O+G 3 Flashcards
What treatment is used for high stage cervical cancer?
platinum-based chemotherapy
What is endometrial hyperplasia associated with?
- Taking oestrogen unopposed by progesterone
- Obesity
- Late menopause
- Early menarche
- Being a current smoker
- Nulliparity
- Aged over 35-years-old
- Tamoxifen
At what point in the menstrual cycle can the IUD be inserted?
Any time
It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum.
What’s the difference between an IUD and an IUS?
conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena)
both the IUD and IUS are more than 99% effective
Uses of IUS
- contraception
- menorrhagia
Mode of action of intrauterine contraceptive devices
- IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
- IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
From when are intrauterine devices effective?
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Risks of intrauterine devices
- IUDs make periods heavier, longer and more painful
- the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
- uterine perforation: up to 2 per 1000 insertions
- the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
- infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
- expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
What advice do you give for couples wishing to become pregnant?
- folic acid
- aim for BMI 20-25
- advise regular sexual intercourse every 2 to 3 days
- smoking/drinking advice
12 months before referral
When is fertility testing done and what does it involve?
12 months of trying to conceive
- semen analysis in the man
- mid-luteal progesterone level in the female to confirm ovulation (7 days prior to beginning next period)
When would you consider early referral to a fertility clinic?
Female
- Age above 35
- Amenorrhoea
- Previous pelvic surgery
- Previous STI
- Abnormal genital examination
Male
- Previous surgery on genitalia
- Previous STI
- Varicocele
- Significant systemic illness
- Abnormal genital examination
What’s the incidence of infertility?
1 in 7 couples
Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes of infertility
- male factor 30%
- unexplained 20%
- ovulation failure 20%
- tubal damage 15%
- other causes 15%
What are the possible results and management for progesterone test?
< 16 nmol/l
Repeat, if consistently low refer to specialist
16 - 30 nmol/l
Repeat
> 30 nmol/l
Indicates ovulation
When would you check for gonadotrophins?
to check for ovarian function in patients with irregular menstrual cycles
A 38-year-old woman complains that she is experiencing hot flushes and has not had a period for the past five months. She is worried that she going through an ‘early menopause’.
What is the most appropriate investigation to diagnose premature ovarian failure?
Follicle stimulating hormone (FSH) level is raised significantly in menopausal patients. Test FSH to confirm menopause. At menopause (and in premature ovarian failure), ovarian function ceases, leading to high levels of FSH due to the removal of the negative feedback mechanisms.
Define premature ovarian failure. How common is it?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
What are the causes of premature ovarian failure?
- idiopathic - the most common cause
- chemotherapy
- autoimmune
- radiation
Features of premature ovarian failure or menopause
- climacteric symptoms: hot flushes, night sweats
infertility - secondary amenorrhoea
- raised FSH, LH levels
What’s the condition?
post-menopausal patient with pain during sex and dryness, they may also have some postcoital bleeding
Vaginal atrophy
What is the criteria for a confirmed miscarriage?
A confirmed miscarriage can be diagnosed on ultrasound if there is no cardiac activity and:
- The crown-rump length is greater than 7mm OR
- The gestational sack is greater than 25mm
What is a cervical ectropion and what causes it? What features can it cause?
- On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.
- Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
Features:
- vaginal discharge
- post-coital bleeding
What’s the most common cause of PPH?
Uterine atony
The uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis
Management of PPH due to uterine atony
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine
- intramuscular carboprost
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade
What causes uterine atony?
It is associated with overdistension, which may be due to:
- multiple gestation
- macrosomia
- polyhydramnios
- other causes
What are the causes of primary PPH?
4 Ts:
Tone - problems with uterine contraction
Tissue - retained products of conception
Trauma
Thrombin
Management for PPH
- call for senior help, anaesthetics and haematology
- ABCD
- deliver placenta
- lie flat
- give oxygen
- IV access
- bimanually compress uterus
- insert catheter to empty bladder
- examine
- FBC, U+Es, clotting, cross-match
- replace blood with FFP if >4 units
- Syntocinon 5 Units by slow IV injection. This should then be followed by ergometrine (contraindicated in hypertension) and then a Syntocinon infusion.
