O&G Flashcards
Premenstrual symptoms management?
moderate (some impact) = Combined OCP
severe (withdrawal from social activities and normal functioning) = SSRI - initial 3 month trial
*If OCP contraindicated eg history of blood clots, give SSRI
management for umbilical cord prolapse?
- Call for senior help, continuous ctg, theatre for immediate delivery
- Prevent further cord compression
- elevation of presenting part of fetus manually or by filling bladder with saline
- on all fours position, knee to chest position or left lateral position. - Emergency c section
- do not push cord back in - but keep warm and moist.
- tocolytics eg terbutaline can be used to reduce uterine contractions if attempts to reduce compression are failing
management for shoulder dystocia
Step 1 = lie woman flat and tell to stop pushing!!!
Step 2 = call for senior help
Step 3 = legs hyperflexed tightly to abdomen (Mc Roberts maneuvre) = 1st line manoeuvre +/- suprapubic pressure
treatment for CIN?
treatment for +ve HPV but normal cytology?
treatment for inadequate smear sample?
- LLETZ
- Repeat in 12 months. then 12 months again. if 2nd repeat the same -> colposcopy
- repeat in 3 months. if 2 consecutive inadequate samples -> colposcopy
what is the routine call frequency for cervcial smears?
AGES 25-49 = every 3 years
50-64 = every 5 years
urge incontinence treatment?
bladder retraining = 1st line
antimuscarinics -> oxybutinin (risk of falls in elderly), tolterodine, darifencacin
mirabegron is an alternative in elderly people to avoid confusion associated with anticholinergics
stress incontinence treatment?
pelvic floor muscle training = 1st line
surgical procedures: e.g. retropubic mid-urethral tape procedures
duoloxetine!! if surgical procedures denied
most common benign ovarian cyst in women under 25?
dermoid cyst, teratoma
most common ovarian pathology associated with Meigs syndrome (ascites, pleural effusion)
fibroma
intrahepatic cholestasis of pregnancy management?
name a differential
Weekly LFTS, pay close attention to fetal movements
ursedoxycholic acid -> symptomatic treatment, emollients
the risk of stillbirth only rises above the population rate once the serum bile acid concentration is ≥100μmol/L. So advise early delivery based on levels
induction of labour at 37 weeks to avoid stillbirth
*20% present with jaundice too
Acute fatty liver of pregnancy -> this will present with abdominal pain and nausea/vomiting also
chickenpox case management in pregnant woman?
chicken pox contact exposure management in pregnant woman?
oral aciclovir if >20 weeks pregnant and presents within 24 hours of rash onset
- check for varicella antibodies
if history of chickenpox unknown/negative antibodies give oral aciclovir 7-14 days post exposure!! NOT` IMMEDIAtely
during pregnancy, fibroids may increase in size due to increased oestrogen -> pelvic pain, pressure symptoms
what is a missed miscarriage?
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding
cervical os is closed
management of pregnant women with GBS bacteuria?
treatment at time of diagnosis
+
intravenous benzylpenicillin given as soon as possible after the start of labour, then at 4-hourly intervals until delivery.
which HPV strains causes cervical cancer?
16 and 18, 33
management of infertility in PCOS?
Management Periods?
management of hirsutism
Clomifene = 1st line
OCP
Co-cyprindiol (dianette): cyproterone acetate + ethinyloestradiol, used in PCOS
complicated by hirsutism and acne (also acts as contraception)
Generally= dietician, weight loss
gestational diabetes definition?
gestational diabetes management?
fasting plasma glucose level of > 5.6. or a 2-hour plasma glucose level of >/= 7.8 mmol/L. I
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met after another 1-2 weeks, insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
Explain how to monitor blood glucose (using glucometer)
Need to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks
thereafter)
Need to have ultrasound growth scans every 4 weeks from 28-36 weeks
Explain that medication will be stopped after delivery but that they will be followed up to
check if glucose problem continues
targets for gestational diabetes management?
fasting: 5.3mmol/L
AND
1 hour postprandial: 7.8 mmol/L or
2 hours postprandial: 6.4 mmol/L
induction of labour methods?
