placenta praaevia?

A

multiparity, advanced maternal age, prior PP, smoking and prior C-section.

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9
Q

What is the management of asymptomatic placenta praevia?

A

Most PP is picked up as a “low-lying placenta” during the 2nd trimester USS.

The woman should therefore have a repeat USS at 32/40. If the placenta remains low then it should be repeated fortnightly until 36 weeks.

At 37 weeks, if the placenta remains low, she should be admitted and elective C-section performed at 39/40.

If bleeding develops, she should be admitted from this point and monitored, with delivery at 37/40 by elective C section.

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10
Q

What are the complications of placenta praevia?

A

PPH is common, because the lower segment of the uterus is not contractile and so does not contract down to staunch bleeding

Foetal complications relate mainly to prematurity and malpresentation.

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11
Q

What is placenta accreta?

A

Abnormal invasion of placental villi into the uterine wall

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12
Q

Risk factors of placenta accrete?

A

more common with PP and with previous LSCS. (E.g. may implant over Caesarean scar and penetrate through the decidua and myometrium)

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13
Q

placenta accreta treatment

A

usually requires Caeasaren-hysterectomy with a high risk of DIC, and should be anticipated in any woman with a previous C-section and low-lying placenta

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14
Q

What is placental abruption?

A

premature separation of the placenta from the uterine sidewall, causing antenatal bleeding.

This may be revealed (PV bleeding) or concealed (large retrouterine blood collection may develop) and minor or major (affecting >1/3 of the placenta; foetal survival very unlikely).

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15
Q

What is vasa praevia?

A

Bleeding from the umbilical vessels (i.e. foetal blood) due to velamentous insertion of cord vessels crossing the cervical os.

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16
Q

Vasa preavia management?

A

An emergency C section should be performed if the foetus is viable, but foetal mortality exceeds 75%

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17
Q

Vasa preavia presentation?

A

It usually presents with scanty bleeding at the time of RoM, along with severe
foetal distress.

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18
Q

Methods of contraception?

A

Non-hormonal
* Abstinence
* Rhythm method
* Barrier – condoms, femidom, diaphragm

Hormonal
* Combined OCP
* Progesterone only pill
* Progesterone depot
* Patches
* IUDs

Sterilisation

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19
Q

COCP - what is it?

A

A single tablet, containing both an oestrogen and progestogen, is taken every day for 3 weeks and stopped for a week, with vaginal bleeding occurring

Negative feedback effect on gonadotrophin release inhibits ovulation

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20
Q

Major complications of COCP?

A
  • Venous thrombosis and VTE
  • Increased CVA
  • Increased risk focal migraine, HTN, jaundice, liver/cervical/breast cancer
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21
Q

Absolute contraindications of COCP?

A
  • History of DVT, CVA, IHD
  • Severe/focal migraine
  • Active breast/endometrial cancer
  • Inherited thrombophilia
  • Pregnancy
  • Smokers >35
  • Active/chronic liver disease
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22
Q

Relative CI of COCP

A
  • Smokers
  • Obesity
  • Chronic inflammatory disease
  • Renal impairment, diabetes
  • Age >35
  • Breastfeeding
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23
Q

Progestogen-only pill - what is it?

A

Slightly less effective and must be taken at the exact samne time every day
* Can be used in older women or if COCP contraindicated
* Progestogenic s/e: vaginal spotting, weight gain, breast tenderness, PMS

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24
Q

Dysmenorrhoea - history of presenting complaint, what to ask?

A
  • How long to be going on for? New onset?
  • Where is the pain
  • When does it happen, in relation to the menstrual cycle
  • Anything make it better
  • Anything make it worse
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25
Q

Dysmennorhoea - other symptoms?

A
  • Are periods regular? How long do they last?
  • Are they heavy?
  • Dyspareunia?
  • Discharge? Abnormal bleeding?
  • urine/bowel symptoms?
  • Bloating, lethargy, weight loss?
  • Symptoms of anaemia (especially if menorrhagia)
26
Q

What is the differential diagnosis of dysmenorrhea?

A

Simple (primary) dysmenorrhoea is the most common cause of painful periods.

Secondary dysmenorrhoea may be caused by fibroids, adenomyosis,
endometriosis, PID and ovarian tumours.

27
Q

Dysmenorrhoea - What examination would you like to perform?

A
  • Speculum examination – for any obvious lesions, discharge.
  • Bimanual pelvic examination – for fixed retroverted uterus (endometriosis, PID), nodular “string of beads” uterosarcal ligaments, pain mimicking presenting features
  • Abdominal examinaton
28
Q

Dysmennorrhoea - What investigations would you like to perform?

