O&G Flashcards
How manage an OP head presentation
Likely will spontanoeusly rotate however if needs rotating after long labour ideally use kielland forceps
What is sign on examination of cocaine use causing placental abruption
Dilated pupils
Hyperreflexia
What give for hypermagnesaemia in after mag sulph
Calcium gluconate
How are ovarian masses managed
Assess on TVUSS whether any M features of cysts
If any M features then refer under 2WW
If
- under 50mm then can rescan in 3 months
- 50-70mm rescan in a years time
- over 70mm consider MRI or surgery
What do if premenopausal woman has an ovarian mass with any complex features of mass
Refer to gynae oncology and measure AFP, LDH and HCG
When refer for RFM
24 weeks
How long after a medical termination of pregnancy is pregnancy test expected to be positive
4 weeks- if longer suggests trophoblastic disease or retained products of conception
Causes of cervical tenderness
PID
Ectopic
What are sections to abortion act
2 doctors in good faith agree
A- continuing would risk life of pregnant woman
B- necessary to prevent grave physical or mental health risk of mother
C- pregnancy not exceeded 24 weeks and continuance would involve risk of injury to physical or mental health of mother
D- not exceedd 24 weeks and would involve risk to mental/physical health of existing children
E- born handicapped
Before 9+0 weeks what are options with regards to medical abortion options
Can do mifepristone and misoprostol at same time or with interval
- bleeding worse with together
- more likely to fail if together
Difference in prep for surgical abortion
All doxycycline 3 days, LMWH for 7 days and anti-D if Rh negative over 10 weeks
Before 14 weeks= oral misoprostol 1 hour before or sublingual misoprostol
14-19 weeks= osmotic dilators or vaginal misoprostol
19-23+6 weeks= osmotic dialtors and mifepristone both the day before
When is pregnancy test given post abortion
Medical up to 10+0 weeks
Is a multilevel pregnancy test which can measure HCG levels
Management of vaginal bleeding pre 6 weeks pregnant
Send home if no previous ectopic
Ask to do pregnancy test in 7 days
Return if positive or still bleeding or pain develops
If negative likely will have miscarried
What to do about anti-epileptics when breastfeeding
Any are fine except barbiturates
What type of C-section do if breech noticed whilst in labour
Category 2 C-section
What is regime for intrapartum antibiotics for GBS
Given at start then at 4 hourly intervals
When can COCP be started postnatally
3 weeks if not breastfeeding
6 weeks if are
How treat UTI if breastfeeding
Trimethoprin
What is combined test result for edwards
Low oestriol and HCG
If have been detected as having GBS in pregnancy what is management post natally
Stay in hospital for 24 hours to monitor
If woman comes in with menorrhagia, what may prompt to do hysteroscopy or TVUSS
Hysteroscopy
- persistent intermenstrual bleeding
TVUSS
- dysmenorrhoea
- bulky uterus
What is synctocinon vs synctometrine
Synctocinon= oxytocin
Synctometrine= synctocinon and ergometrine
What can iliac fossa pain with onset with exercise suggest
Ruptured ovarian cyst
Ovarian torsion
If has laparoscopy which is unremarkable but dye studies show blocked tubes, what is diagnosis
PID as endometriosis would appear on laparoscopy
What is other name for balloon catheter used in PPH
Bakri catheter
When when going from Cu IUD to COCP what extra contraception needed
In first 5 days do not need condoms
If any other times barriers for 7 days
When should ubilical hernias be referred
2 years
How assess viable intrauterine pregnancy on TVUSS
First assess if heartbeat
If is not, see if foetal pole
If there is measure CRL
If not measure gestational sac
If have done USS and shown no heartbeat but is a foetal pole, how interpret CRL
TVUSS
- Over 7mm then miscarriage likely so check with someone for viability or return in 7 days to rescan
- If under 7mm repeat in 7 days
Abdo USS
- record CRL and repeat in 14 days
If no foetal pole how assess gestational sac
TVUSS
- if over 25mm then check viability with someone or rescanin 7 days
