O+G Flashcards
When to suspect ovarian cancer in any woman? What investigations to offer?
> = 50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months. IBS rarely presents for the first time in this age group
NICE recommends that all people with suspected ovarian cancer have an abdominal and pelvic examination carried out. If this is normal, then they recommend measuring CA-125 as the next step. Ovarian cancer cannot be ruled out if an abdominal examination is unremarkable, as the body habitus of patients can affect whether masses are picked up or not, or the ovarian cancer masses may not be large enough to be picked up via palpation.
What mutations seen in ovarian cancer?
BRCA1 or the BRCA2 gene
RFs for endometrial and ovarian cancer
many ovulations*: early menarche, late menopause, nulliparity
What may be useful in umbilical cord prolapse to reduce contractions?
Tocolytics e.g. Terbutaline
When doe cord prolapses often occur?
Around 50% of cord prolapses occur at artificial rupture of the membranes. The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.
What can be done with the bladder to help with cord prolapse?
retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
When is an US indicated with lochia?
If it persists for more than 6 weeks
What is RMI based on? How to calculate?
US findings, menopausal status and CA125 levels
RMI = U x M x CA125
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2 to 5).
The menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal.
The classification of ‘post-menopausal’ is a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy.
Serum CA125 is measured in IU/ml and can vary between 0 and hundreds or even thousands of units.
RFs for placental abruption
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)
Diagnosis of menopause
Blood tests are not required to confirm menopause; it is a clinical diagnosis.
Menopause is diagnosed if:
< 50 years of age AND amenorrhoeic for at least 2 years.
> 50 years of age AND amenorrhoeic for at least 1 year.
What is diagnostic of a miscarriage?
A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity is diagnostic of a miscarriage
Two types of miscarriage with an open os
THINK: I have an open os
Inevitable miscarriage
heavy bleeding with clots and pain
cervical os is open
Incomplete miscarriage
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
Threatened miscarraiage
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
Normal lab findigns in pregnancy
Reduced urea, reduced creatinine, increased urinary protein loss
When can the IUS and IUD be inserted after pregnancy?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks, and not in between this timeframe.
Best contraceptive post pregnancy
POP, The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler what should be offered?
An immediate ultrasound
Treatment of pregnant >20 weeks who develop chickpox if they present with symptoms
generally treated with oral aciclovir if they present within 24 hours of the rash
How long until contraceptives are effective?
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
When can hormonal contraception be started after levonorgestrel?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
What to monitor in mag sulph?
monitor reflexes + respiratory rate
What’s needed for diagnosis of PCOS?
DIagnosis of PCOS needs 2 out of 3 features:
oligomenorrhoea
clinical and/or biochemical signs of hyperandrogenism
polycystic ovaries on ultrasound, oligomenorrhoea or amenorrhoea, and hirsutism
Is a pill free interval necessary?
No
What dose of folic acid should pregnant obese women be given?
Pregnant obese women (BMI >30 kg/m2), should be given high dose 5mg folic acid
What to do if a patient has secondary dysmenorrhoea?
Refer to gynaecology
When do post partum women need contraception?
after 21 days
Do extra precuations need to be taken wehn taking POP and antibiotics?
No
Risks of COCP
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
What can be used prior to induction of labour for slowly progressing labour?
Membrane sweep
Features of a bladder outlet obstruction that lead towards diagnosis of overflow incontinence
Normal bladder function should have a voiding detrusor pressure rise of < 70 cm H20 with a peak flow rate of > 15 ml/second A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction. Voiding symptoms (e.g. straining, poor flow, and incomplete emptying of the bladder) are also suggestive of bladder outlet obstruction.
What does adding a progestogen do to the risk of breast cancer?
Increase it
What do if there is no fluid in posterior vaginal vault and suspecting PPROM?
When investigating suspected PPROM, if there is no fluid in the posterior vaginal vault then testing the fluid for PAMG-1 (e.g. AmniSureµ) or IGF binding protein-1 may be helpful
NOTE: insulin-like growth factor binding protein 1 (IGFBP-1) or placental alpha microglobulin-1 (PAMG-1)
1st line treatment for primary dysmenorrhoea
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
Staging of ovarian cancer
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
Is it safe for mother with Hep B to breastfeed?
Yes
Best measure of oculation
The serum progesterone level will peak 7 days after ovulation has occurred. Therefore, in a 35-day cycle the follicular phase will be 21 days (ovulating on day 21), luteal phase 14 days. Therefore, the progesterone level will be expected to peak on day 28 (35-7).
How long after ulipristal acete should women wait before starting hormonal contraception?
5 days
When can you get pregnant post partum? When to offer medication?
The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding. BUT they can get pregnant from day 21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first
Position of foetal vertex?
Can you offer progesterone contraceptives in current breast cancer?
No, offer IUD
Most common SE of POP
Irregular vaginal bleeding
How are medical abortions undertaken?