A
  • STD tests
  • If history features: CA125 (NB may be somewhat raised in endometriosis)
  • USS – may show ovarian endometriomas
29
Q

What is endometriosis?

A

Ectopic endometrial tissue outside the uterine cavity. It may arise from retrograde menstruation, haematogenous spread, or coelomic metaplasia.

30
Q

What are the management options for endometriosis?

A

Medical:
o combined OCP
o cyclical or continuous progestogens
o gonadotrophin releasing hormone analogues
* Surgical:
o laparoscopic laser ablation/diathermy
o TAH+BSO – “last resort”

31
Q

What do you know about chronic pelvic pain syndrome?

A

occurs when there is chronic pelvic pain with no known organic cause
Non-gynaecological problems may be the cause; IBS is common and
psychological factors may be important

32
Q

Management of chronic pelvic pain syndrome?

A

counselling and reassurance, gastroenterology
referral, laser uterosacral nerve ablation, TAH + BSO.

33
Q

Dyspareunia history of presenting complaint?

A
  • How long has it been going on for?
  • Can you tell me a bit more? - at point of penetration, feel it deep
  • Psychological factors? - new partner?
34
Q

Dyspareunia any other symptoms?

A
  • Pain at other times?
  • Can she use a tampon, have you had a smear
  • Discharge?
  • Bleeding?
  • Periods - regular, irregular
  • Changes around vagina - ulcers, swelling
35
Q

Dyspareunia background history?

A

Past gynae history: infection, smears, any abnormal, any problems or
operations
* Past obstetric history
* PMHx, FHx, DHx (including contraception), SHx

36
Q

Dyspareunia background history?

A

Past gynae history: infection, smears, any abnormal, any problems or
operations
* Past obstetric history
* PMHx, FHx, DHx (including contraception), SHx

37
Q

What are the causes of dyspareunia?

A

Superficial: infection, atrophic vaginitis, vaginal cysts, barthonlon’s abscess + psychological or psychosomatic
Deep dyspareunia: endometriosis or Chronic pelvic infection

38
Q

Dysparenuria - What examination would you like to perform?

A

External examination – especially in superficial dyspareunia: inspect the vulva and vagina for any lesions and try to pinpoint the tender area

If possible, perform a bimanual examination

39
Q

Dyspareunia - What investigations would you consider?

A

STD screen (high vaginal and cervical swabs)
Deep dyspareunia – consider laparoscopy

40
Q

What are the management options for vaginismus?

A

Psychotherapy/ sexual therapy

41
Q

Fertility problems - History of presenting complaint?

A
  • How long have they been trying for?
  • What contraception were they using before?
  • Regular unprotected intercourse?
42
Q

Fertility problems - asking about menstruation?

A
  • Does she menstruate?
  • How long is the cycle? How long does it last? is it regular? Has it changed?
  • When does she start her periods? are they normal?
  • Are they painful?
43
Q

Fertility problems - other questions to ask?

A
  • Hirsutism, acne, weight gain, weight loss?
  • Headaches? Visual changes? Galactorrhoea?
  • Vaginal/pelvic pain? Dyspareunia?
  • Discharge? Bleeding at any other times?
44
Q

How would you define “subfertility”?

A

If conception has not occurred after a year of regular unprotected intercourse.

45
Q

Fertility issues - What examinations would you like to perform?

A
  • General – for PCOS, galactorrhoea.
  • Speculum for discharge, infection.
  • Bimanual – for uterine fixity and pelvic tenderness.
  • Examine the male partner
46
Q

Tell me about polycystic ovarian syndrome.

A

syndrome associated with multiple small follicles on the ovary (PCO)
with biochemical and/or clinical abnormalities.
* These are characterised by increased LH and androgens (particularly relative to FSH), and result in hirsutism, acne, weight gain, oligomenorrhoea and infertility.
* There is also a metabolic syndrome with 40-50% developing diabetes later in life; cardiovascular disease and endometrial and breast cancer are common.

47
Q

What are the treatment options for PCOS?

A

Lifestyle – encourage exercise, weight loss
Clomiphene – blocks oestrogen receptors in the hypothalamus, increasing the release of the FSH and LH
If fertility not desired, the COCP usually regulates menstruation and prevents endometrial hyperplasia

48
Q

What are the treatment options for PCOS?

A

Lifestyle – encourage exercise, weight loss
Clomiphene – blocks oestrogen receptors in the hypothalamus, increasing the release of the FSH and LH
If fertility not desired, the COCP usually regulates menstruation and prevents endometrial hyperplasia

49
Q

What options are there for male factor infertility?