- if under repeat in 7 days
Abdo USS
- record length and repeat in 14 days
How is pseudosac excluded
Presence of eccentrically located hypoechoic structure with a double decidual sign
How to manage pregnancy of unknown location
Take HCG 48 hours apart
If increase over 63% then intrauterine- USS in 7-14 days to confirm
If greater than 50% decrease do pregnancy test in 2 weeks - return if positive
If between 50 decrease and 63% increase come back in 24 hours for full review by early pregnancy
Management of threatened miscarriage
Tell them that if bleeding still there in 14 days return or gets worse return
If disappears continue with antenatal care
If history of miscarriage give vaginal progesterone until week 16
When do pregnancy test in medical miscarriage management
3 weeks
If positive return
if negative is complete
How does expectant management of ectopic work
Measure HCG at day 2, 4 and 7
Looking for fall of over 15%
If after day 7 still decreasing repeat weekly
If not a decrease of over 15% at any time then reassess
A 16-year-old girl attends accident and emergency complaining of mild vaginal spotting. Her serum beta hCG is 4016mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip but are stable. Next investigation
TVUSS
Woman with twin pregnancy has really bad abdominal pain
Ruptured cyst
Management of bleeding post termination bleeding
If well do bloods to check if inflammatory response
If unwell A-E and TVUSS to look for retained products of conception
What is the crown rump length
The distance between top of head to most inferior part/ bottom of their buttocks
What increases cardiac output in pregnancy
Increase HR
Increase stroke volume
Acute presentation of sheehans syndrome
Headache and visual defect
Agalactia
What is difference between anterior and posterior tongue tie
Both are due to short frenulums
Can either be at the back or front
If cant see frenulum then likely problem is posterior
Which NSAID give when breastfeeding
Ibuprofen
What do when depression a clear focus in menopause history
CBT
What is given intraoperatively in hysterectomy to precent infection
Co-amox
Management of nipple cracks
Advise to keep expressing milk but avoid feeding until heals
Management of vulvodynia
Paracetamol/ibuprofen
Amitryptyline
Gabapentin
Classification of prolapses
1- cervix 1cm above hymen
2- cervix between 1cm above and 1cm below hymen
3- cervix reaches introitus
4- cervix extends out of introitus
When are CTGs used in labour
High risk
- DM
- SGA
Fever
Meconium
Synctocinon
Severe LIF pain with fever in post menopausal woman
Diverticulitis
Loin pain, tenderness and unwell in pregnant woman
Pyelonephritis- treat with cefalexin
Lung changes in pregnancy
Increased tidal volume
Increased minute ventilation
Gives feeling of breathlessness
Severe mittelschmerz presentation
Fever
Abdo pain
Fluid in pouch of douglas
If post subfertility screen, hormones, semen and STI screen negatove what do
If suspected underlying disease like endometriosis then laparoscopy and dye
If unclear do hysterosalpingography
What is in foetal hydantoin syndrome
IUGR
Hypoplastic nails
Cleft lip/palate
Microcephaly
Limb problems
What are haematometra and haematocolpos
Blood in uterus and cervix respectively
Features of congenital syphilis
Blood stained rhinitis
Hepatitis
Meningitis
Hitchinson teeth- small widely spaced teeth
Saddle nose deformity
Anterior bowing of shins
Symmetrical knee swelling
Perisoteal reactions
What are more common in a 20smt old cervical polyps or cancer
Polyps
How can BMI affect HRT administration method
If over 30 use dermal
What is risk of using nitrofurantoin near term
Neonatal haemolysis
Analogous male cells of granulosa and theca cells
Granulosa- sertoli
Theca- leydig
How can atrophic vaginitis present
Urinary like stress incontinence
Dyspareunia
Vaginal bleeding
Where does ovarian pain get referred
Peri umbilical area
Medications which cause stress incontinece
Alpha blockers like doxazoxin
When during pregnancy do diabetics get their retinal screening
24-28 weeks
What is it when have irregular bleeding in first few years after menarche
