O&G Flashcards
Who should be offered a GTT (NICE)
BMI above 30 kg/m2
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
Minority ethnic family origin with a high prevalence of diabetes
Glycosuria: 2+ on one occasion or 1+ on 2 occasions
What GTT involves
Mother fasted overnight
Pre-test (fasted) blood glucose
75g glucose drink administered
Blood glucose checked 1 and 2 hours after
Effects of GDM
Fetus:
Fetal macrosomia
Polyhydraminos
Neonatal hypoglycaemia
Neonatal respiratory distress syndrome
Increased still birth rate
Maternal:
Increased risk of traumatic delivery (shoulder dystocia)
Increased c-section risk
Increased risk of GDM in subsequent pregnancies
50% increased risk of developing T2DM within 15 years
Management of GDM?
Offer women a review in the joint diabetes and antenatal clinic within 1 week of diagnosis
Educate women how to monitor blood glucose levels and that they are to keep a diary of results:
o Fasting: 5.3 mmol/L
o 1 hour post meal: 7.8 mmol/L
o 2 hours post meal : 6.4 mmol/L
o Only aim for these results if it is not causing problematic
hypoglycaemia and ensure that women are aware of the dangers
and symptoms of hypoglycaemia Diet and exercise advice (offer to all):
o Eat healthily and replace high GI foods with low GI foods
o Refer all women to a dietician
o Regular exercise e.g. 30 min walk post meal
o Offer a one week trial of diet and exercise to those with fasting
glucose <7mmol/L. If blood targets are not met introduce
medication
HRT follow-up?
3 months of treatment
HRT counselling
- Explain that unscheduled vaginal bleeding is a common side effect of HRT within first 3 months of treatment and should be reported at 3-month review appointment
- Complementary therapies: explain that efficacy and safety of these are unknown
- Stop HRT immediately if:
Sudden severe chest pain (even if not radiating to left arm).
Sudden breathlessness or cough with blood-stained sputum.
Unexplained swelling or severe pain in calf of one leg.
Severe abdominal pain.
Serious neurological effects, including unusually severe, prolonged headach.
Hepatitis, jaundice, or liver enlargement.
Blood pressure above systolic 160 mmHg or diastolic 95 mmHg.
Prolonged immobility after surgery or leg injury.
Detection of a risk factor which contraindicates treatment
o Stress the importance of regular breast self-examination and attending breast and cervical screening.
In the counselling candidate should mention:*
- Sleep hygiene
- Alcohol and caffeine reduction, stopping smoking
- Regular exercise.
Fan at night, loose clothing
Follow up:
o At 3 months to assess efficacy and tolerability
o Annually thereafter unless there are clinical indications for an earlier review
(such as treatment ineffectiveness, side effects or adverse events).
Menopause risks and benefits?
Risks: breast cancer, ovarian cancer. Some irregular bleeding to start with, nausea. Very small risk of CVD.
Benefits - protects bone, symptom control, reduces the risk of colorectal cancer by 1/3
Ix for neonatal jaundice
Bloods:
o FBC: anaemia and WCC for infection
o LFTs
o Bilirubin: both conjugated and unconjugated
o Baby’s blood group
o Serum T4 and TSH
o Blood film: looking for spherocytes etc
o Screen for inherited disorders: pyruvate kinase levels, UDP glucoronyl
transferase, alpha 1 antirypsin, plasma galactose
Urine dipstick (to exclude infection)
Complications of biliary atresia?
May need full liver transplant
Kernicterus
Follow up Kawasaki disease
Follow up
Echo at 6 weeks to confirm absence of aneurysm
Close follow-up with repeat echocardiograms required to rule out
complication of aneurysms
Differentials for leukaemia?
Aplastic anaemia, EBV, hepatitis, neuroblastoma
Follow-up after meningitis?
Hearing tests as can cause deafness
Risk factors of OC?
Personal history
South American, Indian
Family history
Multiple pregnancy
Older age
Urge incontinence cause?
Due to destrusor overactivity
Clomiphene risks?
Multiple pregnancy,
2nd line after clomiphene?
GnRH
Histuism treatment?
COCP (Dianette)
Cyproterone acetate
Follow-up care of PID?
Review in 72 hours and at 2-4 weeks
Large for dates
Differential Diagnosis for large for dates
Constitutionally large for dates (LFD).
