O&G Flashcards
First line surgery for women needing surgery for ectopic pregnancy and no other RFs for infertility
Salpingectomy
(Salpingotomy - option but 20% chance failing and needing more mx so if they have no factors affecting fertility of their other tube then complete removal)
First line Ix for endometrial cancer
Transvaginal US
(If abnormal then endometrial biopsy)
Women who have had a salpingostomy for ectopic pregnancy but following procedure still has discomfort and high HCG - what is the mx
Methotrexate (and/or salpingectomy)
1st line treatment primary dysmenorrhoea
NSAID - mefanamic acid
Premenstrual symptom management
Mild - lifestyle
Mod - COCP (Yasmin)
Severe - SSRI continuous or during luteal phase
Pregnant woman presents with painful vaginal bleeding, foetal heart often absent and might move less
Diagnosis?
Placental abruption (hard, woody uterus)
A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
Dx
Ovarian cyst
Rfs endometrial cancer
Nulliparity, early menarche, late menopause, unopposed oestrogen (HRT not progesterone), obesity, DM, POS, tamoxifen, HNPCC
Which ovarian tumour is ass with development of endometrial hyperplasia
Granulosa cell tumours
Abnormal vaginal bleeding, discharge, pelvic pain, dyspareunia.
Possible malignancy, pathology and Tx
Cervical Cancer
Tx - Hysterectomy + LNs or if fertile then cone biopsy
HPV 16&18
Normal cytology but HPV positive:
After 12m repeat = neg =
If still + after 12m =
If +ve at 24m then =
Normal cytology - test repeated at 12m:
If now neg = normal recall
If still +ve then further repeat in 12m
If then finally neg at 24m = normal recall
But if +ve at 24m still then colposcopy
Inadequate sample from Smear - how many to colposcopy
Inadequate - repeat within 3m. If this (2 samples) inadequate then colposcopy
Inadequate sample from Smear - how many to colposcopy
Inadequate - repeat within 3m. If this (2 samples) inadequate then colposcopy
Endometrial cancer - what are the risk factors
DM, obesity, unopp oestrogen
Symptoms of ovarian cancer
bloating, early satiety, loss appetite, pelvic pain, mass
What does the risk of malignant index include in ovarian cancer
US findings, menopausal status, Ca125
Primary amenorrhoea - CAH vs AIS symptoms
primary:CAH ( increase androgens)- Female with facial hair/deep voiceAIS - F phenotype, mal genotype (testis in abdo)
Secondary amenorrhea - when to refer and the Ix results for Primary ovarian failure vs PCOS
3-6m or 6-12m (if irreg cycles).
↑FSH = primary ovarian failure
↑LH/↑LH:FSH = PCOS (dx is TV US-string of pearls)
PMS - how to diagnose and how to treat
Dx by GnRH to see if it helps. COCP- Yasmin
Stres sincontinence tx
When cough / sneeze
- Pelvic floor exercises
- Surgery/duloxetine
Urge incontinence
1.Bladder retraining
2.Oxybutynin
45-60 year old with vulval itch/skin changes
dx and mx
Lichen sclerosus
No cure
topical steroid and emollients
Heavy bleeding mx
Tranexamic acid (B), Mefanamic acid (Pain + B)
Or Mirena coil -> COCP -> cyclical progesterone
If secondary then refer gynae first
Fibroids Ix and Mx
Hysteroscopy or Pelvic US if larger
<3cm - same mx as heavy bleeding
If larger then GnRH/gynae referral
Contraception in Menopause
Post M= 12m after LMP
Contraception needed 2 years after LMP if <50 or 1Y if >50
Not the depot as >45 is weight gain and ↓BMD (osteoporosis)
HRT contraindications
current/past Breast Ca, any oestrogen sensitive Cancer, undiagnosed vaginal bleeding, untreated endometrial hyperplasia, ↑ risk stroke/VTE (oral HRT), CHD/Bca/ovarianCa
Diagnosis
Ovarian fibroma (benign), pleural effusion, ascites
Meig’s syndrome
What will a pelvic US show for ovarian torsion
Whirlpool sign
Unilateral Unilateral dull ache (intermittent/in intercourse).