ANNOVULATORY dysfunctional uterine bleeding
How often is ECV successful
60%
When consider third line options for shoulder dystocia
After 5 minutes
What does active management involve
Synctocinon after delivery of anterior shoulder
EARLY clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
Controlled cord traction after signs of placental separation
DONE TO REDUCE PPH RISK
If has chosen an induction of labour with intrauterine death what does management depend on
If any bleeding, infection or ruptured membranes then c-section or induction
For all other women offer induction, expectant or C-section
If uterine scar with induction then must use mechanical options
If no scar then use mifepristone then misoprostol
What prompts constant CTG usage
New onset bleeding
Temp above 38 or suspected infection
Oxytocin use
Presence of meconium
If have given vaginal prostaglandin what do next
Reassess in 6 hours
If bishops score under 7 give again
What type of drug is carboprost vs ergometrine
Carboprost- oxytocin analogue
Ergometrine- alpha blocker
What analgesia used if epidural contraindicated
Remifentanil
In episiotomy what muscle are you trying to avoid
Ischiocavernous as involved in sexual function
When consider vaginal delivery in chord prolapse
Cervix fully dilated and head engaged
Must use forceps
How are the anterior and posterior fontanelles described
Anterior- diamond
Posterior- Y
What is Mazzanti technique
When pressure applied on abdomen to help with McRoberts
With SROM what is management
Sterile speculum exam or obtain a sample of liquor to test
Offer IOL or expectant management until 24 hours
Shock out of proportion to bleeding and pain postnatally
Uterine inversion due to pulling on the round ligament which can cause vagal stimulation
MOA of nifedipine, atosiban and terbutaline
Nifedipine- CCB
Atosiban- oxytocin antagonist
Terbutaline- beta 2 agonist
Tests for PPROM
Alpha microglobulin-1
Insulin like globulin binding protein-1
What cervical length suggests preterm labour imminent
Under 15mm
What is cutoff fibronectin to indicate imminent labour
Over 50 suggests labour likely within 48 hours
Generally at what point should women be admitted when theyve started contracting
When cervix reaches 4cm dilated or contraactions every 5 minutes
How is vasa praevia best diagnosed
Trans vaginal and abdominal USS with colour doppler imaging
What is management of vasa praevia when identified pre rupture of membranes
Consider permanent hospitalisation from 32 weeks
Give steroids from 32 weeks
Aim for elective C-section 34-36 weeks
Dose of vitamin D in pregnancy
Should take 10mcg/day
Who should have an OGTT based on identification at booking
People with family history of DM
Previous baby over 4.5kg
BMI over 30
Ethnicity with high DM prevalence
Previous GDM (has OGTT straight away)
Management of pre-existing DM
Ensure low BMI
Good exercise and diet
Folic acid until end of first trimester
Stop all hypoglycaemics except insulin and metformin
Screen for renal and retinal damage within first 3 months
If opt in for congenital syndrome screening what are options
If book early then offered between 11 and 13+6 weeks the COMBINED test
Between 14+2 and 20+0 offered QUADRUPLE test
What do at 16 week visit
Discuss results of blood tests
- infections
- autoantibodies
- rhesus D
- Hb and folate etc
Treat Hb
Offer vaccinations
- pertussis
- influenza ideally in Oct-jan
Discuss mid-pregnnacy scan
When are second blood taken in pregnancy
28 weeks
From when in pregnancy is anti-d required for miscarriage or PV bleeding
From 12 weeks for miscarriage
Post natal management of rhesus negative mothers
Cord blood taken and coombs test done
Give anti-D
What are causes of high vs low AFP
High
- NTD
- pataus
- gastro wall defects
- multiple pregnancy
Low
- maternal DM
- downs
- edwards
When monitor TFTs if hypothyroid and pregnant
2 weeks after a dose change
Once a trimester
Risks of using NSAIDs in pregnancy
PPHN
Oligohydramnios
Premature closure of DA
If metformin is not tolerated in GDM what use instead
Glibenclamide- sulphonylurea
What is association of phenytoin in pregnancy
Cleft lip
Best way of assessning EDD before and after 14 weeks
Before 14- crown rump length
After 14- Biparietal diameter
If refuse induction of labour at 42 weeks what is needed
Twice weekly CTG and USS
Triple test for downs
High bHCG
Low AFP
Low oestriol
What is most appropriate method for monitoring SGA
Doppler of umbilical artery
If SFH is noted to be faltering, what is next thing do
USS to estimate foetal size
Management if epileptic has seizure during labour
IV lorazepam
Second line IV phenytoin and tocolysis
What are indications to do an USS to estimate foetal size
SFH faltering
SFH below 10th centile
Differentiating acute fatty liver and HELLP
Anaemia only in HELLP
Hypoglycaemia in acute fatty liver
If pregnant or peuperal comes in with suspicion of DVT what do
LMWH and duplex USS
What do if pregnant or peuperal woman has come in with DVT suspicion and duplex USS negative despite high suspicion
Treat anyway and rescan on days 3 and 7
If pregnant or peuperal woman comes in with PE and DVT signs what do
ECG and CXR with treatment
Duplex USS
If pregnant or peuperal woman has comes in with DVT and PE signs with positive duplex what do
No further investigations needed
If pregnant or peuperal woman has comes in with PE and no DVT signs what do
CTPA or V/Q
What can be used to treat polyhydramnios
Indomethacin
What is biggest risk factor for stillbirth
IUGR
If refuse insulin what offer
Glibenclamide
Management of candida
1 dose oral fluconazole then return if still bad
Can use intravaginal or topical clotrimzole
Fluconazole CI use itraconazole
If aged 12-15
- refer to GUM
- topical clotrimazole cream
Management of recurrent candida, BV and herpes
Candida- over 4x a year
Induction and maintenance regime
Induction- 3 doses of fluconazole, 1 every 3 days
Maintenance- fluconazole once a week for 6 months
BV- 4x a year
Give metronidazole gel or refer to gum
HSV-6
1st line- encourage bathing technique measures
2nd line- if fewer than 6 times a year can offer aciclovir for episodic treatment
if over 6 can offer suppressive therapy every day
Which bacteria often colonises in BV
Gardnerella vaginalis
Mycoplasma hominis
Management of persistent BV
Use alternative tx to one already used like if used pill use intravaginal
Management of HSV genitally
Ideally refer to GUM
If refused give aciclovir
Management of ectopic if intrauterine pregnancy
Medical mx contraindicated
Management plan for uncomplicated chlamydia infection
1st line- encourage bathing technique measures
2nd line- if fewer than 6 times a year can offer aciclovir for episodic treatment
if over 6 can offer suppressive therapy every day
Test of cure 6/12 later
Dissemninated gonococcal disease presentation
Polyarthritis
Vasculitic rash
Fever
What is cobblestoned appearance of cervix seen in
Chlamydia
What is most likely cause of bartholins abscess
E coli
Chandelier sign
What is most likely cause of bartholins abscess
What becomes corpus luteum
Non-dominant follicles
How does ulipristal acetate work
Progesterone receptor modulator which inhibits ovulation
When need to double the dose of levonorgestel
BMI over 26
Weight over 70kg
On liver induces such as carbamezapine and rifampicin
What do for contraception if take a teratogenic drug like sodium valproate
Use a highly efficient method like Cu-IUD, LNG-IUS or progestogen injection
+
Advise to use barrier protection
OR
If want to use other method like combined hormone contraception or progestogen MUST use barrier protection
What contraception avoid if unexplained vaginal bleeding
Intrauterine device and system
Progestogen implant or injection
What do if miss 2 or more COCP
Take 2 on a day and discount other missed ones
Use condoms until taken pills for 7 days
If on week 1- consider emergency contraception if UPSI
If week 2- no need for emergency contraception
If week 3- finish the pack and then omit pill free period
If develop irregular bleeding on progesterone implant or injection what is management
Rule out other causes like STIs
Then can initiate COCP
MOA of the different contraceptives
LNG-IUS= prevent proliferation of the endometrium and thicken cervical mucous
Desogestrel= prevent ovulation
Injectable and implantable= inhibits ovulation and thickens cervical mucous
Older POP= thicken cervical mucous
How does DM, HTN and multiple CVD risk factors affect smoking
DM
- any fine however if vascular disease then avoid combined
If multiple
- avoid injectable and combined
HTN
- controlled avoid combined and if uncontrolled avoid injectable too
What is placenta accreta vs increta
Accreta- through basal decidua into superficial myometrium
Increta into myometrium
Management of asymptomatic placenta praevia at 32 weeks
Treat as outpatient
- safety net about bleeding and sex
Give steroids at 34-36 weeks
Re-scan at 36 and deliver within a week if still placenta praevia
Management of someone with recurrent bleeding from low-lying placenta/placenta praevia
Tailor between hospitilisation and outpatient based on distance to hospital from home, transport, bleeding episodes and haem results
Can admit steroids prior to 34 weeks
Deliver 34-36 weeks
When and how should deliver if placenta praevia
If asymptomatic 36-37 weeks
If bleeding and risks of preterm then 34-36+6
Ideally C-section but can consider vaginal if low lying and asymptomatic
Management of placenta accreta
MDT approach
Planned c-section at 35-36+6
Trained memebers of team
Blood products present
Resus for a minor PPH
A-E- assess for shock
LIE flat
IV access and take bloods for FBC, clotting
Infused warmed crystalloid
Obs every 15 mins
Fluids used for major PPH
2L isotonic crystalloid then 1.5L colloid
How is PPH prevented
If no risks and vaginal
- oxytocin IM 10units
If risks
- ergometrine-oxytocin unless HTN
If c-section
- oxytocin slow infusion
When do you transfuse platelets in PPH
If below 75
Management of suspected endometritis
Admit to hospital
High vaginal and endocevical swabs
IV clindamycin and gentamicin
What drugs should be avoided if breastfeeding
Abx- Tetracyclines, chloramphenicol, sulphonamides
Lithium
Benzos
Aspirin
Carbimazole
Sulphonylureas
Amiodarone
Chemo
What happens if rhesus positive baby born to negative mother
500IU within 72 hours
Kleihauer test
Cerebral venous thrombosis presentation, investigation and management
Severe headache but can get blurred vision
MRI
IV heparin
Who is at high risk for pre-eclampsia and needs aspirin from week 12 of pregnancy
If 1 of
- HTN during previous pregnancy
- CKD
- DM
- autoimmune condition
If 2 of
- family history of pre-eclampsia
- 10 year gap between pregnancy
- multiple pregnancy
- over 40
- BMI over 35
Chronic HTN management in pregnancy
Stop thiazides, ARB and ACEi
Continue old treatment unless under 70/110
If over 90/140 start labetalol
CI use nifedipine
Both CI use methyldopa
Give aspirin from week 12 and offer PIGF past week 20 to check for pre-eclampsia
Measure every 2-4 weeks
Postnatal mangement if someone with chronic HTN or gestational HTN has given birth
Measure BP daily for first 2 days
Once between 3-5 days
Keep below 140/90
Management of gestational HTN
If 140/90-159/109 then refer to be seen within 24 hours by obstetrician- use pharmacological agents to reduce below 135/85
If over 160/110 then admit immediately and treat until below 160/110- measuring every 15-30 mins
How are people with gestational HTN monitored
Weekly
- BP
-Urine dip
- FBC, LFT and renal function
Every 2 weeks
- USS
Who should be offered placental growth factor
Everyone with gestational HTN or chronic HTN post 20 weeks
If low indicates high risk of eclampsia
How can risk prediction in pre-eclampsia be assessed
PREP-S prediction model
If pre-eclampsia how are you monitored
If treated as outpatient for mild pre-eclampsia
- BP every 48 hours
- FBC, LFTs, renal function 2x a week
- fetal USS every 2 weeks
If in patient for severe
- FBC, LFTs, renal function 3x a week
Management plan for premature labour
Determine if rupture of membranes
If no rupture just dilation and contractions
- admit for tocolytics and steroids (in case goes into labour)
If rupture
- admit
- steroids if before 34 weeks
- mag-sulphate if before 30
- erythomycin until delivery/10 days
- contact neonatologist
What do with delivery in pre-eclampsia
