O+G Flashcards
Which SSRIs can be used in breastfeeding?
Sertraline and Paroxetine
Mx of Post-partum haemorrhage
1st - press on uterus
2nd - IV Oxytocin
3rd - Intrauterine Balloon Tamponade
How do you treat genital warts?
Topical podophyllum if there is more than one and not keratinised
If single and keratinised -> cryotherapy (freeze it off)
When do you investigate a couple’s inability to conceive and how?
After 12 months of regular sex
Male - semen analaysis
Female - Mid-luteal serum progesterone (i.e. day 21 of a regular 28 day cycle). This confirms ovulation.
Exception for earlier investigation is if surgical or STI history or abnormal genital exam.
What is the treatment for eclampsia?
IV Magnesium Sulphate
What do you need to monitor when giving Mag Sulph for eclampsia?
RR, SpO2, reflexes
(can cause respiratory depression)
What is the difference between pre-existing HTN, gestational HTN and pre-eclampsia?
HTN is >140/90
Pre-existing = before 20 weeks gestation
Gestational/Pregnancy-induced = after 20 weeks, but no proteinuria, no oedema
Pre-eclampsia = after 20 weeks, with proteinuria and oedema
If not given on 1st day of cycle, in how many days do the following contraceptives become effective in?
Copper IUD = immediately
POP = 2 days
Everything else = 7 days
Criteria for expectant management of ectopic pregnancy?
No symptoms
No fetal heartbeat
B-HCG 1500 or less, and falling
i.e. needs to be dying/dead
Indication for surgical management of ectopic pregnancy?
Either
>35mm
Foetal heartbeat present
Rupture
How do you medically manage ectopic pregnancy?
Methotrexate + misoprostal
Medical management of miscarriage?
Mifepristone + misoprostal
Which blood thinner is CONTRAINDICATED in breastfeeding (but not pregnancy)?
Aspirin
2nd line Mx of endometriosis?
COCP
1st line Mx of menorrhagia?
if wanting contraceptive -> Mirena IUS
If wants to be fertile -> NSAID (mefanamic acid) or TXA
How does Rhesus disease of newborn work?
Rh D -ve mothers
If foetus Rh D +ve
Any event which causes fetal cells -> maternal blood (termed fetomaternal haemorrhage), will cause irreversible RH D sensitisation of the mother. This means if future babies are RH D +Ve, there will be haemolysis.
We can prevent this with giving Rh D -ve mums routine anti-D immunoglobulin at 28 and 34 weeks.
If MFH event occurs, give anti-D immediately to prevent sensitisation and do Kleihauer test to check extent of MFH.
NB// anti-D immunoglobulin acts as prophylaxis only. Once sensitisation occurs, it is irreversible.
Which herbal remedy is an enzyme inducer and therefore may reduce COCP effectiveness?
St John’s Wort
1st line medication for HTN in pregnancy, regardless of cause?
Oral Labetolol
2nd line medication for HTN in pregnancy, regardless of cause?
(e.g. if patient asthmatic)
Nifedipine
How are reflexes affected in pre-eclampsia?
Remember there is neurological hyper sensitisation (e.g. potential seizures if eclampsia develops)
Therefore, hyperreflexia
How long do you need to continue contraception for if going through menopause?
<50yrs
For 24 months since last period
> 50yrs
For 12 months since last period
Does COCP increase or reduce BMD?
Why?
Increase
COCP contains oestrogen and progesterone.
Former reduces osteoclast activity and bone resoprtion
Latter helps maintain bone.
Which contraceptive method reduces BMD? Why?
Depot injection
Methoxyprogrestin reduces oestrogen levels.
Risks of smoking with pregnancy?
miscarriage
preterm labour
stillbirth
IUGR
Which STIs/Vaginal infections cause raised pH?
The ones that end in vaginosis/vaginalis
(BV, TV)
How to manage exposure to chickenpox in pregnancy?
1) check maternal IgG if immunity unsure
If non-immune, give aciclovir…
(If >20 weeks, give the aciclovir 7-14 days post exposure for better results)
Tx If pregnant women gets chickenpox in pregnancy? Why is it important to treat?
Aciclovir
increased risk of pneumonitis to mother
Increase risk of fetal problems
NOTE: in summary, labour can either be
- Prelabour premature rupture of membranes (PPROM)
-ROM at right time, but prolonged labour
-ROM at right time, and labour normal
-Late (and requiring induction of labour)
What are the indications for induction of labour?
