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 uterine hyperstimiulation defined as?
defined by a high contraction frequency (tachysystole) and duration, for greater than 20 minutes, which may or may not be associated with signs of foetal distress.
How are stage 2-4 ovarian cancers treated?
primarily by surgical excision of the tumour. This may be accompanied by chemotherapy
Most important test for premature ovarian insufficiency
FSH:LH ration >2:1, needs to be repeated 4-6 weeks later for diagnosis
Stereotypical blood test results with PCOS
raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG is normal to low
in the case of PUL, what points towards a diagnosis of ectopic pregnancy?
serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Should aspirin be avoided in breastfeeding?
Yes
What type of insulin is used in gestational diabetes?
Short acting insulin
How long after menopause do you need contraception?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
When may GnRH analogues be used in endometriosis?
if NSAIDs/COCP have not controlled symptoms
How is the thyrotoxicosis phase of postpartum thyroiditis managed?
with propranolol alone
Stages of postpartum thyroiditis
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Thyrotoxicosis treated with propanolol
Hypothyroidism treated with thyroxine
Indications for a CAT 1 C section
suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
Categorisations of C sections
Caesarean sections may be categorised by the urgency
Category 1
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
Category 2
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
Category 3
delivery is required, but mother and baby are stable
Category 4
elective caesarean
Bladder still palpable after urination
, think retention with urinary overflow
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?
TVUSS
Can only make a diagnosis of atrophic vaginitis after ruling out all other pathology e.g. endometrial cancer
1st line investigation in PMB
TVUSS
What cancer does tamoxifen increase the risk of?
Endometrial cancder
How long may pregnancy tests remain positive for after termination?
Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
Management of PPh
PPH is a life-threatening emergency - senior members of staff should be involved immediately
ABC approach
two peripheral cannulae, 14 gauge
lie the woman flat
bloods including group and save
commence warmed crystalloid infusion
mechanical
palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
catheterisation to prevent bladder distension and monitor urine output
medical
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
there is also interest in the role tranexamic acid may play in PPH
surgical: if medical options fail to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
1st line surgical management in PPH
Intrauterine balloon tamponade
How to manage pregnant women who are <6 weeks gestation and present with vaginal bleeding without pain?
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7-10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried
How to manage pregnant women who are >6 weeks gestation and present with vaginal bleeding?
If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
Management of missed miscarriage
oral mifepristone.
48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed.
if bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional
women should be offered antiemetics and pain relief
a pregnancy test should be performed at 3 weeks
Management of incomplete miscarriage
a single dose of misoprostol
women should be offered antiemetics and pain relief
a pregnancy test should be performed at 3 weeks
MOA of mifepristone in miscarriage
progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
MOA of misoprostol in miscarriage
Misoprostol is a prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
What is preferred method of IOL if Bishop score is <6
Vaginal PGE2 or oral misoprostol
NICE guidelines for management of IOL
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
Most common identifiable cause of postcoital bleeding
Cervical ectroption
Management of POI
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of 51 years
US appearance of complete hydatiform mole
ultrasound: ‘snow storm’ appearance of mixed echogenicity
When to offer ECV if nulliparous? Multiparous?
36 weeks, 37 weeks
Is PID a contraindication for IUD?
Yes, absolute
Early scan to confirm dates is done
10-13+6 weeks
Anomaly scan is done
18-20+6 weeks
When is first dose of anti-D prophylaxis given to rhesus negative women?
28 weeks
SEs of GnRH agonists
osteoporosis
What can pre-eclampsia cause to the feotus?
Oligohydramnios
What is done if a cervical smear sample is HPV +ve?
examined cytologically, if cytology abnormaly - refer for colposcopy
Management of stage 1A cervica cancer tumours
Gold standard of treatment is hysterectomy +/- lymph node clearance
Nodal clearance for A2 tumours
For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
Most commonly used chemotherapy agent in cervical cancer
Cisplatin
Management of stage IB tumours in cervical cancer
For B1 tumours: radiotherapy with concurrent chemotherapy is advised
Radiotherapy may either be bachytherapy or external beam radiotherapy
Cisplatin is the commonly used chemotherapeutic agent
For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of stage 2 and above in cervical cancer
Management of stage II and III tumours
Radiation with concurrent chemotherapy
See above for choice of chemotherapy and radiotherapy
If hydronephrosis, nephrostomy should be considered
Management of stage IV tumours
Radiation and/or chemotherapy is the treatment of choice
Palliative chemotherapy may be best option for stage IVB
Older woman with labial lump and inguinal lymphadenopathy
vulval carcinoma
Most common type of ovarian pathology associated with Meigs’ syndrome
Fibroma
ost common benign ovarian tumour in women under the age of 25 years
Dermoid cyst (teratoma)
The most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
HNPCC/Lynch syndrome are a big risk factor for what cancer?