If large may see abdo swelling
Ruptured - sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
Diagnosis
Ovarian cyst
Endometriosis Tx
If not controlled by NSAIDs/COCP then GnRH analogues
surgery
When to ix infertility
Investigations/referral after 12m or 6m if >35
If semen sample is abnormal repeat in 3m
Clue cells, fishy, ph>4.5
dx/mx
BV
Metronidazole
Tx candidiasis
1st lien for non pregnant is oral fluconazole
If preg then crema or pessaries only
chlamydia ix and mx
Gram -ve
NAAT Dx
Doxycycline 100mg BD 7d (not in preg)
Gonorrhoea ix and Mx
Gram -ve diplococci
NAAT Dx
IM Ceftriaxone or if sensitivities known then PO Ciprofloxacin
Test of cure
Syphilis - organism, Mx
Treponema Pallidum - spirochete
Painless ulcers
Argyll Robertson pupil (accommodates but does not react to light) in neurosyphilis
Deep IM benzathine benzylpenicillin
Can have Jarish Herxheimer reaction to tx - fever/rash/tachy after 1st dose. Needs antipyretic’s like paracetamol, no tx
Mycoplasma genitalium mx
Swab/ 1st urine sample
Doxy then azizthromycin
Test of cure
Cervical excitation, bilateral lower abdo pain associated with vaginal discharge, Dysuria
Peri-hepatic inflammation secondary to chlamydia (fitz Hugh Curtis) is RUQ discomfort and fever 38+
diagnosis
PID
Fishy, alkaline, strawberry cervix
Dx, ix, mx
Trichomoniasis
Charcoal swab + microscopy
Metronidazole
Ulcers/blisters, neuropathic type pain, flu like symptoms, dysuria, inguinal LNs
dx, mx
genital herpes
Viral PCR
Aciclovir
After childbirth - the rules of fertility returning, breast feeding as contraception
Fertility returns >21 days.
Lactational amenorrhoea up to 6m if BF + amenorrhoeic
What are the rules with IUS/IUD and cocp after birth
IUS/IUD - within 48hrs or >4weeks
COCP >6weeks if BF but do prgenancy test if uPSI from day 21 post partum
MOA of COCP, the risks and contraindications
Inhibits ovulation
Increased risk breast Ca
Protective for endometrial and ovarian cancer
MEC3= BMI>35
MEC4-Migraine with aura, uncontrolled HTN + VTE
When starting the COCP - when to have extra contraception
Start day 5+ or swapping from POP then extra contraception for 7 days except with desogestrel (no extra needed)
Missing COCP and emergency contraception
If uPSI in delay time…
Missed pill = >24 hours. If missed over 72hrs and NOT taken 7d before straight then emergency contraception
If taken 7days prior then no emergency but barrier 7d after
MOA POP, and the one UKMEC4 CI
thickens mucus (+ desogestrel inhibits ovulation)
UKMEC4 = breast cancer
Delay times for POP
Traditional can delay 3hrs
Desogestrel can delay 12 hrs
When to start POP and add contraception
When start - if not day 1-5 then add 48hrs
emergency contraception and POP
If >3 />12 (as above) and had UPSI within that time of lateness
Depo injection:
How often, MOA
UKMEC3s
S/E
Every 12-13 weeks
Inhibits ovulation and thickens mucus
UKMEC3 - IHD, UE vaginal bleeding, liver Ca
Ass with weight gain, and ↑ risk osteoporosis (so not to >45)
delays fertility
depo injection - when to start and if extra contraception needed
If start after day 5 then need 7d extra contraception
Contraceptive patch - hormones, when to change, when its delayed and if emergency needed
Combined
Change every week for 3 weeks then 1 week off
If >48hrs late swapping then extra contraception 7d and emergency contraception if >48 and UPSI in last 5d
3 types emergency contraception
Levonorgestrel - <72hrs. 1.5mg single dose. Multiple in cycle. Start hormonal contraception immediately after
Ulipristal - <120hrs (Ella one) = Start hormonal C after 5d (use barrier), multiple in 1 cycle fine. Not in severe asthma
Copper IUD <5d or up to 5d after weekly ovulation date
Implant MOA
Inhibits ovulation and thickens
IUD MOA
↓ sperm motility and survival
IUS MOA
Prevents endometrium proliferation and thickens mucus
What happens to HCG every 48hrs in Ectopic pregnancy
Doubles every 48hours
Management of Ectopic pregnancy and when each can be done
Expectant Mx if unruptured/no heartbeat/no pain. HCG<1000
Medicine with methotrexate (don’t get pregnant 3m after) - can have pain but not significant, unruptured, no heartbeat but allowed up to 35mm length. HCG <1500
Surgery - salpingectomy (pain/heart beat)
Pt is pregnant but bleeding 1st/2nd Trimester, with exaggerated symptoms (hyperemesis, large dates)
What is the dx, what might happen to HCG, and IX findings
↑ HCG, ‘snow storm’ pelvic US
( ↓TSH, ↑ thyroxine)
Dx miscarriage and Management
TV US
If recurrent - check antiphospholipid syndrome
Expectant + test 1-2w after
Medical - misoprostol (in Von Willebrand disease)
Surgery (aspiration)
Dx N&V in pregnancy and first line medications
5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
Prochlorperazine
Abortion mx
Mifepristone
Misoprostol
Suction <14w/ evac (14-24 wk)
Pregnant + COnstant lower abdo pain, may be more shocked than appears
Tender, tense uterus with Normal lie and presentation
Fetal heart may be distressed
Placental abruption
Placental abruption
Emergency steroids 24-35 weeks
Pregnant + Vaginal bleeding, no pain
Non tender uterus but lie and presentation may be abnormal
Dx, Mx
Placenta Praevia
Rupture membranes then immediate bleeding
Possible fetal bradycardia
Dx, Mx
If asymptomatic then elective 34-36 weeks
If symptoms then urgent C section
Mx umbilical cord prolapse
Emergency
Can push presenting part fetus back into uterus
If cord is past introitus then minimal handling and keep warm and moist to avoid vasopasm
Pt on all fours or left lateral
Tocolytic can be used to reduce contractions
Retrofill bladder poss
C section usually first line but instrumental vaginal is poss if cervix fully dilated and head is low.