Essentially either 3rd trimester complications, fat baby or late
- Obstetric cholestasis
- Pre-eclampsia
- Intrauterine death
- Diabetic mother, 38 weeks
- 42 weeks (note, they have a membrane sweep at 41)
How do you decide how to induce labour?
Bishop score
<5 - labour not going to happen without induction
8 or more - labour should spontaneously happen
If 6 or less - opt for vaginal or oral prostaglandins
If >6, IV oxytocin or cervical balloon dilation
What are the risks of inducing labour with prostaglandins? Why is it an issue? How would you manage this complication?
Uterine hyperstimulation syndrome
Excessive contraction disrupts blood flow to foetus, causing hypoxia
Also increases risk of the uterus rupturing
Manage by Tocolysis - beta agonists used e.g terbutaline
What timeframe would absence of fetal movements worry you? What would you do to investigate?
24 weeks - refer to fetal medicine unit
Handheld doppler to check fetal heartbeat. If present, CTG 20mins
If absent, USS
When would you expect to notice fetal movements and how should they evolve over time?
notice around 18-20 weeks, should steadily increase until 32 weeks then plateau in intensity
Indications for higher dose 5mg OD folic acid in pregnancy?
previous personal, family or fetal history NTD
Diabetes
Coeliac disease
Obesity
Are antiepileptics safe in pregnancy and breastfeeding?
Sodium valproate should not be used unless absolutely necessary (NTD)
Other drugs can be used and also safe in breastfeeding.
Which trimester of pregnancy is nitrofurantoin contraindicated in?
3rd
What advice would you give regarding statins during pregnancy
Contraindicated!
What is the average age of menopause?
51
When does progesterone need to given as part of HRT and why is this crucial?
If the woman has a uterus.
Otherwise increased risk of endometrial cancer with oestrogen only (causes proliferation of the lining)
Can the mirena coil serve as the progesterone arm of HRT?
YES (for up to 4 years, then replace coil)
If patient on long term steroids, how do you decide if needs bisphosphonates?
If >65, everyone on long term steroids (>3 months) should have bisphosphonates - no need for DEXA
If <65, DEXA first and if osteopenic, need bisphosphonates
When do you start bisphosponates without a DEXA?
1) if >65 and on long term steroids
2) If >75 and had fragility fracture
What is an alternative to HRT to manage vasomotor menopausal symptoms?
SSRIs
Sertraline
Venlafaxine
What are the 4 situations where bisphosphonates may be indicated
Previous fragility fracture (backward)
FRAX score high (forward)
Long term steroids (moment)
DEXA revealed osteoporosis (scan)
Which risks of HRT should you discuss with patients?
Increase risk of
endometrial cancer
DVT (only with oral)
breast cancer
IHD, stroke
What is premature ovarian insufficiency?
menopause before 40
high LH, FSH, low oestradiol
Mx of POI?
Must have HRT until 51, to prevent osteoporosis
Different types of miscarriage?
Complete - prior to 20 weeks gestation, foetus dead inside
Threatened - bit of blood, os closed
Inevitable - bleeding and os open
Incomplete - os open, retained products
How to minimise HIV vertical transmission
1) Mum ART prior to birth
2) C-section
3) Neonate gets ART - zidovudine if mum viral load <50, otherwise full triple ART
4) NO BREASTFEEDING
How to treat chickenpox in pregnancy? Why is it important?
aciclovir if presenting within 24hrs of rash onset
Because x5 increase risk of pneumonitis
Side effects of ‘mini pill’ (POP)?
Most common = irregular vaginal bleeding
Biggest risk factor for umbilical cord prolapse?
Artificial Rupture of Membranes
Management of umbilical cord prolapse?
Obstetric emergency!
-keep cord warm and moist
-woman on all 4s whilst preparing for C-section
How do you manage smoking in pregnancy?
1st - CBT and motivational interviewing
How to manage HSV in pregnancy?
If 1st episode of HSV and in 3rd trimester, should give daily acivlovir until birth, and ensure C-section
if recurrent HSV, treat woman but inform that transmission to baby is low.
Most common ovarian cysts?
Follicular cysts (type of physiological cyst)
What are the types of ovarian cysts?