Endometrial
maternal pyrexia, maternal tachycardia, and fetal tachycardia
Chorioamnionitis
What medication causes folate acid deficiency?
Phenytoin
BEST WAY TO REMEMBER BISHOP SCORE - LEARN THIS
Cervical position (posterior/intermediate/anterior)
Cervical consistency (firm/intermediate/soft)
Cervical effacement (0-30%/40-50%/60-70%/80%)
Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
Foetal station (-3/-2/-1, 0/+1,+2)
What type of cysts usually occur in early pregnancy? Are they normal?
In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards.
Worst presentation of breech
Footling presentation
What type of HRT doesn’t increase risk of DVT?
Topical
Type of HRT with least side effects
Oestrogen patch
When can expectant management of an ectopic be carried out?
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
What type of cyst may cause pseudomyxoma peritonei if it ruptures?
Mucinous
Most common type of ovarian cyst
Follicular cyst
Primary amenorrhoea
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
Secondary amenorrhoea
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
What is used to classify the severity of nausea and vomiting in pregnancy?
The Pregnancy-Unique Quantification of Emesis (PUQE)
What is a particular risk for women with PCOS when undergoing IVF?
Ovarian hyperstimulation syndrome
A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance. What is the most likely diagnosis?
Teratoma (dermoid cyst)
Presence of a foetal heartbeat on ultrasound in the context of an ectopic pregnancy is an indication for
surgical management
Treatment of CIN
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia.
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Associations of pre-eclampsia
Intracerebral haemorrhage
Pulmonary Oedema
Fetal prematurity
Fetal IUGR
A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding. Dx?
Ovarian cyst
A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen. Dx?
Appendicitis
What should happen if a woman with known placenta praevia goes into labour?
Emergency CS should be performed, irrespective of Bleeding
Best Contraceptive for migraine with aura
Copper IUD
A 33-year-old woman visits her general practitioner complaining of inability to conceive after two years of trying with a regular partner. She has a body mass index of 28 kg/m² and an existing diagnosis of polycystic ovarian syndrome. Which drug is most likely to help restore normal ovulation in this case?
Metformin
Weight loss is the first-line treatment for overweight or obese women with polycystic ovarian syndrome (PCOS) who are struggling to conceive. If this fails - either because the woman is unable to lose weight or because she cannot conceive in spite of losing weight - then metformin can be added as an adjunct. Metformin has been shown to have a beneficial effect on ovulation and conception rates in patients with PCOS.
long-term complication of vaginal hysterectomy with anteroposterior repair
Vaginal vault prolapse
three features of Meig’s syndrome are:
a benign ovarian tumour (usually a fibroma)
ascites
pleural effusion
SSRIs of choice in breastfeeding women
Sertraline or paroxetine
What management is advisable for all postmenopausal women with atypical endometrial hyperplasia? Why?
A total hysterectomy with bilateral salpingo-oophorectomy, due to the risk of malignant progression
What may happen to uterine fibroids during pregnancy?
They may grow
What AB is safe in breastfeeding?
Cephalosporins e.g. ceftriaxone
Type of gonadal dysgenesis
Turners
Example of GnRH agonist
Leuprolide
Presentation of fibroid degeneration during pregnancy
low-grade fever, pain and vomiting.
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress
admit and administer steroids
A 23-year-old woman is being reviewed on the labour ward.
She is 39 weeks gestation. She felt her waters breaking 2 hours ago.
She is G1P0, has no had no complications throughout her pregnancy and has no significant past medical history.
On examination, her Bishop’s score is calculated as 10. A vaginal exam confirms that her amniotic sac has ruptured. There is no evidence of contractions yet. Foetal heart rate is reassuring at 140/min.
What is the most appropriate next step in her immediate management?
Reassure and monitor
A Bishop’s score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
Most common cause of PPh
Uterine atony
Causes of PPH
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
A 36-year-old woman gives birth to healthy twin girls. Which agent is most likely to be used after the birth to facilitate delivery of the placenta and to prevent postpartum haemorrhage?