Medical abortions are undertaken using mifepristone followed by prostaglandins (misoprostol)
Most common cause of postmenopausal bleeding
Vaginal atrophy
How long should women take folic acid for in pregnancy?
Women should be encouraged to take folic acid 400mcg OD 3 months before conception up to 12 weeks gestation
Safest form of contraceptin in suspected/personal history of breast cancer or confirmed BRCA mutation
copper coil
When can a contraceptive implant be inserted after childbirth?
anytime
A 36-year-old woman who used to inject heroin has recently been diagnosed HIV positive. She is offered a cervical smear during one of her first visits to the HIV clinic. How should she be followed-up as part of the cervical screening program?
Attend cervical cytology
Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.
Other than Down’s, what else causes increased nuchal translucensy?
Congenital heart defects
Can emergency contraception be used more than once in the same cycle?
Both levonorgestrel and ulipristal can be used more than once in the same cycle
When is expectant management not suitable in miscarriage?
if evidence of infection or increased risk of haemorrhage
How should a woman >= 55 years of age presenting with postmenopausal bleeding (i.e. more than 12 months after menstruation has stopped) be managed?
referred using the suspected cancer pathway (within 2 weeks) to exclude endometrial cancer
Most common cause of puritus vulvae
Contact dermatitis
What blood test should be considered in women with recurrent vaginal candidiasis?
A blood test to exclude diabetes
When is combined test done? What is measured?
these tests should be done between 11 - 13+6 weeks
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the hCG tends to lower
When is quadruple test done? What is measured? What do results show?
quadruple test
if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A
continuous dribbling incontinence after prolonged labour
Vesicovaginal fistulae
Reccomended delivery type if <50 viral copies at 36 weeks
Vaginal delivery
Most common cause of puerperal pyrexia
Endometritis
Most common complication post TOP
Infection
Best way to measure SFH
US
What is red degeneration of fibroids? When does it Occur?
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
NOTE: Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
How should third stage of labour be manged actively?
Active management lasts less than 30 minutes and involves the following:
Uterotonic drugs
Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
Controlled cord traction after signs of placental separation
Guidelines suggest the use of 10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder.
NOTE: Ergometrine should be avoided in hypertension
if 2nd repeat smear at 24 months is now hrHPV -ve, what to do?
Return to routine recall
Contradiction for epidural anaesthesia during labour
Coagulopathy
If ovulation has likely occurred, what is the best emergency contraceptive to give?
Copper IUD
What is retinopathy of prematurity?
premature baby born before 32 weeks and has been receiving 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.
What normally happens to blood pressure during pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy levels before term. During a healthy pregnancy, blood pressure will typically fall during the first half of pregnancy due to systemic vasodilation and increased blood volume. The systolic pressure tends to drop by 5-10 mmHg and the diastolic by as much as 10-15 mmHg. This decrease reaches its nadir between the mid-second and early third trimester, after which it gradually rises back towards baseline prepregnancy levels just before term.
Which contraceptive has a risk of delayed return to fertility?
Injection
Examples of contraceptives that are unaffected by enzyme inducing drugs (e.g. carbamezapine)
Copper intrauterine device - causes heavy bleeding
Progesterone injection (Depo-provera) - causes weight gain
Mirena intrauterine system
What is oligohydramnios? What can cause it?
Oligohydraminos is a conditions where there is a deficiency of amniotic fluid during pregnancy. This can often present as smaller symphysiofundal height.
Renal agenesis is a cause of oligohydraminos (abnormally low volume of amniotic fluid) as the amniotic fluid is mainly derived from foetal urine.
What is potter sequence? what does it cause?
Potter sequence
bilateral renal agenesis + pulmonary hypoplasia
Causes oligohydramnios
Preferred method of smoking cessation in women
Nicotine replacement therapy
first-line medication for non-pregnant women with vaginal thrush
Oral fluconazole
Most effective form of emergency contraception
Copper IUD
When should pregnant patients with T1DM monitor blood glucose levels?
4x
daily fasting, pre meal, 1 hour post meal and bedtime tests
raised blood pressure above 160/100 mmHg combined with the significant proteinuria, despite receiving labetalol treatment, mx?
emergency admission for monitoring and management of the hypertension in a controlled environment, with delivery being an option if there is no improvement.
Results you would expect in a Down’s syndrome pregnancy
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
When is a Kleihauer test quired?
For any sensitising event after 20 weeks gestation, Anti- D prophylaxis should be given first
What is measured in combined test?
It involves an ultrasound scan for nuchal translucency and a blood test for levels of Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A). In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised.
Features of a complete miscarriage
Complete miscarriage is a spontaneous abortion with expulsion of the entire fetus through the cervix.
Pain and uterine contractions stop after fetus has been expelled.
Diagnosis: U/S shows an empty uterus
MAnagement of PPROM if <34 weeks
Admit for at least 48 hours and prescribe ABs and steroids
What medication can be given in PPROM?
erythromycin for 10 days
What is vasa praevia? How does it present? Classic triad?
