O&G Flashcards
What is the quickstart method for contraception? What is involved? Which methods not suitable for?
Starting outside of 1st 5 days, risk prengnacy. Do urine bHCG on day and repeat in 4 weeks, condoms for 7 days (3 for POP). Not safe for IUD + cyproterone COCPs.
What are the contraindications to the COCP? 9 categories.
6 weeks postpartum, Age >35 + smoking <>15 within 1 year, BMI >35, CVD risk factors (HTN except only in preg, IHD, AF, complicated diabetes), prev VTE or FDR < 45 w VTE or prolonged immobility or known mutations, migraine w aura (old migraines ok), BRCA carrier or breast ca, decomp cirrhosis/current GB disease/liver ca, antiphospholipid antibodies.
What contraception methods are safe in the setting of: postpartum, CVD risk factors, unexplained bleeding, prev breast ca.
PP: Implanon, depot, POP. CVD: Implanon, IUD, POP. Bleeding: COCP, POP. Breast ca: copper IUD only.
What medications can affect the efficacy of the COCP?
Rifampicin, antivirals, St John’s wort, carbamazepine, phenobarbitol, phenytoin, topiramate.
What are suitable contraceptive options for women over 45? How is this monitored?
Age 45 can insert mirena and keep till 55. From 50, avoid COCP and depot. IUD, POP, implanon okay. If no period, check FSH, if >30 can stop contraception in 12mo. Can stop contraception at age 55.
What are 2 forms of POP? How do they work? How long do they take to be effective? What is their window period?
Microlut (levonogestrel) - thick mucus + suppress ovulation 60%. 3 days to start, 3hr window (caution vomiting/diarrhoea). Slinda (drospirenone) - suppress ovulation. 7 days to start, 24hr window.
When is breastfeeding a viable form of contraception?
Amenorrhoea in 98% if 6mo postpartum, baby fully breastfed and no long intervals between feeds (4h day, 6hr night)
What supplements are recommended in early pregnancy?
Folic acid 0.5mg, 5mg if prev/Fhx neural tube defect, GDM, BMI >30, antiepileptic use; 1mo prior and for first 3mo of pregnancy. Iodine 150microg. Vitamin D 400U recommended, check if risk factors.
What tests are recommended in early pregnancy?
FBE, fasting BSL, HIV, Hep B, syphilis, rubella, urine MCS + proteinuria, chlamydia < 25 or high prevalence, genetic carrier screening, CST if due. Hep C if risk factors, Vit D if risk factors, gonorrhea/trichomonas/BV if symptoms/risk, CMV if children around, TFTs if risk.
What tests are done to look for chromosomal abnormalities during pregnancy? When? Risks?
NIPT from 10 weeks. Combined FTS from 9/11 - 13+6, screen for T18, 21 and 13. 2nd trimester screen from week 14. Diagnostic tests are CVS weeks 11-13, amniocentesis from week 15, 1% risk of miscarriage.
Which pregnant women are screening for thyroid disease, vitamin D and iron deficiency?
T: PHx, FHx, autoimmune diseases, prev miscarriage/infertility, goitre. D: dark skin, south lattitude, low sunlight exposure, obesity. I: ATSI, immigrant, vegetarian.
How are back, pelvic pain and N/V managed in pregnancy?
BP: common, fitness/strengthen, panadol. P: strength/stabilise, fitness ball, water based exercise. NV: pyridoxine 12.5mg BD , add doxylyamine 25mg at night. 2ndline :maxalon, ondans, stemetil (cat C)
How are psychotropics in pregnancy counselled - benefits, risks, strategies. Which drugs need an urgent plan?
B: reduce neglect, harm/distress ofmother. R: preterm, congenital abnormalities, IUGR, neonatal adaptation in serotonin. Aim low doses, avoid polypharmacy, avoid abrupt cessation and rec 2nd trimester scan + observation of neonate postpartum. Lithium, carbamazepine, valproate.
