O&G Flashcards
Define primary amenorrhoea
No periods by age 15 in girls with normal secondary sexual characteristics (such as breast development),
or by 13 in girls with no secondary sexual characteristics
Define secondary amenorrhoea
Cessation of menstruation for 3-6 months in women with previously normal and regular menses
or
6-12 months in women with previous oligomenorrhoea
PCOS features
- Subfertility and infertility
- Oligomenorrhea and amenorrhoea
- Hirsutism, acne (due to hyperandrogenism)
- Obesity
- Acanthosis nigricans (due to insulin resistance)
What would you expect PCOS bloods to show?
Get insulin resistance so high insulin and high LH usually seen. There is overlap with metabolic syndrome.
Raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. This is best measured days 1-3 of bleed
Prolactin may be normal or mildly elevated.
Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
Sex hormone-binding globulin will be low - Insulin suppresses hepatic production of SHBG, so get higher levels of free circulating androgens.
gonadotrophins and progesterone
Consider OGTT
What are the Rotterdam criteria?
PCOS diagnostic criteria:
Need 2 out of these 3:
1) Oligo/amenorrhoea
2) Clinical and/or biochemical signs of hyperandrogenism - e.g. hirsutism, acne, or elevated levels of total or free testosterone
3) Polycystic ovaries on USS
defined as the presence of 12 or more follicles (measuring 2–9 mm in diameter) in one or both ovaries and/or increased ovarian volume (greater than 10 cm3).
PCOS management
1) Weight management advice
2) For Hirsutism & Acne: COCP might help (3rd gen) as these have fewer androgenic effects. Co-cyprindiol can also be used - has an anti-androgen action.
If not helping, topical eflornithine can be tried.
Spironolactone, flutamide and finasteride may be used under specialist supervision
3) For infertility: Specialist led - usually clomifene 1st line then metformin or combination
What is androgen insensitivity syndrome?
X-linked recessive
End-organ resistance to testosterone causes genotypically male children (46XY) to have a female phenotype.
Features
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
Diagnosis
46XY genotype testing
Management
counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy
Turners syndrome:
45,XO or 45,X.
Features:
Short stature
widely spaced nipples
webbed neck
bicuspid aortic valve
coarctation of the aorta
primary amenorrhoea
high-arched palate
gonadotrophin levels will be elevated
horseshoe kidney: the most common renal abnormality in Turner’s syndrome
Define premature ovarian failure
How would you investigate?
cessation of menses for 1 year before the age of 40
High FSH (over 20) with no periods in a woman under 40 = ovarian failure
What is Sheehan syndrome?
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
Features may include:
agalactorrhoea
amenorrhoea
symptoms of hypothyroidism
symptoms of hypoadrenalism
What is urge incontinence
- AKA Overactive bladder.
-Is due to detrusor overactivity
-The urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
What is stress incontinence
Due to e.g. coughing/sneezing.
What is overflow incontinence?
Incontinence due to bladder outlet obstruction, e.g. due to prostate enlargement
How do you investigate incontinence
- Bladder diary (min 3 days)
- Vaginal examination - ? prolapse/ ‘Kegel’ exercises
- urine dipstick and culture
- urodynamic studies
Management of urge incontinence
- Bladder retraining - min 6 weeks.
- Medications: antimuscarinics are first-line (oxybutynin, tolterodine or darifenacin).
Immediate release oxybutynin should, be avoided in frail older women.
- Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Management of stress incontinence
Pelvic floor exercises.
Surgical options: e.g. retropubic mid-urethral tape procedures
Duloxetine (SNRI) may be offered if they decline surgery.
How long is VZV immunoglobulins effective for? ie what time frame does it need to be given in?
10 days.
If continuous exposures, this is defined as 10 days from the appearance of the rash in the index case.
What is shingles?
Shingles is caused by the reactivation of dormant VZV in dorsal root ganglion.
VZV
1)Risks to mum?
2)Risks to foetus
3) Risk to baby
1) - Maternal pneumonitis
2) - Fetal varicella syndrome (if below 20 weeks) - get things such skin scarring, microphthalmia, underdeveloped limbs, microcephaly and learning disabilities
3) Shingles particularly if 3rd trimester.
Severe neonatal varicella if mum develops rash between 5 days before and 2 days after birth.
How to manage chicken pox exposure in pregnancy?
If under 20 weeks and mum is not immune then VZIG. If in doubt do urgent blood test for antibodies.
If over 20 weeks can give VZIG OR antivirals. These have to be given 7-14 days after exposure ( more effective).
How to manage actual chicken pox in pregnancy
Ask a specialist.
Likely to say if over 20 weeks aciclovir if within 24 hours from rash onset.
If under 20 weeks aciclovir ‘with caution’
What is HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
Severe form of pre-eclampsia.
Pre-eclampsia definition
-New-onset blood pressure ≥ 140/90 after 20 weeks of pregnancy, AND 1 or more of:
-Proteinuria
-Other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Moderate risk factors for pre-eclampsia
-First pregnancy
-Age 40 years or older
-pregnancy interval of more than 10 years
-BMI of 35 or more at first visit
- family history of pre-eclampsia
-multiple pregnancy
High risk factors for pre-eclampsia
- hypertensive disease in a previous pregnancy
- CKD
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
When would you treat people with risk factors for hypertensive disorders in pregnancy and what with
If 1 or more high risk
If 2 or more moderate risk
Aspirin75-150mg from week 12 of pregnancy
How long before surgery do you need to stop HRT/ COCP?
4 weeks
(VTE risk)
What would low gonadotropins and high gonadotropins indicate in relation to amenorrhoea?
What would happen in Turners?
low levels = hypothalamic cause
raised levels = ovarian problem (e.g. Premature ovarian failure)
Raised if gonadal dysgenesis (e.g. Turner’s syndrome)
A rhesus -ve management
Anti D at 28 and 34 weeks
4Ts PPH
Tone
Trauma
Thrombin
Tissue
What do tocolytics do
Examples
Suppress uterine contractions
Nifedipine indometjacin
PPH management
OECall mum
- Basics from A->E (warm IVI)
- Palpate fundus of uterus
- IV oxytocin
- Ergometrine (slow IV/IM, C/I if htn)
- Carboprost IM (not if asthmatic)
misoprost S/L - Balloon tamponade
What is secondary PPH
Secondary PPH occurs between 24 hours - 6 weeks. It is typically due to retained placental tissue or endometritis.
Contraindications to HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
How do you decrease risk of endometrial ca from HRT
Give combined oral or transdermal HRT so that the oestrogen is not left unopposed.
Only need to do this if the woman has a uterus
Risk of HRT
Increased risk of:
- Breast & endometrial Ca
- stroke
- VTE but only with oral. Topical is ok
Non-HRT menopause management options
Vasomotor sx: fluoxetine, citalopram or venlafaxine
Self help/CBT
lubricants
Vaginal oestrogen
Main indications for HTR
Vasomotor sx e.g. hot flushes, headaches, insomnia.
Premature menopause - menopause before 40 - (risk of osteoporosis without HRT).
What type of HRT can peri and postmenopausal women have?
Monthly - oestrogen daily, progestogen at the end of the cycle for 10–14 days.
OR
3 monthly Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks
What type of HRT do postmenopausal women need?
continuous combined.
This can be using Mirena for progesterone
Ectopic pregnancy Investigation
Bhcg, TVUS
When can you expectantly manage an ectopic?
What does this mean
monitor for 48h and monitor HCG. if rises needs intervention
Can do:
If less than 35mm
No fetal heart beat
hCG <1,000IU/L
Asymptomatic
When can you medically manage an ectopic?
How?
If less than 35mm
No fetal heart beat
HCG over 1500
No significant pain
Give methotrexate. Pt must attend f/u
When would you surgically manage an ectopic?
How?
If over 35mm
with Fetal heart beat
May have ruptured
HCG over 5000
Salpingectomy )remove a tube)= first-line for women with no other risk factors for infertility
Salpingotomy (cut a hole in the tube) if risk factors for infertility such as contralateral tube damage.
around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
Induction of labour steps
- Stretch and sweep
- Vaginal prostaglandin E2 (PGE2)
also known as dinoprostone - Oral prostaglandin E1
also known as misoprostol - Maternal oxytocin infusion
- Amniotomy (‘breaking of waters’)
- Cervical ripening balloon
passed through the endocervical canal and gently inflated to dilate the cervix
Bishop score interpretation.
What scores for what methods of IOL?
< 5 indicates that labour is unlikely to start without induction
≥ 8 there is a high chance of spontaneous labour, or response to interventions made to induce labour
Bishop less than 6or 6: Vaginal prostaglandins or oral misoprostol
Bishop >6 amniotomy and an intravenous oxytocin infusion
Which contraception can decrease bone mineral density?
Depo
Most common type of ovarian cyst?
Follicular
Types of benign tumours
Germ cell: Dermoid AKA mature cystic teratomas - most common benign ovarian tumour in woman under 30
Epithelial:
- Serous cystadenoma - most common benign epithelial tumour
- Mucinous cyst adenoma
2nd most common, big, if ruptures may cause pseudomyxoma peritonei.
Stromal: Fibroma - associated with Meigs (this, asclites and plural effusion).
Most common type of ovarian ca
Around 90% are epithelial
Specifically, 70-80% are serous carcinomas
Indications for external cephalic version
Breech at 36 weeks in nullip
Breech at 37 weeks in multip
What is the combined test and when is this done?
Combined = USS & Blood test
done between 10-14 weeks
Assesses for Downs syndrome, Edwatds and Pataus.
What results would suggest Downs syndrome?
Thicker nuchal translucency,
High HCG
Low ↓ PAPP-A
When would you do quadruple test and what is this?
Between 14-20 weeks. Done if you book later than 14 weeks or if a combined test couldn’t get a nuchal translucency.
Only tests for Downs syndrome, not as accurate as combined.
Alpha-fetoprotein - Low
Unconjugated oestriol - Low
HCG - High
Inhibin A - High
What happens if combined/quadruple test indicates high risk?
NIPT or CVS offered
Biggest risk factor for cervical ca
many sexual partners
Smoking also RF
Risk factors for ovarian ca
Things that give you many ovulations e.g. early menarche, late menopause
BRACA 2
How long of you need contraception for after a medical management of ectopic.
3-6 months - methotrexate = teratogenic.
How to treat Fibroids?
Pill/IUS
GnRH agonists can decrease size but usually short term option as menopausal SEs
Surgery/uterine artery embolisation/chop it out
When do people need 5mg folate?
Blood disorders
Obese
NTD hx
Epilepsy meds
Diabetes
When to refer for fertility
Usually after a year of trying but if woman over 36 consider earlier