A

Treatment of specific conditions e.g. lifestyle changes, cool loose clothing, gonadotrophins
Sperm extraction, donor insemination

50
Q

Tell me about IVF?

A

eligible for IVF on the NHS if the woman is aged between 23 and
39, and they have been unable to conceive for 3 years. Usually couples can get 3 cycles, and priority is given to couples who do not already have children

eggs are collected under local anaesthetic by aspirating follicles under US control; they are incubated with washed sperm and transferred to a growth medium. Transfer into the uterus then takes place. Luteal phase support is also given

There is increased risk of perinatal mortality and morbidity, and increased multiple pregnancy

51
Q

Gestational diabetes HoPC?

A

Any symptoms? – polyuria, thirst, nausea, feeling unwell
History of this pregnancy
* All scans etc normal so far; no complications; UTI, infection
Background
* POHx – especially of gestational diabetes, macrosomia (>4.5kg, ~10lb), unexplained foetal death

52
Q

How would you confirm a diagnosis of gestational diabetes?

A

Glucose tolerance test

53
Q

What are the complications associated with pre-gestational diabetes in pregnancy?

A

Maternal: pre-eclampsia, chronic HTN, DKA, polyhydramnios, pre-term labour,
Caesarean, urinary tract/wound/endometrial infection, diabetic retinopathy,
hypoglycaemia, coma

  • Foetal: congenital abnormalities (2-3x risk, related to HbA1c, including cardiac,
    skeletal, GI, renal), spontaneous abortion, mortality (especially with DKA),
    macrosomia, delayed foetal maturation
54
Q

Menopause - key history points?

A
  • Age
  • Periods? – becoming irregular, stopping
  • Vasomotor changes – “hot flushes”
  • Psychological – insomnia, poor concentration, anxiety, lethargy, reduced libido
  • Skin and breast changes, hair loss
  • Increased risk of prolapse, urinary incontinence
  • Bone mineral loss ! osteoporosis – fractures
  • Increased cardiovascular risk
  • Sexual dysfunction
55
Q

Menopause - What would you do if this woman was 35?

A

Menopause before age 40 is defined as premature menopause.
* I would like to confirm the menopause with some blood tests. The hormonal hallmarks of the menopause are a low oestrodiol with a high FSH and LH (due to loss of negative feedback); the useful diagnostic test is a high FSH.
* I would then want to counsel the woman and discuss HRT

56
Q

What kinds of HRT do you know about?

A

Usually a combination of oestrogens and progestogens – as unopposed
oestrogen increases the risk of endometrial cancer. If the woman has had a
hysterectomy, oestrogen alone can be used.
* Taken in 28 day cycle, usually with monthly bleeds or no menses.
* Other preparations include implants, transdermal patches or vaginal gels.

57
Q

What are the advantages of HRT?

A

Short-term relief of the symptoms of the menopause
* Reduces bone density loss and pathological fractures, and partially reverses
established osteoporosis
* Reduces collagen loss in the skin, may preserve a “younger” appearance
* Reduces bladder dysfunction, may increase libido, protects against bowel
cancer, tooth loss and possibly Alzheimer’s, macular degeneration and
cataracts

58
Q

What are the disadvantages of HRT?

A

Short term side effects: oestrogenic or progestogenic side effects, continued menstruation, headaches, breast tenderness, fluid retention, pre-menstrual symptoms – most diminish after 3 months
* Menstruation
* Slightly increased risk of breast cancer
* 2-4x risk of thromboembolic disease
* Possibly slightly increased risk endometrial cancer, even with progestogens

59
Q

Menorrhagia HoPC

A
  • How much are you bleeding?
  • How long has it been going on for?
  • What is your cycle like?
    Any other symptoms?
60
Q

Mennorhagia - specific symptoms

A

o Dysmenorrhoea
o Pelvic pain
o Dyspareunia
o Intermenstrual bleeding
o Post-coital bleeding
o Discharge
o Problems with bowels/urine

  • How are you in yourself?
    o Tiredness
    o Fainting
    o Shortness of breath
    o Weight loss/gain
    o Appetite
61
Q

How would you define menorrhagia?

A

menstrual bleeding which is sufficient to cause distress or disruption to the woman’s life

62
Q

How can you assess blood loss in menorrhagia?

A

flooding and the use of double protection are indicative of
pathological levels of blood loss, as is iron deficiency anaemia

Again, the most important indication may be the effect it is having on a woman’s life

Obs and Gynae osce (5 decks)

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