If before 36 weeks continue with surveillance and consider antenatal steroids unless
- sats less than 90
- failure to control BP with 3 anti-hypertensives
- placental abruption
- continuining deterioration of symptoms and blood results
If after 36+6 then deliver within 48 hours
What do if no fetal movements felt by 24 weeks
Referral to foetal medicine unit
Causes of oligohydramnios
Premature rupture of membranes
IUGR
Post-term gestation
Pre-eclampsia
Potter sequence
Posterior urethral valve
Who is regular US surveillance to measure cervical length indicated in
History of preterm birth or spontaneous loss in second trimester but cervical length over 25mm
If found to go under 25mm pre 24 weeks then do TV cerclage
Who is vaginal progesterone indicated in for prevention of preterm birth
History of spontaneous preterm birth or miscarriage in second trimester
How should ICP be monitored
1 week after initial blood tests then on individual basis
When give birth with ICP
Depends on levels of bile acids
If 19-39: by 40 weeks
If 39-100: 38-39
Over 100: 35-36
If have asymmetrical IUGR how are monitored
USS every 2 weeks
Doppler USS twice weekly
If develop chorioamnionitis after PPROM how manage labour
Induce in 24 hours
Antibiotic choice if allergic to penicillin in GBS IAP
If non-severe allergy use a cephalosporin
If severe use vancomycin
What do if prelabour rupture of membranes and GBS status is positive
Before 34 weeks expectant management
After 34 weeks can expedite delivery
If after 37 immediate induction
Management of herpes infection in pregnancy
In first and second trimester
- treat with oral acyclovir unless encephalitis
- for delivery treat from 36 weeks with aciclovir until delivery
If in third trimester
- aciclovir until delivery and should be C-section
How is parvovirus confirmed in pregnancy then what is management
2 positive IGM readings
Infection takes 6 weeks to affect baby
Therefore referral to foetal medicine within 4 weeks to do an USS of the middle cerebral artery every 2 weeks
Management of UTI in pregnancy first 2 trimesters
First line- nitrofurantoin for 7 days
Second line (no response in 48 hours or contraindicated)- cephalexin, amoxicillin
How manage refusing a c-section with HSV
IV infusion of aciclovir during the pregnancy and close liason with neonatologist
In HIV vaginal delivery, what is not recommended
Prolonged rupture of membranes
Artificial rupture of membranes
What suggests foetal anaemia on middle cerebral artery USS
Elevated peak systolic velocity
Management of chickenpox if breastfeeding
Aciclovir within 24 hours of onset of rash
Are IAP given for GBS if C-section
No unless rupture of membrane or preterm
What antibiotics if get PID in pregnancy
IV erythomycin and ceftriaxone
Management if varicella infection around the time of birth
Try to give birth at least 7 days after onset of rash
If give birth within 7 days then give baby VZIG
If in 7 days post natal then give infant VZIG
In HIV vaginal delivery, what is not recommended
Prolonged rupture of membranes
Artificial rupture of membranes
Hepatitis B vaccine schedule if born to positive mother
One within 12 hours of birth
One at 1-2 months
One at 6 months
Management of feto-foetal transfusion syndrome
Refer to feotal meicine for ablation of interconnecting vessels
When are twins recommended to be born
Dichorioic diamniotic- 37
Monochorionic diamniotic- 36
Monochorionic monoamniotic- 32-33+6
What causes pansystolic murmur in pregnancy
Dilation of tricuspid valve
Which conditions reduce in severity over pregnancy
MS and rheumatoid arthritis
What needs to be done to AEDs during pregnancy
Increase the dose
How does pruritic urticarial papules and plaques of pregnancy present
Itchy rash starting on stretch marks and spreading anywhere with umbilical sparing
Starts at end of pregnancy
How does pemphigoid gestationis present
Itchy rash which starts in the umbilicus that can develop into blisters
How does prurigo gestationis present
Rash of the trunk and arms with abdominal sparing
How does impetigo herpetiformis present