Vasa praevia describes a complication in which fetal blood vessels cross or run near the internal orifice of the uterus. The vessels can be easily compromised when supporting membranes rupture, leading to frank bleeding.
The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.
NOTE: Usually has a preceding rupture of membranes
What is HCG secreted by?
synctiotrophoblasts, can be detected in maternal blood as early as day 8 after conception
A 27-year-old woman attends colposcopy as she had moderate dyskaryosis on her recent cervical smear. On colposcopy she has aceto-white changes and a punch biopsy followed by cold coagulation. Histology of the biopsy shows CIN II. When should she next be offered cervical screening?
6 months
Women who have been treated for CIN II should be offered cervical screening at 6 months through cervical screening and a HPV test of cure.
Do patients with endometritis need admission?
Yes, always
What are women who have been admitted with hypermesis gravidarum given? Why?
IV normal saline with added potassium as hypokalaemia is common
When is AFP rasied in pregnancy?
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
If semen sample abnormal, when to organise repeat?
3 months
What does station mean?
describe the head in relation to the ischial spine
A 40-year-old pregnant woman is seen for her 41 week check. Her blood pressure has consistently been 140/90 mmHg for the last 2 weeks. Her booking blood pressure was 110/70 mmHg. You administer labetalol to treat the high blood pressure. What should be the next step in the management?
Induction of labour, can be offered to people post-term
What is Erb’s palsy?
Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.
Cottage-cheese like discharge
Thrush
Investigations of post menopausal bleeding in order
Post-menopausal bleeding should always be investigated. The initial investigation is a transvaginal ultrasound scan to look at the endometrial thickness. Pipelle biopsy is used to sample the endometrium and in most cases can be used to diagnose endometrial cancer. Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when pipelle has been inconclusive.
MOA of contraceptive implant
Inhibits ovulation
Elevated LH/FSH levels and low oestradiol
POI
What does of levonorgestrel is taken?
1.5mg
How often is injection given for depot?
every 12 weeks
Most appropriate investiation following bladder diaries when a patient has stress incontinence
Urodynamic studies
Types of twins
Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic
What are monoamniotic monozygotic twins (identical) associated with?
Monoamniotic monozygotic twins are associated with:
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
Edward’s syndrome quadruple test result
Edward’s syndrome: quadruple test result
↓ AFP
↓ oestriol
↓ hCG
↔ inhibin A
menorrhagia, subfertility and an abdominal mass
Fibroids
Treatment for vaginal vault prolapse
sacrocolpoplexy
Treatment for vaginal wall following a cystocele
anterior colporraphy
What is a galactocele?
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
What is the most common explanation for short episodes of decreased variability on CTG? How long is classed as short? Give some other causes
The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG is that the foetus is asleep. However, if the decreased variability lasts for more than 40 minutes, we start to worry.
Other causes of decreased variability in foetal heart rate on CTG are due to maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (< 28 weeks, which is not the case here), foetal tachycardia (> 140 bpm, again not the case here) and congenital heart abnormalities.
What is the mechanism of oxybutynin?
Antimuscarinic anticholinergic
Absolute contraindications to vaginal birth after caesarean
Uterine rupture or classical C section scar (vertical)
Anaemia cutoff values in pregnancy
first trimester Hb less than 110 g/l
second/third trimester Hb less than 105 g/l
postpartum Hb less than 100 g/l
When switching from a POP to a COCP, how long barrier contraception needed?
7 days
What other treatment should admitted patients with hyperemesis gravidarum receive?
Pabrinex (vitamins B and C)
Can you give COCP to transgender patient undergoing testosterone therapy?
No, as it can antagonise the effect of testosterone therapy
How is cultured GBS in mother treated during pregnancy?
IV benpen
Best form of contraception in women over 40
IUS or IUD
WHen should methotrexate be stopped before trying to conceive? WHo should stop?
6 months before conception, both man and woman
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well. Diagnosis? Ix?
Vesicovaginal fistula, and urinary dye studies
Following an ABC approach initial management for PPH?
palpating the uterine fundus and catheterising the patient
What is a single prolonged deceleration lasting 3 minutes or more classed as?
Abnormal
What supplement should all pregnant take?
A daily supplement containing 10 micrograms of Vitamin D
Suspected PE in pregnant women with a confirmed DVT
treat with LMWH first then investigate to rule in/out
Symptoms of urgency and frequency, recurrent negative urine cultures and the finding of a complex ovarian cyst on ultrasound are suggestive of what?
gynaecological malignancy - warrants urgent referral to gynaecology
only effective treatment for large fibroids affecting fertility
Myomectomy
Urge incontinence management
bladder retraining for 6 weeks then oxybutynin (mirabegron used in frail elderly patients)
Women with suspected PCOS should have the following investigations
pelvic ultrasound, FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
Main complication of IOL
uterine hyperstimulation
What is preferred method of IOL if Bishop score is <6
Vaginal PGE2 or oral misoprostol