Medical treatments for postpartum haemorrhage secondary to uterine atony include oxytocin, ergometrine, carboprost and misoprostol
What medication is 1st line for infertility in PCOS?
Clomifene
While working on a gynaecology ward you are looking after a 67-year-old female who has had an endometrial biopsy for post-menopausal bleeding. Which of the following ovarian tumours is associated with the development of endometrial hyperplasia?
Granulosa cell tumours.
NOTE: . Sex cord stromal tumours (Thecomas, Fibromas, Sertoli cell and granulosa cell tumours) are associated with an increased production of hormones. The sub-type Granulosa cell tumours are associated with the development of endometrial hyperplasia.
What is atypical hyperplasia of the endometrium classified as? How does it develop?
premalignant condition, develops due to overstimulation of endometrium by oestrogen
when may referral to a midwife-led breastfeeding clinic may be appropriate?
If a breastfed baby loses > 10% of birth weight in the first week of life
What is a screening tool for postnatal depression?
Edinburgh Postnatal Depression Scale (EPDS)
How long should Mag Sulph treatment be carried out for?
at least 24 hours after last seizure
Can you attempt external cephalic version for a transverse lie?
It is reasonable to attempt ECV for a singleton fetus presenting in transverse lie so long as the membranes have not yet ruptured and the patient is not in active labour. In order to prevent the fetus from spontaneously reverting to a transverse lie, it is recommended that the membranes are ruptured to speed up the delivery process.
Criteria for lactational amenorrhoea
amenorrhoeic, baby <6 months, and breastfeeding exclusively
Women who have a positive pregnancy test and either abdominal, pelvic or cervical motion tenderness, management?
Refer for immediate assessment as patient may have an ectopic pregnancy
purple lesions noted on abdomen during pregnancy
striae gravidarum
Dark line running vertically down middle of abdomen in pregnancy
linea nigra
Medical management of PPH in order
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
TVUSS findings that are diagnostic of a miscarriage
demonstrating a crown-rump length greater than 7mm with no cardiac activity is diagnostic of a miscarriage
Management of premenstrual syndrome
Mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)
Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)
What corticosteroids are adminstereed antenatally to reduce chance of NRDS?
betamethasone 2 dose 12mg IM 24 hours apart
When is CVS carried out?
diagnostic test, which will show the fetal karyotype and will give a more accurate result than the combined test which is a screening tool. CVS is however usually performed between 11 weeks and the end of the 13th week
When is amniocentesis carried out?
amniocentesis is a diagnostic test that will show the fetal karyotype and will give a more accurate result than the combined test. Amniocentesis is usually performed from week 15 onwards, and so Katie should be booked for an amniocentesis to confirm the presence or absence of trisomy 21.
How long is folate taken for in pregnancy?
Upto 12 weeks
How long is vitamin D taken for in pregnancy?
Through - 400IU
How to manage a patient with post partum endometritis?
Admit, send vaginal swabs and blood cultures, start intravenous (iv) antibiotics and arrange a pelvic ultrasound scan
NOTE: This is because still at a high risk of sepsis. Vaginal swabs sent because likely cause of infection is genital tract
1st line medication for moderate PMS
COCP
What medication is used for treatment of hirsutism and acne in PCOS? How does it work? Other effects?
Co-cyprindiol, marketed as ‘Dianette®’, combines cyproterone acetate and ethinylestradiol. It is commonly used in PCOS treatment for hirsutism and acne. Cyproterone acetate acts as an anti-androgen, reducing sebum production and hair growth. It also inhibits ovulation and induces withdrawal bleeds.
Management of bartholin’s cyst in <40? in >40?
In patients under 40, a Bartholin cyst is found incidentally, causing no concerns; no treatment is required. In patients over 40, removal and submission of the tissue for histology are necessary to rule out vaginal carcinoma.
What medication to give in patients with asthma with dysmenorrhoea?
Paracetemol, as can’t give NSAIDs e.g. mefenamic acid
How long after the baby delivered should the placenta be delivered? If not delivered, what to do?
within the hour, doctors contacted at 30 mins, then observe for 30 mins before giving IM syntocinon and breastfeeding
Most common incision site for C section
Suprapubic incision
Should inguinal nodes be removed in vulval cancer? Which ones?