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
management of pregnant women with autoimmune conditions eg SLE, antiphospholipid syndrome?
low dose aspirin from 12 weeks pregnancy to date. to prevent pre-eclampsia
when do baby blues occur?
management
3-7 days post delivery
reassurance and support
when does postnatal depression occur?
management?
usually start within a month and peak at 3 months
CBT
SSRI if severe
When is screening done for gestational diabetes?
oral glucose tolerance test (OGTT) = 1st line
- women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
- women with any of the other risk factors for GDM should be offered an OGTT at 24-28 weeks. RFs= BMI >30, previous baby >4.5kg, first degree relative with diabetes, family origin with high prevalence
rokitanskys protuberance in a mass in ovary indicates?
teratoma/dermoid cyst
Premature ovarian insufficiency symptoms?
diagnosis?
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
RAISED!! FSH, LH levels
low oestradiol
diagnosis:
- elevated FSH levels demonstrated on 2 blood samples taken 4–6 weeks apart
how is downs syndrome tested for antenatally
combined test = standard
may use quadruple test instead
if these test show higher chance of down syndrome then perform:
- NIPT
- Or amniocentesis/CVS
placental abruption RFs?
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios!!
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
1st line treatment for pre-eclampsia in woman with asthma?
nifedipine
how often is cervical screening carried out?
every 3 years for patients aged 25-49 years and every 5 years for patients aged 50-64 years.
every 1 year HIV +ve
how to confirm ovulation?
Take the serum progesterone level 7 days prior to the expected next period
history of endometriosis, acute abdomen, and the pelvis filled with fluid all point towards?
ruptured endometrioma
vasa previa classic triad?
rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.
PPH medical management?
ABCDE approach - cannulas, cyrstaloid infusions
palpate uterus
IV oxytocin = first line!!
other options include: ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
upper limit of Bhcg in weeks 9 -12 of pregnancy?
300,000 mIU/ml i
hyperemesis gravidarum criteria?
management
5% !!pre-pregnancy weight loss
dehydration
electrolyte imbalance
admit for IV saline and potassium = 1st line. THEN prescribe oral cyclizine or promethazine (antihistamines) and discharge
when should insulin be commenced for GDM?
if fasting glucose is >= 7 mmol/l at time of diagnosis
which pregnant women should be given a higher dose of folic acid at 5mg?
BMI > or equal to 30. diabetes!!, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD.
otherwise give 400mcg to others
which condition occurs when placenta attaches past myometrium through the outer wall of uterus and can attach to organs such as the bladder?
placenta percreta
first line treatment for menorrhagia?
intrauterine sytstem/mirena coil if contraception desired
contraception not desired = mefanamic acid/ tranexamic acid
tetracylcines eg doxycycline, lymecycline are _ in pregnancy
contraindicated -> negative effect on child skeletal development and discolouration of teeth
how long should magnesium treatment for preclampsia last?
24 hours after delivery or 24 hours after last siezure
what is the most common cause of PID?
chlamydia
management of pregnant women with HTN but blood pressure that is consistently <160/110mmHg?
home management -> oral labetalol and weekly follow up
endometrial hyperplasia symptoms?
- simple endometrial hyperplasia without atypia = high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypical endometrial hyperplasia: hysterectomy + bilateral salpingo-oophorectomy
medical abortion medication?
oral mifepristone! (anti-progestin)
+ prostaglandinds to sti ulate contractions (misoprostol)
when should booking visit occur?
anomaly scan?
8-12 weeks
18- 20+6 weeks
what testing occurs during booking appointment for women?
HIV, syphilis and hepatitis B
a positive urine pregnancy test is considered normal uptil how many weeks after abortion?
4 weeks
signs of ectopic pregnancy?
RFS?
abdominal pain, vaginal bleeding
absence of intrauterine pregnancy on ultrasound + pelvic free fluid (ruptured?)
PID
previous ectopic
endometriosis!!!