What are 4 considerations of SSRIs in pregnancy? Which is safest? Which are least safe and for breastfeeding?
Association w poor growth (not proven), possible teratogen/cardiac malformation/miscarriage (paroxetine, venlafaxine), neonatal adaptation, persistent pulmonary hypertension - very slight risk. Sertraline safest. Fluoxetine highest conc in milk. Don’t start fluoxteine or parox, but may cont if already started, dw patient.
What are 3 points of discussion in an unplanned pregnancy?
Confidential unbiased nondirective counselling, screen for abuse, 1800myoptions for information.
What are 6 causes of early pregnancy bleeding? What investigations are done?
Implant bleed (2wk from ovulation), miscarriage, ectopic, cervical or vaginal (infection, ca, polyp), uterine infection, perigestational haemorrhage. Rarely molar pregnancy. Serial bHCG (48-72hr) transvaginal U/S (visible if bHCG >1500/2000), blood group/antibodies.
What are 7 minor and major causes of antepartum haemorrhage? Definition and other ddx?
Min: marginal placental bleed, cervical ectropion, blood-stained show. Maj: placental abruption, placenta praevia, vasa praevia, uterine rupture. Bleed >20wk. DDx: UTI, haemorrhoid.
How is an antepartum haemorrhage managed?
Lie supine w lateral tilt, IV access, rapid fluid resus (may need blood), monitor vitals + FHR + CTG, do U/S before any speculum/digital exam incase of praevia.
What are the risk factors + sx for placenta praevia and placental abruption?
PP: prev c-section/uterine surgery, prev praevia, advanced age. Painless bleeding. PA: trauma, smoking, cocaine, HTN, PROM. Bleeding, tenderness and possible contractions.
What are the risk factors for pre-eclampsia? Risks of pre-eclampsia?
RF: prev preeclampsia, HTN, pre-existing diabetes, SLE, antiphospholipid syndrome, obesity, CKD. M: seizures, renal failure, DIC, pulmonary oedema, HELLP. F: IUGR, preterm delivery, death.
Consider aspirin from 12 weeks.
What is pre-eclampsia? What are severe symptoms? What tests are indicated?
New HTN after 20 weeks + involvement of renal/haem/liver/neuro or pulm oedema or IUGR. Headache, visual changes, RUQ pain, altered mental status, dyspnoea/oedema. Ix: FBE, UEC, LFT, urine ACR, U/S.
What is gestational hypertension vs chronic hypertension? How is this managed in pregnancy?
HTN after 20 weeks or before. Screen for preeclampsia. 1st line: labetalol, methyldopa
What are 12 things to consider in a 6 week post partum check?
Pregnancy complications, labour/delivery, perineal tears, lochia, breastfeeding, bowel/urinary issues, sleep, mood - EDPS, return to exercise (walk, avoid high impact 3mo), sex - contraception, cervical screening, rubella ok in breastfeed but delay 6mo from transfusion.
Post partum endometritis - timing, DDx, tests, mx.
Within 1 week, infected RPOC, PID ?septic aborption. Ix: U/S, blood cultures, endocervical swab MCS + PCR (C, G, Myco). Rx: augmentin or bactrim + metro. Severe: IV gent, metro, amoxicillin.
What are 4 signs of adequate breast milk supply? What can help?
Growth (150g per week, birth weight by 2w), 5-8 wet nappies, passing stool at least once per day, settled between feeds with good tone/skin. Hold skin to skin, breastfeed freq (2-3h), review attachment, express after feeds, lactation consultant, rarely domperidone (EPSE, long QT).
What are 6 causes of pain with breastfeeding? How is the most common managed?
Thrush, mastitis, milk blister/white spot, blocked duct, dermatitis, poor attachment/trauma - lanolin cream, panadol, avoid tight bra, review attachment/lactation consultant, feed from other side first, rest for 1-2 feeds: pump from affected side.
Lactational mastitis - 4 nonpharm mx, pharm mx and indication.
Breastfeed as usual (feed from affected first to drain), covered cold packs 10min/hr, gentle massage to axilla for lymphatics (no deep/firm), lactation consultant review attachment. If systemically unwell or not improve in 48hr, fluclox/diclox 5-10d. Keflex if allergy, clinda if severe.
How is breastfeeding reduced - wean and post abortion?
Aim to drop feeds per day by 1 per week, express only for comfort but avoid excess. In abortion, cabergoline 1mg stat + tight bra.
Symptoms/signs of nipple thrush and management.
Burning stinging pain, persists after feed, tender to light touch. Pink/shiny nipple or flaky. Baby: daktarin QID then D (2wk). Mum: oral fluconazole 3 doses over 1 week then oral nystatin TDS and daktarin gel to nipple QID for 1 week.
Risks of PND? Diagnosis. 5 aspects of management.
Suicide, infanticide, psychosis. EPDS >13. Optimise supports (carer cert), parent infant therapist - PANDA, crisis lines, psychology - CBT first line, if severe use sertraline.
What tests/workup indicated in decreased foetal movements?
After 28 weeks. Do abdo exam, symphysis fundal height, BP. FHR w doppler. Need CTG within 2 hours and U/S within 24hr - urgent hospital. Don’t use kick charts.
What is recurrent pregnancy loss? What workup is indicated and for what causes? Advice for parents.
2 losses. Karyotype of POC +/- parents for genetic (eg. chromosomal anomaly); U/S for fibroid or septate uterus; screen for hypothyroid, diabetes, thrombophila (antiphospholipid - lupus anticoag + cardiolipin Abs). Avoid drugs/alc/smoking, healthy BMI, < 3 cups coffee.
What is the ovulation window? What female causes are of infertility are considered and when/how is testing done?
5d before + day of ovulation (14d before period, daily/2nd daily intercourse. PCOS, endometriosis, PID/STI, prolactinoma, early menopause. Ix after 12mo or 6mo if > 35yo –> Day 2 FSH, LH, oestradiol; AMH level, TSH, U/S pelvis - anatomy, follicle count, endometriosis.
What are causes of primary and secondary amenorrhoea?
No period age 15/16: constitutional delay, ovarian dysgenesis (Turner), imperforate hymen or mullerian agenesis. Both: Hypothalamic (stress/illness/exercise); pituitary (prolactin), hypothyroid, PCOS, pregnancy, Secondary: early menopause, adrenal (CAH, cushings), meds (OCP, antipsychotics - prolactin, chemo).
What exam and investigations are indicated for amenorrhoea?
Height - turners, acne/facial hair PCOS, galactorrhoea (prolactin), hypothyroidism, BMI, systemic illness. FSH, LH, oestradiol, TSH, prolactin, U/S, pregnancy test.
What is secondary dysmenorrhoea? Presentation, possible causes and mx.
Pain from a disorder, not physiological. Later in life, change in pattern, Fhx of endo, dyspareunia or IMB. Endo, adenomyosis, fibroid, PID, cervical stenosis. Mx: Contraception, NSAID (ibuprofen, ponstan, naproxen for 2-3d). 2nd: heat, TENS, acupuncture.
What are the possible causes of intermenstrual bleeding? 9
Polyps, adenomyosis, leiomyoma, endo/cervical ca, coagulopathy, ovulatory dysfunction. Cervicitis/endometritis - STI, thyroid dysfunction, cervical ectropion.
What tests/workup for intermenstrual bleeding?
Pregnancy, co-test, STI screen. If 1 episode of post-coital and normal cotest then stop. If more than 1 or not post-coital, do colposcopy/refer. If persistent and risks consider coags screen + U/S for endometrial thickness (max 4mm post, 5mm peri, 12mm pre).
Investigations and management of menorrhagia?