The lymphatic drainage of the vulva is to the inguinal nodes. Even if there is no clinical evidence of lymphatic involvement, the inguinal nodes should be removed.
MOA of mifepriston
nhibiting progesterone, promoting endometrium degradation, cervical ripening, and increasing the uterus’ sensitivity to prostaglandins.
MOA of misoprostol
Misoprostol then triggers uterine contractions to expel the pregnancy
painful abdominal mass in a woman
ovarian cyst or tumour
What would be seen on USS in oesophogael atresia in a 36 week antenatal check?
Polyhydramnios - issue swallowing so more fluid
What is the anaemia in pregnancy due to?
Increase plasma volume leading to a dilutional anaemia
What happens to HR and SV in pregnnacy?
Despite vasodilatation, an increase in the heart rate and stroke volume increase in cardiac output. The blood pressure may drop initially, but by term it normalises.
What is there an increased risk of T1DM in pregnancy?
Polyhdramnios
Where does cervical cancer first metastasise too?
pelvic lymph nodes along the iliac arteries
Where does endometrial cancer first metastasie to?
the para-aortic lymph nodes.
multiple bilateral ovarian cysts and new onset hypertension in pregnancy
GTD
ovoid mobile parasites are seen on a wet saline mount.
Trichomoniasis
What is classed as slower than average cervical dilation during the active stage of labour?
less than 0.5 cm per hour over 6 hours
When performing an amniotomy in failure to progress, when to assess progress?
Progress post-amniotomy is assessed after two hours. If suboptimal, an oxytocin infusion is commenced to regulate and strengthen contractions, usually along with an epidural for pain relief.
Monitoring of diabetics during pregnancy
the NICE guidelines recommend that these patients are reviewed in a Joint Antenatal and Diabetic Clinic every one to two weeks to ensure any problems are addressed promptly and appropriately to reduce the risk of maternal and fetal complications.
Pelvic pain and DIC with no bleeding
Conceleaed placental abruption
If Hx of hysterectomy and BMI >30, preferred type of HRT?
Oestrogen patch, reduces risk of VTE and no need to worry about endometrial cancer
most common cause of PMB
Vaginal atrophy
Treatment of baby in a HIV positive pregnancy
Zidovudine for 4-6 weeks
Bilateral ovarian tumours, mass in stomach, adenocarcinoma positive on biopsy
Krukenberg tumours - signet ring cells
How can endometriosis affect CA125?
Can cause an increase due to presence of endometrioma - ectopic endometrial tissue
most common vulval carcinoma
SCC
most common lcoation of ectopic
ampulla
most likely location for ectopic to rupture
isthmus
androgen binding protein is produced where?
Sertoli cell
Management of HSV in pregnancy
Oral aciclovir is recommended for primary infection, while suppressive therapy with aciclovir is offered from the 36th week until delivery. Expectant vaginal delivery is the primary option, with consultant-led care.
Management of cystourethrocele
Anterior colporrhaphy
Sx of nipple thrush
typically bilateral and are associated with sharp burning pains in the nipple and retroareolar tissue and red, swollen areas and can be associated with severe itching, leading to nipple inflammation and fissuring
Management of nipple thrush
The mother and the baby should be treated – the former with topical miconazole after feeds for two weeks and the latter with oral miconazole gel. This is licensed for infants of four months of age and above.
1st line AB in UTI management in pregnancy, one CI?
Nitrofurantoin, avoid during term as can induce neonatal haemolysis. USE CEFALEXIn
What type of HRT is best to avoid VTE?
Transdermal patches
Earliest possible diagnostic test for Down’s?
Chroionic villous sampling
Most common cause of neonatal seizure within 24 hours
Neonatal hypoglycaemia
IUDs and ectopics
Less likely to become pregnant wit IUD, more likely o be ectopic if become pregnant
Management of PID
Give intramuscular (im) ceftriaxone stat and a 14-day course of doxycycline and metronidazole
Preferred method of induction if bishop’s score <6? then what?
As the Bishop’s score is <6, vaginal PGE2 is used. The administration of prostaglandin should be followed up by a reassessment of the cervix 6 h later. If the Bishop’s score is still <7, further prostaglandin is administered and reassessment again made after a further 6 h.
1st line medication in menorrhagia if trying to conceive
Either mefenamic acid or transexamic acid
Transexamic acid is used if asthmatic or IBD
What is Irregular and unpredictable uterine bleeding within the first years of menarche called? What is it caused by?