Blistering skin condition with cocontaminat febrile illness
Postnatal management of pre-eclampsia
If over 160/100 then have to stay in
If over 150/100 then must be monitored every 2 days
If less than 150/100 checked weekly and weaned off anti-hypertensives
If less 130/80 can stop anti-hypertensives
Post natal management of GDM
If new onset GDM- stop all medications after birth, offer fasting glucose 6 weeks after
If T1DM- put on sliding scale and when starts eating again give pre-pregnancy dose
If T2DM- can resume metformin but avoid others
At 6 weeks postnatal how interpret fasting glucose
If under 6- repeat annually
If 6-6.9- At high risk of developing DM so offer lifestyle interventions
Over 7- initiate testing for T2DM
What drugs can use for vasomotor symptoms in menopause that are not HRT
SSRI- fluoxetine, citalopram
SNRI- venlafaxine
Clonidine (alpha 2 agonist)
Gabapentine
Genitourinary symptoms management in menopause
1st -Vaginal oestrogen
2nd- increase dose
3rd- opsemifene
Contraindications to HRT
Breast cancer currently or in past
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Active liver disease
Thrombophilic
Previous VTE
Oestrogen dependant cancer history
Can you have HRT with prior VTE
Only if being actively anti-coagulated
Management of premenstrual syndrome
Mild
- lifestyle- exercise, small meals 2-3 hours apart, stop smoking alcohol
Moderate
- COCP
Severe
- SSRI for luteal phase or continuous
What are at risk adolescents for PCOS
Girls who do not quite meet the criteria for PCOS diagnosis
How manage at risk girls for PCOS
Start on the COCP then before 8 years post menarche withdraw the COCP for 3 months and assess if is hyperandrogenin anovulation
Then need to assess endometrial thickness in PCOS
If less than 1 period every 3 months
Amenorrhoea management in PCOS
prescribe cyclical progestogen for 14 days to induce a withdrawal bleed and then refer for TVUSS
If over 10mm get sampling
If normal then offer either low dose COC, cyclical progestogen or LNG-IUS depending on whether wants withdrawal bleeds or has acne etc
If does not wish to have any of these then refer to specialist where will be offered USS every 6-12 months
Weight loss also useful
Management of pain in primary dysmenorrhoea
Mefanemic acid and paracetamol
2nd line COCP
3rd line can use POP or Mirena
What are spiral arteries
Supply the endometrium
Investigations for primary amenorrhoea
TSH
FSH/LH
Prolactin
Testosterone
TVUSS
What do if prolactin 500-1000
Primary amenorrhoea investigation
Repeat
How to manage amenorrhoea caused by excess exercise, weight loss or stress
Refer all to endocrinologist to rule out pituitary tumour
If ruled out
Excess exercise- reduce exercise and refer to sports physician if possible
Stress- manage stress
Weight loss- dietician or relevant services if ED
When refer to gynae for secondary amenorrhoea
POI in under 40
Recent uterine or cervical surgery suggesting asherman or endometritis
Infertility
How to daignose asherman syndrome
Hysteroscopy
Management of vulvovaginitis
Good hygiene
Wear cotton undergarments
Management plan if unprovoked vulvodynia
First line- amitryptylline
Second line- gabapentin or pregabalin
What type of drug is mefanemic acid
Prostaglandin inhibitors
In PMS, how give the COCP
Omit pill free period
What defines primary dysmenorrhoea
It occurs within 1 year of menache
What is best drug for dysmenorrhoea if dont want to take a pill every day
Mefanemic acid as can be given as a short course
How to interpret mid luteal progesterone
Under 16- repeat and refer if chronically low
16-30- repeat
Over 30- normal indicating ovulation
Which contraceptives cause infertility after removal
Injectable- a year
Dermal and vaginal ring a few months
Management of mild and moderate OHSS
As an outpatient
- paracetamol
- oral fluids
- monitor every 2-3 days
- can do paracentesis if need to in outpt setting with USS
When admit with OHSS
- are unable to achieve satisfactory pain control
- are unable to maintain adequate fluid intake due to nausea
- show signs of worsening OHSS despite outpatient intervention
- are unable to attend for regular outpatient follow-up