Physiological: follicular (most common), corpus luteum
Benign germ cell: dermoid (have epithelial lining so have skin, hair, teeth)
Benign epithelial: serous cystadenoma, mucinous cyst adenoma
Criteria for pre-eclampsia prophylaxis and what is the prophylaxis?
Major risk factor:
previous pre-eclampsia
known HTN
known DM
known CKD
Minor:
1st pregnancy
over 40yrs
10 year gap with previous
BMI>35
Prophylactic dose aspirin 75mg
Symptoms of twin-twin transfusion syndrome?
sudden increase in abdomen size/pain (due to polyhydramnios of recipient twin)
Why is TTTS an issue?
Donor = oligohydramnios
Recipient = polyhydramnios
Due to polyhydramnios and so large uterus, increased risk of uterine atony and so PPH
Fetal growth restriction due to diversion of fluid away and need for preterm delivery
Mx of TTTS?
-Monthly USS checks
-Weekly antenatal checks after 30 weeks
-Iron and folate supplement
-Early delivery 38-40 weeks
-Precaution at birth including 2 obstetricians present
Causes and overall management of secondary dysmenorrhoea?
Causes:
Adenomyosis
Endometriosis
PID
IUD complications
Refer to gynae
Difference in symptoms between primary and secondary dysmenorrhea?
Primary = pain hours before period starts
Secondary = pain a couple days before period starts
Gestational diabetes diagnosis and management?
OGTT
5678
i.e. fasting > 5.6
if >7 start insulin
if 6-7 and complications - start insulin
otherwise try diet/exercise for 1-2 weeks and then initiate metformin if still an issue
Who should you screen for gestational diabetes?
South asian
Obese
previous gestational diabetes
previous macrosomic baby
1st degree relative with diabetes
Which anti-epileptics safe in pregnancy?
Lamotrigine
Carbamazapine
Levetirecetam
Causes of PPH?
4 T’s
Uterine atony
Retained placenta (tissue)
thrombin (clotting disorder)
Trauma (e.g. perineal tear)
What tends to be the side effect of progesterone only contraception (pill, implant, injection)
irregular bleeding
Management of fibroids if affecting fertility?
Myomectomy (without GnRH agonists)
These only shrink fibroids whilst taking the medication, but they also suppress axis so can’t get pregnant.
Is there a screening programme for ovarian cancer (even if BRCA1/2 positive)?
NO
Explain how smear testing pathway works
Tests for hrHPV (16 and 18)
if negative, back to routine
if positive then cytology
if cytology abnormal -> colposcopy
if cytology normal, repeat in 12 months.
if at 24 months (i.e. at 2nd repeat) - cytology positive, then colposcopy
What’s the management of pelvic inflammatory disease?
IM ceftriaxone, 14 days of doxycycline and metronidazole
What are the possible complications of PID?
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Infertility
Increased risk ectopic
Rupture of which cyst causes pseudomyxoma peritoneii?
Mucinous cystadenoma (type of benign epithelial ovarian cyst)
Can the fetal head spontaneously turn in labour from OP to OA position?
YES
What are the stages of labour?
Stage 1 - start of labour to full cervical dilation
Stage 2 - from full dilation to delivery
(split into passive and active)
if active lasts >1hr, consider instruments such as Ventouse, forceps or C-section
Stage 3 - delivery of placenta
How do you manage pre-existing HTN in pregnancy?
Switch to oral labetolol whilst they await specialist review
What are the symptoms of placenta praaevia?
Abdominal pain not in keeping with any visual changes or PV bleeding
3rd trimester
Shock
If CTG shows late decelerations what does this suggest?
Fetal distress
What is Vitamin D recommendation during pregnancy?
10 micrograms per day
When are booking appointment and booking scan?
When is nuchal scan and what does it look for?
8-12 weeks
11-14 weeks
Checks nuchal translucency for Down’s
What are potential liver problems in pregnancy?
-Obstetric cholestasis (ursodeoxycholic acid to help symptoms)
-Acute Fatty Liver
-HELLP syndrome (can be a complication due to severe pre-eclampsia - both stem from endothelial dysfunction)
Criteria for 5mg folic acid ?
Personal, family or fetal history of NTD
taking antieplipetics
obese
coeiliac disease
diabetes
When should ECV be tried for breech?
Earliest at 36 weeks
(before this, baby may turn itself)
If TVUSS reveals simple ovarian cyst, what should you do?
pre-menopausal - repeat in 12 weeks
post-menopausal - refer gynae as cysts uncommon due to physiology at this age
NB// loculated (complex) ovarian cyst more likely to be malignant than simple cyst.