Anovulatory dysfunctional uterine bleeding, caused by immaturity of the hypothalamic–pituitary–ovarian hormonal axis and anovulatory dysfunctional uterine bleeding
What volume of amniotic fluid is considered to be consistent with polyhydramnios?
> 2-3L of amniotic fluid
What is uterine hyperstimuloation diagnosed as? How to treat?
more than six contractions in ten minutes, < 60 s between contractions
Need to reduce the oxytocin infusion rate
Management of HIV positive pregnant females who did not previously require medication (<50 copies)
commence combined antiretroviral therapy in the second trimester, by the 24th week of gestation, and continue this lifelong. Combined antiretroviral therapy is in the form of three agents.
what happens to lung capacity in pregnancy?
Decreases by about 200ml
When is the latest women with GDM can give birth?
40+6
What happens to blood plasma in pregnancy?
Increases
1st line managment for females experiencing breastfeeding difficulties
one-to-one visit from a health visitor or breastfeeding specialist nurse
When is vacuum aspiration performed? When is surgical evacuation of products of conception performed?
Before 14 weeks, this can be performed by vacuum aspiration, whereas after 14 weeks of gestation, surgical evacuation of products of conception is used
1st line medical management of fibromyalgia
Try paracetemol and NSAIds, then amitryptilline (TCA)
Rotterdam criteria for PCOD
if two criteria are met: oligomenorrhoea/amenorrhoea, signs of hyperandrogenism, and ultrasonographic evidence of polycystic ovaries
1st line management of PCOs
OCP
Common SE of laparascopyy
Shoulder pain, caused by retained CO2 gas
Definition of proteinuria
Persistent urinary protein of > 300 mg/24 hours
What AI condition can cause premature menopause?
Addison’s disease
Normal epithelial lining of endometrium, becomes what in malignancy?
Simple columnar, becomes stratified sqaumous
CI for fluoxetine in menopause?
when woman is on tamoxifen
NOTE: Can be given with a history of breast cancer, but NOT when on tamoxifen
Managemne tof severe PMS
Fluoxetine, 3 month trial
pale, shiny areas of skin, white papules, and plaques
Lichen sclerosis
World Health Organization (WHO) breastfeeding recommendations
Exclusive breastfeeding for six months, followed by a combination of foods and breastfeeding up to two years of age or beyond
1st line management of lichen sclerosis
clobetasol propionate
Then can use tacrolimus
What conditions are those with GTD at risk of?
Pulmonary metastasis and thyroid dysfunction
What hormone increases in menopause?
FSh
Important contraindicatrion to IUS
distorted fibroid uterus
Can you use NSAIDs in breastfeeding?
Yes
What to do with dose of levothyroxine in pregnancy?
Increase it
Mx of cellulitis around C section wound site
Fluclox, if pen allergic - ertyrhomycin
What ABs are given during total abdominal hysterctomy?
IV co amox
Mx of allergic rhinitis in preganncy
Oral loratadine
Rate of labour in a nulliparous woman
0.5-1 cm per hour in a nulliparous woman
Hrt recommened in irregular meses
cyclical HRT - Oestradiol one tablet daily for a three-month period, with norethisterone on the last 14 days
HRT reccomended in regular menses
cyclical combined HRT - Oestradiol one tablet daily, with norethisterone on the last 14 days of the cycle
How long should a smear test be peformed after pregnancy?
3 months
Most common site of referred ovarian pain
Periumbilical area
What is the most common type of urinary incontinence in females?
Genuine stress incontinence
Standard method for treating anaemia in pregnancy
A trial of iron supplementation, followed by a re-check of the full blood count at two weeks,
Most specific test for IDA in pregnancy
Serum ferritin is the most specific test, with levels below 30 μg/l indicating iron deficiency in pregnancy.
A 26-year-old female is in the second stage of labour. The fetal head is not descending, and the obstetrician decides to perform a ventouse extraction. He injects local anaesthetic into a nerve that crosses the ischial spine. This nerve then passes along the lateral wall of the ischiorectal fossa embedded in the obturator internus fascia in Alcock’s canal.
Which nerve is involved?
Pudendal nerve
mass contains smooth muscle bundles in a whorled appearance.
Fibroid
What criteria warrants continous CTG monitoring during labour?
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour
