O+G Flashcards
Endometriosis risk factors
Nulliparty/late childbearing
Early menarche
Delayed menopause
Hydrocolpos
First degree relative with endo
White
Smoking
Low BMI
Endometriosis symptoms and signs
Dysmenorrhoea
Dysparaeunia
Subfertility
Chronic or cyclical pelvic pain
Bloating
Lethargy
Dyschezia
Constipation
Low back pain
Dysuria (2/3 have interstitial cystitis)
Exam likely normal but also:
Tenderness or nodules/masses in adnexae/posterior fornix
Bluish haemorrhagic nodules in the posterior fornix
Decreased uterine mobility - may be fixed and/or retroverted
Uterine enlargement
Endometriosis management
TXA for heavy bleeding
Suppression of ovulation for at least 6/12 via:
-POP (1st line)
-COCP (2nd line)
-IUD
-GnRH agonist (gosrelin)
Laparoscopic surgical Tx
Endometriosis complications
Sub-fertility/infertility
Adhesions
Inflammatory bowel disease
Ectopic pregnancy risk is greater
?Ovarian cancer
Ectopic pregnancy risk factors/at risk groups
Previous ectopic pregnancy
Previous tubal surgery or pathology
PID
Smoking
Current or previous IUD use
IVF
Indication for USS or endometrial biopsy in anovulatory bleeding. (Risk of cancer or hyperplasia)
<35yo and at least one of:
-chronic anovulation for 2-3 years
-diabetes
-FHx colon cancer
-infertility
-nulliparity
-obesity
-tamoxifen
Adolescent, obese, years of anov bleeding
>35, esp if obese
Not responding to medical therapy
Causes of chronic anovulation
Thyroid disorders
DM
PCOS (6-10)
Hyperprolactinaemia
Eating disorders
Some antipsychotics or antiepileptics (they cause raised prolactin)
Menorrhagia causes
50% unknown
Coagulopathy (von Willebrands #1)
Thyroid dysfunction (hypo)
Fibroids
Endometrial polyps
Liver disease
Menorrhagia treatment
POP
NSAIDs
TXA
Mirena
Endometrial ablation/polypectomy/ embolization/fibroidectomy
Menorrhagia investigation indications
HCG, CBC, TSH
Coag screen if:
-flooding
->7 days of bleeding
-FHx bleeding disorder
-hx tx for anaemia
-hx of excessive bleeding
USS to assess for structural abnormality
Endometrial biopsy if not responding to treatment or risk factors for cancer and >35yo
Excessive menstrual bleeding definition
Changing pads every 1-2 hours
Clots bigger than 1 inch
“very heavy” bleeding reported by patient
Anovulatory bleeding - treatment
COCP
POP
Early pregnancy bleeding causes
Miscarriage - 10-20%
Ectopic pregnancy - 1-2%
Endometrial implantation
Gestational trophoblastic disease (rare)
Cervical and vaginal lesions (rare)
Anovulatory bleeding definition
Irregular or infrequent periods
Flow ranging from low to heavy
Includes:
-amenorrhoea (no periods for 3 cycles or more)
-oligomenorrhoea (occurs at periods of >35 days)
-metroragghia (irregular intervals and periods lasting >7 days)
Late pregnancy bleeding causes
Placental previa. Incidental finding in 2nd trimester, resolves in 90%
Placental abruption - 1% of pregnancies. #1 cause of serious PV bleeding in pregnancy. Fatal mortality 10-30%. 50% <36 weeks
Vasa previa - rare but up to 100% mortality as can cause foetal exsanguination
Normal HCG rise
66% every 48 hours
(ectopic can mimic this in up to 20% of cases)
Late pregnancy bleeding management
Placenta previa - avoid PV digital exam as may exacerbate bleeding. Speculum is ok. Bedrest from 3rd trimester if sig bleed. Steroids. Avoid sex and tampons
Abruption - may require prompt delivery
Risk factors for placenta previa
Multiparty
Tobacco smoking
Uterine curettage
Previous caesarian
Multiple gestations
Older age
Chronic HTN
Risk factors for placental abruption
Pre-eclampsia
Chronic HTN
Multiparty
Maternal cocaine, tobacco or methamphetamine use
Previous abruption
Trauma/sudden deceleration injury
Uterine fibroids
Thrombophilias
Short umbilical cord
Vasa previa risk factors
Low-lying and 2nd trimester placenta previa
IVF
Multiple gestation
Marginal cord insertion
Abruption - presentation
Vaginal bleeding
Uterine/fundal pain
Back pain
Foetal distress
IUGR/pretem labour/feotal death may occur
DIC (10%)
PPH definition and management
Minor = 500-1000ml <24 hrs post delivery
Major = >1000ml
IVL x2 large bore
Examine vagina looking for lacerations (more likely in absence of atony) or uterine inversion
Assess for uterine atony - if present give 10 units oxytocin IV and perform bimanual massage
If major PPH commence warmed IVF
-up to 3.5L then move to blood
-after 4 units blood give FFP
-keep fibrinogen >2g/L by use of cryoprecipitate
-TXA
-platelets if <75
Hyperemesis gravidarum facts
1% of pregnancies
Starts week 4
Peaks week 9
90% resolved by 16-20 weeks
Unlikely if begins after 12 weeks
More likely in Pacific women (?H. pylori ?thyroid)
Hyperemesis gravidarum treatment
Small meals, low in fat, high in carbs
Acupressure
Lie down for nausea
Frequent small volumes fluid PO
Avoid getting hungry
Check ketones
Metoclopramide
Cyclizine
Prochloperazine
Promethazine
Ondansetron last-line
If severe consider thiamine and omeprazole and referral
Consider underlying H. pylori infection and hyperthyroidism
Pre-eclampsia definition
3-8% of pregnancies in NZ
New HTN after 20 weeks AND:
-proteinuria (+/- oedema)
-LFT dysfunction
-renal impairment
-haematological dysfunction eg low platelets, haemolysis
-neurological dysfunction eg headaches, flashing lights, clonus
-maternal organ dysfunction
Pre-eclampsia risk factors
Major:
Existing HTN
Diabetes
Personal history of pre-eclampsia
FHx pre-eclampsia
SLE or antiphospholipid syndrome
Oocyte donation
Minor:
BMI >35
Age >40
African, Indian, Maori or PI
Primip
Multiple pregnancy
Change in partner
Sperm donation
FHx PET on fathers side
PET features (hx, exam)
Pregnancy >20 weeks AND any of:
-new oedema
-severe headache
-visual sx eg scotoma
-chest pain
-SOB
-vomiting
-upper abdominal pain esp RUQ
-reduced urine output
-reduced foetal movements
Exam
-HTN - 140/90, severe if 160/110
-hyperreflexia
-abdominal tenderness
-oedema
PET treatment
Refer to hospital, do not do bloods
Control BP with nifedipine, labetalol, hydralazine
Magnesium sulphate
Emergency contraception: how to
Check date of LMP and calculate date of likely ovulation
Check timing of UPSI
Consider possibility of non-consensual sexual activity
Consider pregnancy test
Consider STI test
Consider whether ECP or IUCD (copper only)
ECP:
1.5mg levonorgestrel single dose
Check no contraindications eg VTE hx, active breast cancer
Higher risk of failure in:
-UPSI close to ovulation
-subsequent UPSI in same cycle
-missed first week of COCP
-weight >70kgv(consider double dose)
-increased time since UPSI (12 hours ideal, 72-96 is limit
IUCD can be used up to 120 hours post UPSI, is most effective. Use ECP while organising
Urethral discharge treatment
Azithromycin 1g stat or doxy 1/52
If purulent add ceftriaxone
Patient advice and FU post PID
Use condoms for 14 days post treatment and 7 days post partner treatment
3/12 partner tracing
Repeat bimanual in 3/7 - if still sore refer to O&G
Repeat STI check in 3/12
HSV facts
20% of carriers will have no lesions
Transfer can occur without lesions but 100-1000x more likely with lesions
Fomite transfer highly unlikely as virus
does not survive at room temperature
Lesions last 4-15 days
Recurrences can be triggered by:
-sunlight
-stress
-minor trauma
-pre-menstrual
Complications include:
-urethritis
-proctitis
-neurogenic -leg and thigh pain
-meningitis
-widespread if immunocompromised
HSV treatment
Initial presentation:
-7-10/7 valaciclovir
Recurrence can be either episodic if not severe symptoms or suppressive if severe or frequent symptoms
Refer if herpes proctitis or pregnant
HSV patient advice
Partner infection does not necessarily indicate infidelity
Use salt washes
Dilute urine by drinking more
Pee in bath/shower
Topical anaesthetic - may sting initially
No cancer risk
Avoid sex until lesions healed
Printed information
HPV facts
Long latency
75% of population affected
Pain, bleeding and itch common sx
Self-treatment with podophyllotoxin or imiquimod.
Clinic treatment with cryotherapy
HPV need for referral
Pregnant
Extensive
Cervical
Immunosuppressed/HIV
Diabetes
Intra-urethral
Treatment failure
Primary syphilis features
50% asymptomatic
Incubation 10-90 days
Chancre, not always painless, not always solitary
30% multiple lesions
Inguinal LN
Secondary syphilis features
2-24 weeks latency
90% involve skin changes
-usually trunk but can be palms and soles
-can be confused with guttate psoriasis or pityriasis rosea
-alopecia
-condylomata lata
-neurological signs
Some constitutional sx
Tertiary syphilis
Gumma
Aortitis
Neuro sx: paraesthesia, ataxia, dementia, deafness, visual impairment
Chlamydia treatment
Doxycycline first line as better at treating rectal chlamydia (which is asymptomatic in 90% of women)
Azithromycin second line for those unlikely to take full course. Also contributes to resistance