When is anaemia screened in pregnancy and what are the thresholds for starting oral iron in 1st/2nd/3rd trimester
1st trimester start PO iron when <110
2nd T is <105
3rd trimester is <100
When is booking apt
8-12 weeks
AT how many weeks (apt) are dates confirmed in pregnancy
10 - 13+6
When is the DS screening + translucency scan
11- 13+6
When is anomaly scan
18-20+6
Tx of UTI in pregnancy
7d Abx even if asymptomatic
Avoid nitrofurantoin 3rd trimester
(Amoxicillin after snesitivities)
Cefalexin
The triad of Pre-Eclampsia and Mx
HTN, Proteinuria, Oedema
Aspirin 12+ weeks + Labetolol then after delivery - enalapril
Dx Eclampsia, Mx and what to monitor with mx
Seizures >20 weeks
IV Mg SO4 - continue until >24hrs after last seizure or delivery
(monitor urine output, reflexes, RR, 02 sats
-> HELLP syndrome
Folic acid def - what is the risk of this and what are the folic supplement doses in pregnancy
400 mcg till 12 weeks or
5mg if high risk (AED, BMI>30, history of NTD)
When to screen for OGTT, the thresholds and management
Screen OGTT
If prev had then immediate OGTT and one at 24-28 weeks
If just have RFs then one at 24-28 weeks
FG>5.6
2 hours glucose >7.8
FG>7 = insulin started
FG <7 = diet + exercise-> metformin
Jaundice in pregnancy - Intraheptic cholestasis pregnancy (features, Mx)
3rd Trimester, pruritis, no rash, -> bilirubin
Ursodeoxycholic acid, weekly LFTs + induced 37weeks as risk still birth
Jaundice in pregnancy - Acute fatty liver - features, mx
Acute fatty liver = Abdo pain, N&V, headache, jaundice, hypoglycaemia, Severe-> eclampsia
↑ ALT, supportive care.
-> HELLP
CPR rules whilst pregnant
15 deg tilt LHS and deliver <4m
Shoulder dystocia caused…
Adduction and internal rotation arm - waiters tip
Dx?
Erbs palsy - damage to upper brachial plexus
PPH Mx
ABCDE
Bimanual uterine compression
IV oxytocin +/- ergometrine
IM Carboprost
Intramyometrial carboprost
Surg - balloon catheter
Cord prolapse mx
ABCDE
Bimanual uterine compression
IV oxytocin +/- ergometrine
IM Carboprost
Intramyometrial carboprost
Surg - balloon catheter
Uterine rupture mx
Push back, hold + oxytocin
If fail - fill vagina with fluid and surgery if that fails
Bishop score - what is this representing
Prior to induce labour
<5 = likely to need induction
Placenta accreta - what is it
Placenta attach to myometrium and doesn’t properly separate in labour - PPH risk
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalisincreta: chorionic villi invade into the myometriumpercreta: chorionic villi invade through the perimetrium
GBS props
If history infection in prev baby etc
Benzyl penicillin in labour
Proph and Mx of preterm labour
Prophylaxis = Vaginal progesterone (can get hyperstim) 16-24 weeks, cervical cerclage 16-28 (where dilation)
Tococlysis can stop contractions
Betamethasone if <36 wks (lung) + MgSO4 (<34wks) - brain
Induction of labour options
41-42 weeks
Membrane sweep from 40 weeks
Vaginal PGE2 or cervical ripening balloon
Artificial rupture with oxytocin
IUFD - mifepristone + misoprotsol
Carboprost MOA
Stimulate uterine contractions
PG analogues
Oxytocin MOA
Stimulate ripening cervix, contract uterus and lactation role
Nifedipine MOA
CCB to decrease smooth muscle contractions
Terbutaline
B2 agonist - suppress ocntractions