Pregnancy, CST if due, FBE/ferritin +/- coags, TSH. No hormones if cyclical. If persistent 6mo or pain for 3mo or concern re endo/fibroids, do U/S. Mx: IUD first line, NSAID, tranexamic acid, OCP, cyclical POP. Acute: tranexamic acid or medroxyprogesterone 10mg 4-8hr or norethisterone.
What are the indications for referral for menorrhagia?
Not responding 6mo, fibroid >3cm, severe pain, fertility planning eg endo, risk of ca - PCOS w oligomenorrhoea, obestiy, age >45, unopposed oestrogen use, thick uterus (>12mm pre, >5 peri).
What are the non-hormonal/pharm options for menopausal symptoms?
CBT, mindfulness, hypnosis for vasomotor, weight loss if overweight, cooling techniques. Flushes: SSRI/SNRI (escitalopram, desvenlafaxine), gabapentins also help w sleep/pain, clonidine.
What are the contraindications to systemic HRT? What are the contraindications to oral HRT?
Starting age >60, prev VTE/TIA/AMI, uncontrolled HTN, oestrogen dependent ca (breast/endometrial) or undiagnosed bleeding, high risk of breast ca, significant liver disease, SLE. Oral: risk factors for VTE/CVD (obesity, smoking, diabetes, HTN), liver/gallbladder disease.
What are the 4 hormonal treatment options for HRT?
Oestrogen only (no uterus). Combined cyclical if perimenopausal. Combined continuous if >1y since period or on cyclical for 1 year w less bleeding. Tibolone - synthetic steroid, risk breast but not assoc w VTE.
How is HRT reviewed - titration, bleeding.
Review 6-8 weeks then 6mo. Increase oestrogen if flushes ongoing. Cyclical: Bleeding should occur after day 10 of progesterone (if not, increase dose). Cont: can get breakthru bleeding for 3-6mo. Only ix if heavy, postcoital or high risk.
5 causes of post menopausal bleeding? What are baseline tests?
Endometrial ca, endometrial polyp, endometrial hyperplasia w HRT, atrophic endometritis/vaginitis, cervical cancer. Cervical co-test, U/S.
What are risk factors for endometrial cancer (warrant gynae for post menopausal bleeding)? What will gynae do and when?
Chronic anovulation, PCOS, unopposed oestrogen, tamoxifen use, Strong Fhx of endo/colon ca (Lynch syndrome), nulliparity, endometrial thickness >4mm, obesity. Endometrial biopsy with/wo hysteroscopy, within 6 weeks.
Urinary incontinence history - symptoms, risk factors, associated conditions.
Stress or urge. RF: parity, vaginal deliveries, chronic cough, constipation, smoking, alcohol/caffeiene/sweeteners, high impact exercise. Assoc: UTI sx, bowels, haematuria, limb weakness/saddle, prolapse sx, diabetes, NPH (gait, confusion)
7 exam findings and 5 investigations to consider in urinary incontinence?
Palpable bladder, atrophic vaginal mucosa, cough test, prolapse, constipation, lower limb neuro, CCF signs. Bladder diary recommended (hold 400mL day, 800 night), exclude UTI, diabetes, consider U/S renal tract + urine cytology.
What are 7 aspects of non-pharm management of overactive bladder?
Healthy weight, treat constipation, optimise fluid intake, reduce stimulants (coffee, alcohol), use pads, pelvic floor strengthening w physio (avoid cough/weights), bladder training - scheduled voiding
What are 3 medications to help treat overactive bladder - frequency, mode, SE.
Oxybutynin TDS (non-selective anticholinergic) - dry mouth, blurred vision, constipation, delirium. Solifenacin (selective anticholinergic) - hepatic impairment. Mirabegron (beta 3 agonist) - HTN, long QT.
Features of bartholins cysts/abscess and management.
