Management Flashcards
Post Menopausal Bleeding
Bimanual & speculum Cervical smear if not up to date TVUS to measure endometrial thickness If >4mm or >1episode PMB: - endometrial biopsy +- hysteroscopy pipelle, hysteroscopy under paracervical LA block or under GA
Bleeding in early pregnancy
Admit if: ectopic suspected, septic miscarriage, heavy bleeding
Resuscitate if req
Remove any products in os (pain, bleeding, vasovagal shock)
If non viable + heavy bleeding: IM ergometrine
If septic: swabs + IV abx
Rhesus -ve + medical/surgical/expectant>12wks:
Threatened miscarriage I.e. Viable
90% with viable fetus detected at 8 wks will not miscarry
Bed rest, progesterone and hCG do not prevent miscarriage
Non-viable pregnancy
Expectant: if not septic
Medical: misoprostol, incomplete 600 mcg, missed 800mcg
Surgical: if heavy bleeding/septic/preferred by patient
ERPC- under anaesthetic vacuum aspiration
Complications of miscarriage management
Expectant + medical: heavy painful bleeding 24hr direct access to emergency gynae service for advice/treatment
May require surgical evacuation
Infection rates are all 3%
Surgical: uterus perforation / asherman’s syndrome if part of endometrium removed, more expensive
Symptomatic ectopic pregnancy
Admit (NBM) + fluid resus if req IV access, Hb + cross match Urine B-HCG TVUS Either: laparoscopy/otomy or medical management
Subacute ectopic pregnancy
Surgical: laparoscopy with salpingostomy/ectomy
Medical: if unruptured with no cardiac activity,
Acute PID
Urine dip, MC+S High vaginal swab, endocervical swab Abx: doxycycline + metronidazole Analgesia + Contact tracing Complications: tubo-ovarian abscess, Fitz-Hugh-Curtis synd (peri hepatitis+ adhesions), tubal infertility, ectopic preg, chronic pelvic pain
Endometriosis
Medical:
Analgesia: tranexamic acid
COCP: microgynon 30
Progestogens: medroxyprogesterone acetate
GNRH analogues: triptorelin up to 6 months
Antiandrogens
Danazol: anti-oestrogen, anti- progesterone, 3-6 months
Surgical: to improve fertility
IVF often indicated
Placenta praevia
Admit Stabilise Heavy/far from hospital admit from 30-32 wks until delivery Planned Caesarean section 38-39 wks Major haemorrhage -> emergency c section
Chorioamnionitis
Deliver without delay: oft c section
Abx for mother + baby
Paediatricians present
Pre labour SROM
No digital examination - introduces infection
Obtain sample liquor
Sterile speculum exam: visualise cervix, cough
At term: immed induction of labour or expectant management
Which should NOT exceed 96 hrs, generally induced at 48hrs post SROM
Pyelonephritis
MSU: dip, M C + S
Renal US: hydronephrosis
Uterine tightenings = risk of preterm labour + bacteraemia
Speculum as silent cervical dilation can occur
Rx: analgesia, fluids, Iv abx
UTI
Freq, dysuria, suprapubic pain, fever, tachycardia Uterine tightenings, perform speculum MSU: dipstick with M C + S Fx: cephradine, amoxicillin Recurrent UTI req further investigation
Suspected ectopic + shock
ABC!
Fluid resuscitate, urine BHCG, urgent cross match,
prep for theatre:
Urgent laparotomy
Obstetric cholestasis
For itching: chlorphenamine
Fetal monitoring: incr risk pre term delivery, intracranial haemorrhage, fetal distress, intrauterine death
Deliver 37-38 wks
Severe cases = ursodeoxycholic acid to reduce bile acids
Ovarian cancer
Bloods: CA125, Pelvic+ abdo US, CXR, CT CAP
Specialist gynae cancer unit
Benign: laparoscopy- excision or drainage
Epithelial malignant: hysterectomy + bilat oophorectomy, infracolic omentectomy…. Oft palliative debulking
Intraperitoneal disease: obstruction, cachexia
Liver mets
Malignant pleural effusion
Prolapse
Pelvic floor exercises may improve incontinence
Won’t improve established prolapse
HRT: increased oestrogen + vaginal blood flow = improved connective tissue function
Surgical: anterior/posterior repair, hysterectomy
Premature labour
Confirm EDD correct
Exam: abdo, spec with swabs, urine dip, mat bloods, CTG, US
Inform special care baby unit/ transfer to hospital with facilities for preterm babies
Corticosteroids
Tocolytics
Vaginal delivery if appropriate
Uterine inversion
Help
Start maternal resus
Do not attempt to separate placenta, attempt to manually replace uterus and placenta to relieve vasovagal shock
Tocolytic therapy
O’Sullivans: 2L warned fluids PV
Johnson’s transvaginal fundal pressure
Huntington: traction on round ligaments at laparotomy with simultaneous vaginal pressure
Haultain’s incise uterine fundus to allow manual re inversion
Hysterectomy = last resort
Prophylactic abx and oxytocin once uterus resited
PPH medical management
Atonic uterus:
Empty bladder, rub up uterine contractions, admin oxytocics,
Bolus IV ergometrine -> oxytocin infusion
Bimanual compression
Carboprost IM
For infection: cefuroxime + metronidazole
PPH surgical management
laparotomy:
carboprost into myometrium,
B lynch suture, under sew placental bed, tamponade test - balloon uterine or internal iliac artery ligation,
Last resort: hysterectomy
Stage 1+2 endometrial cancer
Radical hysterectomy
Bilateral salpingo-oophorectomy +- lymphadenectomy
Adjuvant radiotherapy if high risk of recurrence
Stage 3 endometrial cancer
Surgical debulking
Radiotherapy
Chemotherapy
Stage 4
Palliative care
Incurable
Fibroids
Medical: progesterone tablets, GNRH analogues
Surgical: myomectomy, uterine artery embolisation, hysterectomy
Uterine rupture
Stop any oxytocin infusion
Immed laparotomy req to deliver baby and arrest bleeding
Repair uterus if possible, otherwise emergency hysterectomy
Stress incontinence
Conservative
Pelvic floor exercises with physio - 3 months
8 contractions 3x /day, continue if beneficial
Surgical
Urge incontince/overactive bladder
Weight loss Smoking cessation Physiotherapy Solifenacin Fesoterodine
Vasomotor sx in menopause
HRT Elleste solo: estradiol only if other source of progestogens with uterus (endometrial hyperplasia/cancer) Elleste duet: estradiol + norethisterone Evorel: estradiol + norethisterone Oestrogen implants?
Stillbirth
Oral mifepristone
Vaginal misoprostol
If indicated I.e. Wrong lie -> c section