Polyhydramnios.
o The increased discomfort, irritable uterus and shortness of breath suggest polyhydramnios.
o Amniotic fluid is produced almost exclusively from the fetal urine from the second trimester onwards. Polyhydramnios is given to an excess of amniotic fluid, AFI > 95th centile for gestation on ultrasound estimation.
o Causes of polyhydramnios:
Maternal
Diabetes -
Placental
Chorioangioma
Arterio-venous fistula
Foetal
Multiple gestation
Mono-chorionic – twin-twin transfusion syndrome
Idiopathic
Oesophageal atresia, Duodenal atresia, Neuromuscular
fetal condition and anencephaly – prevent swallowing of
the amniotic fluid
Renal complications
The previous dating and second-trimester USSs have excluded multiple pregnancy and fetal anomaly which might be associated with polyhydramnios (e.g. duodenal atresia).
Wrong dates.
Multiple pregnancy.
Macrosomia (e.g. secondary to diabetes).
Hydrops.
Investigations for polyhydramnios
Glucose tolerance test of the mother
USS
1. Confirm LFD (BPD, abdominal circumference);
2. Measure liquor volume;
3. Exclude multiple pregnancy;
4. Exclude fetal anomaly that may have been missed on earlier scans
5. Identify evidence of hydrops (e.g. fetal oedema/effusions and/or ascites).
Rhesus status and antibodies – hydrops
Risks of polhydramnios?
Pre-term labour, PPROM, cord prolapse, unstable lie, PPH, malpresentation
Differential diagnosis of PCB
Differential diagnosis of PCB
Uterine:
Neoplasia
Hyperplasia Polyps
Fibroids
Cervical:
Ectropion
Endocervical polyp
Complication of COCP
Chlamydia or other STI
Cervical malignancy
Vaginal:
Trauma
Atrophy
STI Urogenital:
Haemorrhoids
Investigations for PCB?
Full STI screen:
o Endocervical swab for chlamydia
o Endocervical swab for gonorrhoea
o High vaginal swab for trichomonas and candida (not an STI but could
cause vaginitis and thus PCB)
Take a smear to exclude CIN/ malignancy although this is highly unlikely
considering her age
Always investigate PCB to exclude significant pathology
Three treatment options for cervical ectropion?
o Stop COCP and switch to another contraceptive o Cold coagulation of the cervix
o Diathermy ablation of the ectocervix
Confirming PPROM
Nitrazine testing: Allows for the detection of amniotic fluid which alkaline compared
to vaginal secretions which are acidic. Elevated pH turns nitrazine stick black.
Ultrasound: Amniotic fluid volume directly correlates to the latency period in
PPROM
Amniocentesis: Sample amniotic fluid can be sent for Gram stain and MC&S to
establish the cause of the intrauterine infection
Treatment of PPROM?
Senior help, ABC assessment
High vaginal swabs, CTG continuous, erythromycin. Needs IOL.
In pregnant women with diagnosed PPROM, delivery should be considered at 34 weeks of gestation. Where expectant management is considered beyond this gestation, women should be informed of the increased risk of chorioamnionitis and the decreased risk of respiratory problems in the neonate.
Testing amniotic fluid in PPROM?
Insulin-like-growth factor binding protein 1 or placenta alpha microglobumin-1 (PAMG-1)
Premature labour risk factors?
Young maternal age, chorioamniotis, polyhydramnios, sepsis, illegal drug use, pre-eclampsia, previous preterm delivery
Treatment of premature labour?
Management
Continuous fetal monitoring
Maternal steroids:
o Betamethasone IM – ideally two doses between 12-24 hours apart
Tocolytics:
o Aim to prolong labour for 24 hours to:
Allow steroids to be effective
Transfer of mother to unit with NICU facilities
o Choice agents:
Atosiban (oxytocin antagonist) Ritodrine (beta agonist)
Nifedipine
GTN
Assessing prolapse?
POP-Q score
Causes of prolapse?
Vaginal delivery and pregnancy
Congenital factors, menopause, iatrogenic
Ix for prolapse?
Observations, BMI, abdo exam, speculum and bimanual, pelvic USS,
Prolapse treatment
Conservative
Weight control.
Stop smoking.
Pelvic floor exercises.
Vaginal pessaries (e.g. ring or shelf) may be used to provide symptom relief if the patient is unfit for operation, or wishes to avoid, surgery. Pessaries are more likely to be helpful in women with a prominent suprapubic arch and strong perineal body for support; otherwise the pessary is easily expelled. Pessaries are generally replaced every 4–6 months.
Medical
Vaginal oestrogen cream or HRT.
Surgical options
Prolapse surgeries
Sacrohysteropexy, Manchester repair, vaginal hysterectomy with sacrospinous fixation,
Causes of reduced fetal movements
Prolonged periods of fetal sleep without any compromise.
Fetal compromise.
Fetal death.
Fetal movement decreases with advancing gestational age, oligohydramnios, smoking, betamethasone therapy.