Cysts 1-3cm, not painful. Sitz baths or warm compress, may drain if large. Abscess - >3cm or pain/inflamed, from piercing, STI, skin infection, hair. Abx, sitz, incision.
Causes of vulvovaginitis - 5 dermatoses, 4 infections and 2 others.
Irritant dermatitis, atopic dermatitis (eczema), lichen sclerosus, lichen planus, psoriasis. Candida, herpes, BV (grey, smelly) trichomonas (itch, frothy fishy green). Atrophic vaginitis, provoked vestibulodynia.
How is vulvovaginal candidiasis treated? - nonpharm, pharm, recurrence, ddx.
Take swab. Loose cotton underwear, avoid sprays/soaps, wash hands before touching, gentle wipe dry. Clotrimazole 1% 6 nights or 100mg 6nights or 10%/500mg 1 night. Alt: nystatin cream, oral fluconazole 150mg. Recur if >3 in a year: fluconazole 3 doses then weekly for 6mo. DDx: candida glabrata, use nystatin.
Features of lichen sclerosus, associations, risks, management.
White sclerotic/shiny, itchy patches, may be painful/blistered in figure 8 around anogenital. Assoc: autoimmune (thyroid, vitiligo). R: labial fusion/phimosis, dyspareunia, SCC 5%. Refer - can do biopsy, high dose topical steroid, monitor for cancer yearly.
Causes of vulvodynia (4 categories), mx.
Lube: poor arousal, fear, hormone (age, breast feeding). Skin - UTI, eczema, thrush. Vaginismus (tightness): from prev trauma/infection. Deep: endo, fibroids, PID, prolapse. Mx: avoid painful sex, avoid irritants, can use topical lidocaine and see vulval spec. Vaginismus: education, pelvic floor physio, psychology, systemic desensitisation w dilators.
How is CST performed around pregnancy? Young people < 25?
Use cytobroom/swab (no brush). If positive, do culposcopy for invasive disease. Post pregnancy recommended from 6 weeks, usually done at 3mo for good cervical cells. If sex < 14 (before HPV) OR immunosuppressed 5 years, do screen.
What CST is recommended in older women? Immunosuppressed? Post hysterectomy?
From 70 either test, if neg cease, if +ve do colposcopy. If severe immunosuppression, screen 3y and colposcopy if +ve. Hysterectomy from HSIL - cotest for 2 years. Subtotal hysterectomy, screen as usual. Others, don’t need.
What features are diagnostic of PCOS? What tests are used in the workup of PCOS?
Oligoovulation, hyperandrogen, polycystic. Bloods if no clinical androgens: total testosterone, FAI, LH/oestradiol/progesterone for phase, 17 progesterone for CAH, TSH, prolactin, bHCG for others. U/S if >8y post menarche for at least 12 follicles if bloods not diagnostic.
What are 6 aspects of PCOS management? What are the risks?
Aim BMI < 25, emotional support, regulating periods/reducing androgens, fertility, metformin if high BMI or T2DM as adjunct. Risks: T2DM (do OGTT), OSA, depression, high cholesterol, CVD risk, endometrial hyperplasia.
What are 4 options to help manage periods in PCOS? Benefits?
COCP most effective, mirena, cyclical progesterone (short term only), metformin may help as adjunct. Need to counter anovulatory cycles which lead to high oestrogen - reduce cancer risk. Aim for 4 periods per year unless on OCP.
What is first line management of infertility in PCOS? What can GPs and specialists do?
Lifestyle - diet, exercise, 5% weightloss if overweight. Can add metformin esp BMI >30, while waiting. Specialist: letrozole, gonadotrophins, drilling, IVF.
Ovarian ca - risk factors, protective, symptoms, exam findings.
Fhx, Fhx breast/colon/uterine ca, BRCA gene or lynch syndrome, nulliparity, smoking, HRT. Prot: COCP, parity, breast feeding. Sx: bloating, early satiety, urinary freq/incontinence, abdo pain, fatigue. Ex: mass, ascites, lymphadenopathy, effusion
What tests may be indicated in someone with risk factors for ovarian cancer? What are suspicious features on US (4)?