IVF
progesterone only pill
how to distinguish pre-existing hypertension from Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia)
the latter do not occur before 20 weeks!!! pregnancy
before pregnancy or before 20 weeks, no proteinuria or edema = pre existing htn
note, if a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review
A 57-year-old lady presents to the postmenopausal bleed clinic with a 2 week history of light vaginal bleeding, and mild pain on intercourse. She is otherwise well. On vaginal examination she is tender and has slight dryness. What should be done next in clinic?
referral to secondary care and TVUS must be done first to exclude endometrial cancer. atrophic vaginitis is a diagnosis of exclusion.
normal TVUS = oestrogen cream or referral to HRT clinic
abnormal TVUS (>4mm), then endometrial biopsy would be done.
what is the main complication of induction of labour? how does it present?
uterine hyperstimulation
high contraction frequency (tachysystole) and duration, for greater than 20 minutes, which may or may not be associated with signs of foetal distress.
which ectopic pregnancy should be managed surgically?
when should ectopic pregnancies be managed expectantly? what does this involve?
ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L s
expectant management if:
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L AND declining!
= safety netting (for pain, bleeding) and asked to return in 48 hours for serum B-hcg
when treating acute VTE in pregnancy, what must be measured/monitored?
anti-xa activity
can you breastfeed on anti-epileptic medication?
yes
Fetal movements should be established by 24 weeks gestation.
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler, what is the next step?
immediate ultrasound
if heartbeat present on ultrasound ->CTG for at least 20 min
advice for patient with lactational mastitis?
continue breastfeeding
Woman aged > 30 years with dysmenorrhoea, menorrhagia, symmetrically enlarged, boggy uterus is most likely?
adenomyosis
25 weeks pregnant woman with history of watery discharge but no fluid seen on speculum examination and a closed os. positive fibronectin. how do you manage?
watery discharge not enough to diagnose premature rupture of membranes.
raised fibronectin indicateds inreased risk of preterm labour -> therfore admit and give IM steroids to promote fetal lung maturity. also monitor blood glucose in diabetics as steroids may cause hyperglycemia
what is retinopathy of prematurity?
visual impairment seen in premature baby born before 32 weeks and had received oxygen treatment.
Over-oxygenation can cause retinal vessel proliferation which can lead to a loss of the red reflex and neovascularisation seen in the examination.
why should cooked liver be avoided in pregnancy?
high levels of vitamin A
signs of ovarian torsion?
enlarged ovary with free pelvic fluid
whirlpool sign! (also seen in volvulus)
ultrasound is indicated if lochia persists beyond?
6 weeks
USS to look for retained products of conception
which drug when used as an anti-emetic in pregnancy can cause extrapyramidal side effects (tremor, increased upper limb tone)
metoclopramide -> thus not used as 1st line!
name some potentially rhesus sensitizing events for pregnent women
Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)
management of anemia in pregnancy?
start oral iron replacement therapy
if in
First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L
what investigation can be done for urinary incontinence when the type is not known?
urodynamic studies
placenta accreta?
increta?
percepta?
present with pph
accreta = placenta attaches to myometrium
increta = invades myometrium
percepta = invades all layers of uterus and can reach organs eg bladder
Which condition presents with low values in quadruple test bar inhibin which is normal?
edwards syndrome
what risk is associated with odansetron use in pregnancy?
increased risk of cleft lip/palate if used in 1st trimester
when should anti-D be given to a resus negative pregnant woman?
at 28 and 34 weeks
what is a ring pessary used for?
pelvic organ prolapse
first line investigation for P-PROM?
sterile speculum investigation
Further management
Admit to antenatal ward to perform sterile speculum examination to look for pooling of amniotic fluid and administer following:
o 1st line = oral erythromycin
Then IM betamethasone for lung maturity
when should a pregnant woman with HTN be admitted to the maternal unit for observation?
when BP >/= 160/110
first line investigation for pregnant woman with vaginal bleeding?
TVUSS to assess the viability of the pregnancy and determine the source of bleeding.
Should the pregnancy be viable then other management options such as Rho(D) immunoglobulins would be considered if the woman is Rh-negative,
What supplement should all pregnant women take daily
10 micrograms of vitamin D
key side effect of magnesium sulfate? what should you monitor?
what is the antidote?
respiratory depression
monitor resp rate (and check reflexes)
antidote = calcium gluconate
If PPH medical management fails, what is first line surgical management?
intrauterine balloon tamponade (intrauterine bakri-catheter). - particularly if uterin atony suspected as main cause
other interventions:
B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled -> hysterectomy is sometimes
what is a galactocele?
painless firm breast lump occuring in women that have recently stopped breastfeeding