Management of stress induced amenorrhoea
Encouraging the woman to eat a more normal diet and to avoid exercising
is the ideal management
Anorexia is a chronic disease that is often refractory to treatment.
Explanation that her periods will return if she increases her BMI may
possibly encourage her to put on weight.
The combined oral contraceptive pill should be prescribed in the
meantime, which will prevent osteoporosis and bring on periods, albeit pharmacologically induced.
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Referral to a specialist eating disorders unit is vital in addressing the long-term problem for this woman.
Commonly, eating disorders arise out of childhood difficulties and family or group therapy should be considered.
If the investigations suggest renal or hepatic impairment then inpatient management is likely to be necessary.
SGA investigations?
BP, urinanalysis, CTG, USS, doppler
Regular check ups, USS and dopplers during pregnancy (every 2-4 weeks) and may have to deliver early
N.B: The symptom of bleeding between the pill-free interval in a woman taking the combined oral contraceptive pill is known as breakthrough bleeding. History should include:
Has she been missing any pills?
Has she taken any other medication, which might interefere with the COCP (e.g.
antibiotics, enzyme inducers)?
Has she had any intercurrent illnesses causing diarrhoea or vomiting?
Has she ever had any sexually transmitted infections, or been investigated for
this?
How many sexual partners has she had in the last 3 months?
Has she recently changed the COCP that she uses?
IMB differentials?
- COCP related
o Poor compliance
o Infection causing poor pill absorption o Drug interactions
o Inadequate oestrogen component
o Pregnancy - Unrelated to COCP
o STI: chlamydia, gonorrhea and trichomonas o Non –STI: Candida
o Cervical: Ectropion or polyp
o Bleeding disorder
IMB ix?
Obs, abdo, vaginal and speculum exam, high vaginal and endocervical swabs, pregnancy test, USS if required
STI Advice?
Avoid intercourse, including oral and rectal, before treatment of partners is completed.
Use condoms when treatment is complete, as this is the only contraception that protects against ST)’s.
A follow up interview within 2-4 weeks
Retesting if any doubt about complete treatment. Test of cure should be
performed a minimum of 5 weeks after initiation of treatment
If change of partner, retesting between 3-12 months
Management of stress incontinence
Conservative:
Lifestyle
Control exacerbating symptoms:
o Reduce weight
o Stop smoking to relieve chronic cough
o Alter diet and consider laxatives to avoid constipation
Pelvis floor exercises: properly taught PFE can improve symptoms or cure
in up to 85% of women. 1st line for 3 months. 8 contractions, at least 3 times a day.
Medical:
Duloxetine: SNRI drug. Common s/e is nausea
Surgical:
Transvaginal or transobturator tape
Colposuspension
Periurethral bulking injection in refractory cases or unsuitable for
surgery.
Questions for TOP?
Patient’s feeling about pregnancy, her partner, future life plans, LMP,
Long acting contraception, safeguarding, STI screen
Arrangement for follow-up, support groups etc.
Surgical methods of abortion
Surgical methods
Perform chest examination to see if they are up to general anaesthesia
0-14 weeks of gestation
o Vacuum aspiration with suction cup and blunt forceps
Either electric or manual vacuum aspiration
Dilate the cervix
Vacuum aspiration under 7 weeks of gestation should be
performed with appropriate safeguards to ensure complete
abortion
After 14 weeks of gestation
o Dilatation and evacuation under general anaesthetic
Cervical preparation for surgical abortions
o Should be considered in all cases
o Misoprostol vaginally or sublingually prior to surgery
o Prevents cervical trauma and haemorrhage leading to future
cervical incompetency
Pain relief for surgical abortion
o NSAIDS
Follow up after abortion?
After
Follow-up
o 2 weeks after the procedure to check: Abortion is complete
Exclude an ongoing pregnancy
Check for possible pelvic infection
Assess the womans emotional state
Advice on contraception and sexual health
Medical
o Anti-D to RhD-negative women Contraception
o OCP, IUCD
o All hormonal methods should be started on the day of the abortion. o Female sterilisation is usually performed 6-8 weeks after an
abortion, as it has a higher failure rate when undertaken at the time of surgical abortion.
RISKS OF C-SECTION:
Surgical e.g. haemorrhage, infection, long recovery, thromboembolic disease
Anaesthetic
Increased risk of IRDS (infant respiratory distress syndrome)
VBAC where is birth?
Labour ward
Continuous CTG
Disadvantages of VBAC?
E C-section, sar rupture
VTE/PE Ix?
Observations, examination
ECG, ABG, CXR
Doppler USS, thrombophilia screen, anti-cardiolipin antibodies