Screening for breast and colon cancer. In post menopause, U/S and Ca125 helpful. Solid area, ascites, papillary structures, blood flow.
Breast lump - history features, assessment.
Hormone history, Fhx breast/ovarian ca, weight, alcohol, smoking. Lump exam (size, shape, location, consistency, mobility, tenderness); U/S if < 35, U/S + mammogram if >35. Non-excisional/core biopsy. Triple test for all lesions and refer if abnormal.
Features and causes of pathological nipple discharge. Management.
Unilateral, single duct, spontaneous, bloody. Papilloma (benign but can have atypical area), duct ectasia - benign, older women. Cancer 5-15% usually DCIS. Infection - mastitis. Do mammogram + U/S.
Features and causes of benign nipple discharge, workup.
Bilateral, milky, multiple ducts, maybe yellow/green. Most from prolactin (tumour, hypothyroid, drugs - antipsychotic, maxalon). Others: eczema, pagets disease. bHCG, TFT, UEC, prolactin level and do imaging (unless resolved and obv benign). If antipsychotic, use aripiprazole (psych to do)
What are possible presenting symptoms of endometriosis? When is referral indicated?
Pain, dysmenorrhoea, dyspareunia, period/cyclical GI symptoms OR urinary symptoms, infertility. Refer if significant sx, seeking fertility, bowel/bladder involvement, mass/nodule or sx not responding to 3mo of painrelief +/- hormones.
What are risk factors for an ectopic pregnancy? What are 3 signs of ruptured ecoptic?
Prev ectopic, prev tubal surgery, sterilisation or IUD, IVF, prev STI/PID, smoking, OCP. Do speculum - blood and/or cervical motion tenderness, peritonism, shock.
How is rubella and pertussis exposure managed in pregnancy?
R: check IgG and IgM, high risk in 1st trimester, consider abortion. Rare risks after 16wk. P: if close contact w infectious person within 2 weeks, and last month of pregnancy, treat prophylactically.
How is varicella exposure managed in pregnancy?
Exp if living together, F2F contact 5 min or 1hr in same room. If prev VZV, no treatment. If unsure, check VZIG levels - give ZIG within 96hr or up to 10d if no prev immunity. If after 96h from exposure, consider antiviral therapy for 2nd half of pregnancy.
Pelvic organ prolapse risk factors(7), mx options (8).
Pregnancies (assissted + vaginal), menopause, age, constipation, chronic cough, obesity, smoking. Mx: weight loss, avoid lifting, smoking cessation, treat constipation, pelvic floor muscle training. Ring pessary, topical oestrogen post menopause (may reveal urine incontinence). Surgery 2ndline due to risks.
How is a medical termination of pregnancy achieved? When can it be done? What are contraindications?
Mifepristone (stops pregnancy), misoprostol (induce labour,take 24-48hr after). Bleeding 3h later for 10-16d. Must be within 2h from hospital, < 9 weeks gestation and intrauterine (need U/S first). C/I: long term steroids, chronic adrenal failure, coagulopathy.
What is premature ovarian insufficiency? Risks, Ix and treatment.
Amenorrhoea before 40. Risks: symptoms, bone loss, CVD, infertility, autoimmune conditions. Check elevated FSH, DEXA, TFTs, CVD risk. Rec treating with oestrogen until age 51 unless cancer –> OCP or MHT w progesterone or MHT w mirena.
What are 3 benign cervical abnormalities? What 3 cervical changes need referral?
Ectropion - columnar epithelium visible. Nabothian cyst/follicles (yellowish mucous retention cyst). Atrophy post menopause - wider, pale. Polyp if >3cm or atypical, any bothersome changes (pain/bleeding), warts + leukoplakia risk malignancy.
