O + G Flashcards
What is gestational diabetes
Gestational diabetes refers to diabetes triggered by pregnancy and it is caused by reduced insulin sensitivity during pregnancy and it resolves after birth. The most significant complication of gestational diabetes is a large for dates foetus and macrosomia. This poses a risk of shoulder dystocia. Longer term, women are at higher risk for developing type 2 diabetes after pregnancy.
What are the risk factors for gestational diabetes?
- Previous gestational diabetes
- Previous macrosomic baby (over 4.5kg)
- BMI over 30
- Ethnic origin (black carribean, middle eastern and south Asian)
- Family history of diabetes (first degree relative)
- Polyhydramnios
When is an OGTT scan done for gestational diabetes
24 - 28 weeks. If diabetic soon after the appointment and again in those week if the first one is normal
Type 1 diabetic before pregnancy advice
- Speak to diabetic team
- Continous glucose monitoring to stabilise glucose
- HbA1c monitored monthly
- 5mg folic acid daily until 12 wk preg - prescribed
- Assess renal function and retinal function baseline
- 150mg aspirin from 12 wks to reduce preclampsia risk
Type 1 diabetic interpartum pregnancy advice
- Increase insulin use and monitor regularly.
- Sometimes need appt with diabetes specialist in pregnancy clinic 1 - 2 wk - can be a telephone call
- scans 12, 20 week
- USS 28,32,36 - look at growth and liquor
- umbilical artery doppler if IUGR
- fetal echo at 20 week
Glucose targets for pregnancy women
fasting - 5.3mmol/L, 1 hour after meal - 7.8, 2 hours after 6.4
Diabetic mother delivery week
Deliver by 39 weeks
Monitor acidosis, avoid maternal hyperglycaemia (put on sliding scale of insulin during labour)
Aim for a vaginal delivery <12 hours, if prolonged do CS.
CS if estimated weight >4kg
Stop infusions at delivery.
Post natal advice on diabetic pregnancy
Maternal: insulin can rapidly be changed to pre pregnancy dose, breast feeding is advised.
Baby: risk of hypoglycaemia therefore early and regular feeds recommended.
What are the risks of diabetic pregnancy
- macrosomic baby
- miscarriage
- diabetic retinopathy
- diabetic nephropathy
- DKA for type 1
- preclampsia
- polyhydramnios
- shoulder dystocia
Causes of intermenstrual bleeding
cervical cancer - (24 - 64)
vaginal cancer
vulval cancer
cervical polyp
fibroid
STI - PID although painful
IUD
Blood thinner or progesterone pill
Causes of painful vaginal bleeding
ectopic pregnancy
fibroid
PID
vaginal infection - BV
trauma
endometriosis
menstrual cramp
Causes of painful vaginal bleeding in pregnant women
Miscarriage, ectopic, molar pregnancy, placenta previa, cervical infection, pre term labour. placental abruption
Causes of painless bleeding during
Subchorionic Hematoma, cervical polyp, vaginal infection, placenta previa, implantation
What is placenta praevia?
- Placenta Praevia means the placenta is lying low in the uterus
- Bleeding comes from seperation of the placenta itself as the lower segment of the uterus forms or from cervical dilation later in pregnancy
- Blood usually comes from the maternal blood supply
- It is a serious medical condition and requires close monitoring
How do you manage placenta praevia
- Emergency delivery (if mother or baby is in haemodynamic distress)
- Re-scan with elective caesarean section if the placenta remains low
- Consultant led monitoring, likely as an inpatient due to bleed
States that maternal steroids would be given if early delivery is indicated
Advise patient to avoid physical tasks due to risk of bleeding e.g. housework and sexual intercourse ?
The Kleihauer Betke test isutilized to determine if there is fetal blood in maternal circulation, with a threshold of 5 mL. The rosette test is performed by incubating the Rh-negative maternal venous whole blood sample with anti-Rho(D) immune globulin.
Obstetric Examination
Ultrasound abdomen
CTG
Anti-D was given within 72 hours of the onset of bleeding if Rh-ve
Antenatal corticosteroids if immediate delivery is not indicated
Senior review - emergency/elective c-section
What is amniocentesis and when is it done
- Removing small sample of fluid from the amniotic fluid to test for Downs, edward and patau. But increase risk of miscarriage.
Done between 15 - 20th week of pregnancy
What is preeclampsia?
> 140/90 after 20wk, proteinuria and oedema or other organ involvement
What are the consequences of preclampsia?
- eclampsia
- other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
- fetal complications
- intrauterine growth retardation
- prematurity
- liver involvement (elevated transaminases)
- haemorrhage: placental abruption, intra-abdominal, intra-cerebral
- cardiac failure
Features of severe preclampsia
- hypertension: typically > 160/110 mmHg and proteinuria as above
- proteinuria: dipstick ++/+++
- headache
- visual disturbance
- papilloedema
- RUQ/epigastric pain
- hyperreflexia
- platelet count < 100 * 10/l, abnormal liver enzymes or HELLP syndrome
What are the risk factors for pre-eclampsia
High risk
* hypertensive disease in a previous pregnancy
* chronic kidney disease
* autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
* type 1 or type 2 diabetes
* chronic hypertension
Moderate risk factors
* first pregnancy
* age 40 years or older
* pregnancy interval of more than 10 years
* body mass index (BMI) of 35 kg/m² or more at first visit
* family history of pre-eclampsia
* multiple pregnancy
What is the management of pre-eclampsia
Initial assessment
- NICE recommendarranging emergency secondary care assessmentfor any woman in whom pre-eclampsia is suspected
- women with blood pressure ≥160/110 mmHg are likely to be admitted and observed
Further management
- oral labetalolis now first-line following the 2010 NICE guidelines.Nifedipine (e.g. if asthmatic)and hydralazine may also be used
- delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
What are the advantages of COCP
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
What are the disadvantages of COCP
people may forget to take it offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be see
Whilst some users report weight gain whilst taking the combined oral contraceptive pill a Cochrane review did not support a causal relationship
When is COCP effective?
- If started within 5 day of cycle it is immediately effective. Any other time it is 7 days alternative contraception needed. 21 days with 7 day bleeds but you can have continuous for up to 3 times without bleed.
What emergency contraception are available? Which one can be taken within ovulation
- Levonelle - 3 days of unprotected
EllaOne (uliprisal acetate) - single table - 5 days of unprotected sex (safe and more effective than levonelle)
Copper IUD - up to 5 days - within 5 days of ovulation.
Tablet no take after ovulation
What are the disadvantages of levonelle, ella one and copper IUD
Levonelle and EllaOne - both cause N+V, next period early or late
Ellaone - asthma no, cant be given with other hormones
IUD - uncomfortable procedure but LA used. Small risk of infection, coming out, perforation and breath through bleed. Menorrhagia possible.
Where can you get emergency contraception?
GP clinic, sex health clin, NHS walk in, pharmacies, some A + E
What are the causes of postmenopausal bleeding?
Vaginal Atrophy - most common
HRT
Endometrial Cancer - rule out
endometrial hyperplasia
Cervical cancer
Ovarian cancer
Vagnal cancer
Trauma
Vulval cancer
bleeding disorder
How do you treat vaginal atrophy?
Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
How do you treat endometrial hyperplasia
dilatation and curettage is performed to remove the excess endometrial tissue