- have critical OHSS
Normal ranges for male sperm factors
Motility- at least 50% should have normal motility
Morphology- over 4% good morphology
Sperm count- over 15 million is good sperm count
Volume- over 1.5 ml
How does clomiphene regime work
In oligomenorrheic women give a progestogen for 10 days and anticipate a withdrawal bleed. Once this happens give clomiphene on day 2 of the period and continue for 5 days
It is most effective when patient on period
How manage infertility in PCOS in GP
If BMI over 25 recommend weight loss
Ask to have regular sex for 2 years then can refer to fertility clinic for clomiphene etc
What does dyskaryosis mean
Hyperchromatic nucleus or irregular nuclear chromatin
How is normocytic anaemia managed in pregnancy
Trial of oral iron for 2 weeks
If no improvement then further tests
When do multiple pregnancy women have blood tested
Booking and 28 weeks
On top of this have at 20-24
What causes severe suprapubic pain post operation
Urinary retention
Leading maternal cause of death
Suicide
How are contractions assessed on CTG
Less than 5 in 10 minutes= white
5 or more in 10 minutes, hypertonus = amber
How is baseline foetal HR determined
Looking at mean foetal HR over last 10 minutes
How is foetal HR assessed on CTG
White- baseline between 110-160
Amber- 100-109, can’t determine base line or increase of HR over 20 since start of labour or review 1 hour ago
How deal with HR 100-109 but has been stable throughout whole labour with normal accelerations and decelerations
Manage as normal labour
How is variability of CTG assessed
Measure the difference in HR between highest and lowest HR in a minute segment in between contractions
How manage an absence of variability
Low threshold for expediting
How assess variability on a CTG
White- 5-25 beats per minute
Amber- fewer than 5 BPM for 30-50 minutes, more than 25 for up to 10 minutes
Red- fewer than 5 BPM for more than 50 minutes, more than 25 beats per minute for 10 minutes, sinusoidal pattern
When need to get an urgent review by obstetrician for consiering expediting delivery when reduction in variability of under 5 minutes
- combined with intrapartum rfx
- combined with rise in foetal HR
What are decelerations defeined as
Reduction in foetal HR by over 15 lasting at least 15 seconds
What defines repetitve decelerations
If occur in over 50% of contractions
How are decelerations classified
White- No decelerations, early decelerations, variable decelerations
Amber decelerations- repetitive variable decelerations with any concerning characteristics for less than 30 minutes, variable decelerations with any concerning characteristics for more than 30 minutes,
repetitive late decelerations for less than 30 minutes
Red- repetitive variable decelerations with any concerning characteristics for more than 30 minutes,
repetitive late decelerations for more than 30 minutes, acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more
What are early vs late decelerations
Early= slowing with onset early in contraction and returns to baseline by end of contraction
Late= slowing after onset of contraction and low point more than 20 seconds after peak of contraction
What is hypertonus
Contraction lasting over 2 minutes
What are accelerations defined as
Increase in HR over 15 lasting over 15s
How deal with accelerations on CTGs
Sign of normal and healthy baby, no concern
What makes a CTG suspicious vs pathological
Suspicious= 1 amber feature
Pathological= 1 red or 2 amber
Neonatal care of baby
APGAR at 1 and 5 minutes
Record time of first respiration
Ensure skin to skin ASAP
Dry and wrap in a towel
Initiate feeding within I hour
After 1 hour measure head circumfrence ,weighing and bathing
Care of babies in presence of meconeum
Assess HR, tone and RR
If abnormal use laryngoscope to remove meconeum
If healthy admit to neonatal ward with observations at 1,2,4,6,8,10,12 hours
Management of baby born after prelabour rupture of membranes 24 hours pre labour
Keep baby in for 12 hours
Assess at 1, 2, 6 and 12 hours
Varicella exposure in 7 days post partum
Give VZIG only if mum not immune