Causes of oligohydramnios?
i.e foetus produces less urine
Renal agenesis (Potter’s sequence)
Pre-eclampsia
IUGR
Emergency contraception types?
Levornogestrel - within 3 days
Ulipristal - within 5 days (can’t give if asthmatic)
COpper IUD - within 7 days
Mechanism of action of the progesterone contraceptive methods?
POP - thickens cervical mucus
Depot progesterone injection - inhibits ovulation
Mirena - thins endometrium
Side effect of Depot progesterone injection?
Weight gain
When should you admit patients with pre-eclampsia?
If BP >160/110
If fetal distress
If other signs of severe pre-eclampsia such as headache, blurry vision etc.
Which cancers does COCP increase risk of?
Breast and cervical
Risk factors for cervical cancer?
HPV 16 and 18 - BIGGEST ONE
Smoking
COCP
Risk factors for ovarian cancer?
Essentially more ovulations
early periods
late menopause
never pregnant
BRCA1/2 gene
Should you do CA125 on asymptomatic women?
NO
NB// Blood + open os = inevitable miscarriage
What does cervical excitation indictae?
Either PID or Ectopic
(the only 2 things that cause it)
How do you manage shoulder dystocia?
1) McRobert’s manoeuvre (hip flexion and abduction)
2) Episiotomy
What are the neonatal and maternal complications of diabetes?
Neonatal are macrosomia, shoulder dystocia, respiratory distress syndrome, polycythaemia, hypoglycaemia, low electrolytes
Maternal are polyhydramnios (as the baby sees more) and therefore preterm labour (due to increased pressure)
What is ovarian hyperstimulation syndrome?
Caused by GnRH agonists e.g. in IVF
Essentially get overstimulation of ovaries and too many follicles developing -> 3rd spacing of fluid causing ascites, oliguria, abdominal pain and promoting DVT
When should booking visit take place?
8-12 weeks
What is the treatment of DVT/PE in pregnancy? Cons of each imaging modality?
Rather than DOAC, it is LMWH
(DOACs are teratogenic)
CTPA - increased risk of maternal breast cancer, as they’re sensitive to radiation
V/Q - increase in risk of childhood cancer
Which contraceptives work by inhibiting ovulation?
COCP
Desogestrel (type of POP)
Implant
Depot
Which contraceptives work by thinning endometrium?
Mirena IUS
Which contraceptives work by thickening cervical mucus?
POPs (apart from desogestrel)
How do emergency contraceptives work?
They inhibit ovulation
(but copper IUD kills sperm and ova)
Examples of drugs not safe whilst breastfeeding?
Aspirin
Amiodarone
Sulfsalazine
Methotrexate
Antibiotics which are safe include penicillins and cephalosporins
Which contraceptive causes delayed return to fertility?
Injection
What are the side effects of progesterone injection?
weight gain
delayed return to fertility
What are the UKMEC4 criteria?
> 35 and smoking 20 cigs/day
Migraine with aura
Previous stroke or IHD
BMI >35 and 1st degree relative who had DVT <45yrs
Uncontrolled BP - i.e. 160/110
Current breast cancer
Previous VTE
Antiphospholipid syndrome
BREASTFEEDING AND <6 WEEKS POSTPARTUM
What is a contraindication to all hormonal methods of contraception?
Breast cancer
What is the term given for temp >38 in first 2 weeks postpartum, what is likely aetiology and how should you manage?
Puerperal pyrexia
Most common cause is endometritis
Requires hospital admission for IV Abx
Other sources of infection include breast and womb (organs needed with birth) - endometritis, mastitis
Infection of perineal wound
UTI
The usual timeframe to begin infertility investigations is after 12 months of trying - but what are the exceptions and when should you investigate these?
Investigate after 6 months if either male or female have had previous STI, genital surgery, current abnormal genital exam
Or if women >35 (clock’s ticking!)
Or man has varicocele (reduces fertility)
What are the criteria for expectant management of ectopic?
Asymptomatic
foetus <35mm
No foetal heartbeat
BHCG <1500 and downtrending
What are the symptoms of ectopic?
usually RIF/LIF pain, pregnancy positive
(also vaginal bleeding, general abdominal pain)
What are the indications for surgical management of ectopic?
Symptomatic
BHCG >5000
Foetus >35mm
Foetal heartbeat present
What to do if you miss 1 dose of COCP?
Take missed one and carry on - no issue
What happens if you miss 2 doses of COCP?
Depends which week you’re in
Needs extra thought if in week 1 or week 3
Week 1 - emergency contraception if you’ve had sex this week or in week prior
Week 2 - no action needed
Week 3 - omit pill free interval if you have one and just continue taking pill into the next week
What is the management of PPROM?
Admit for 48hrs observation
Give steroids to mature foetal lungs
Give 10 days Abx prophylaxis to all PPROM patients to cover for GBC Chorioamnitis (oral macrolide)
At around 34 weeks, should start thinking that risk of infection risen to likely outweighs risk of lung immaturity (have had time to develop by then, especially with steroids)
How can you spot PPROM?
Examine with sterile speculum to look for pooling of amniotic fluid in posterior vaginal vault. If uncertain test for PAMG-1
What is intrapartum GBS prophylaxis and who is given it?
IV benpen
preterm labour or previous GBS
How do you manage preterm labour in absence of ROM?
Stop the labour - give tocolytics and mature the foetal lungs with steroids.
What are the risk factors for endometrial cancer?
Increased oestrogen exposure including diabetes!
Insulin resistance and increased resultant insulin secretion is pro-osteogenic
NB// Painful PV bleeding - placental abruption
Painless PV bleeding - placenta praevia
What should you do if you spot placenta praevia at 20 weeks?
Rescan at 32 weeks
Final scan at 37 weeks determines delivery method
If persist, require C-section
Organisms responsible for neonatal sepsis?
<48hrs = GBS (from mum)
> 48hr = staph A or E (from environment)
How soon after partum can woman start taking POP?
Immediately
If started after 21 days, however same rule as usual in that it takes 2 days to become effective, so use barrier for this 2 days
Causes of primary vs secondary amenorrhoea?
Primary includes CAH, gonadal dysgenesis (e.g Turner’s), functional hypothalamic
Secondary is ovary failure and iatrogenic
-PCOS, Premature Ovarian Insufficiency
-Ashermann’s (uterine surgery causing adhesions), Sheehan’s (hypopituitarism due to pituitary necrosis due to PPH)
-Functional (exercise, stress)
-Prolactinoma
What do variable decelerations indicate on CTG vs late?
Cord Compression
Late - fetal distress - emergency C section
Indications for CTG during labour
1) Obs going off - spike temp, BP >160
2) Vaginal bleeding
3) Use of oxytocin to help with labour requires careful monitoring with CTG
If GBS identified during pregnancy, at any time, how do you manage?
It is commensal and only a risk to foetus during partum. Treating beforehand not been shown to reduce intrapartum infection risk.
Therefore, just intrapartum IV Benzylpenicillin
How long before POP is considered ‘missed’?
Traditional POPs - 3hrs late
Cerazette = desogestrel - 12hrs late
Features of congenital rubella syndrome?
Sensorineural deafness + congenital cardiac abnormality (e.g PDA)
What are the body temperature changes around ovulation?
Dips just before ovulation, then rises after due to progesterone
Features of congenital chickenpox infection during pregnancy?
Limb hyopplasia
Small head
Rudimentary digits
What are the symptoms of vulval carcinoma and what are the risk factors?
Painless hard growing mass on vulva with inguinal lymphadenopathy, in an older women
i.e. risk factors are age, HPV and smoking
NB// copper IUD and Mirena are contraindicated in unexplained bleeding and STI infection
Do laparoscopic findings of endometriosis have any correlation with symptom severity?
No
How do you use the combined patch, and when is it considered ‘late’?
weekly combined patch, but 4th week of every month, patch free to induce bleed.
if delay in new patch >48hrs, considered late and so need to apply new one but use condoms for 7 days and take emergency contraception if sexually active
What is the classic history of ectopic pregnancy?
Period of amenorrhoea, then with lower abdominal/iliac fossa pain +/- PV bleeding +/- shoulder tip pain + pregnancy test positive
What are the causes of PV bleeding in 1st trimester?
ECTOPIC PREGNANCY
MOLAR PREGNANCY
MISCARRIAGE
What are the causes of PV bleeding 3rd trimester?
Bloody show
Placental abruption (can also happen 2nd trimester)
Placenta praevia
Vasa praaevia
Are most anti epileptics safe during breastfeeding?
YES