- Carboprost (contraindicated in asthma) and then misoprostol 1000 micrograms rectally are then recommended.
- If pharmacological management fails then surgical haemostasis should be initiated.
A 70-year-old woman is seen in the acute medical unit with shortness of breath and abdominal distension. A chest x-ray shows a right pleural effusion. An ovarian mass is removed but it is found to be benign on histology. What is this syndrome called?
Meig’s syndrome
What are the 3 features of Meig’s syndrome?
- a benign ovarian tumour (normally a fibroma)
- ascites
- pleural effusion
What are the 4 main types of ovarian tumour?
- epithelial/surface derived tumours (65%)
- germ cell tumours (15-20%)
- sex cord-stromal tumours (3-5%)
- metastasis (5%)
How do you manage hypertension during pregnancy?
- At conception: no agent except ACE inhibitors is known to be teratogenic
In the second and third trimesters:
- ACE inhibitors are fetotoxic and contraindicated
- Full beta blockers slow fetal growth and are best avoided
- Labetalol and Methyl dopa are the drugs of first choice
- Nifedipine and alpha blockers (doxazosin or prazosin) appear to be safe
- Diuretics are undesirable but can be used.
How do you manage eclampsia?
- AIRWAY… (position, suction, oxygen, anaesthetist)
- IV line
- Stop the convulsion (IV lorazepam)
- Control the blood pressure ……..
(parenteral labetalol or hydralazine) - Prevent further convulsions (parenteral MgSO4)
- Deliver
What should women do to prevent neural tube defects?
- all women should take 400mcg of folic acid until the 12th week of pregnancy
- women at higher risk of conceiving a child with a NTD should take 5mg of folic acid until the 12th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
→ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
What causes folic acid deficiency?
- phenytoin
- methotrexate
- pregnancy
- alcohol excess
Where is folic acid found and what does it do?
Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.
Functions
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
Which drugs are ok to give to mothers who breastfeed?
- antibiotics: penicillins, cephalosporins, trimethoprim
- endocrine: glucocorticoids (avoid high doses), levothyroxine*
- epilepsy: sodium valproate, carbamazepine
- asthma: salbutamol, theophyllines
- psychiatric drugs: tricyclic antidepressants, antipsychotics (clozapine should be avoided)
- hypertension: beta-blockers, hydralazine
- anticoagulants: warfarin, heparin
- digoxin
Which drugs should be avoided during breast feeding?
- antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- psychiatric drugs: lithium, benzodiazepines
- aspirin
- carbimazole
- methotrexate
- sulphonylureas
- cytotoxic drugs
- amiodarone
What are the degrees of perineal tear?
- first degree: superficial damage with no muscle involvement, tear within vaginal mucosa only
- second degree: injury to the perineal muscle, but not involving the anal sphincter, tear into subcutaneous tissue
- third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn - fourth degree = laceration extends through external anal sphincter into rectal mucosa
A 51 year-old woman presents to her GP with a nine month history of urinary incontinence. Examination of her abdomen is normal. Urinalysis is normal. A diagnosis of detrusor muscle over-activity is made and the patient is commenced on oxybutynin. What is the mechanism of oxybutynin?
Anti-muscarinic
What receptors cause detrusor muscle contraction?
muscarinic cholinergic receptors
Does noradrenaline relax or contract the bladder?
Relax
What can be given prior to surgery to remove uterine fibroids? Why is it given?
GnRH agonists reduce the size of the uterus prior to surgery. The risk of post-operative blood loss is directly related to the size of the uterus.
Should COCP be given before surgery?
No, increases risk of VTE
What’s the diagnostic criteria for hyperemesis gravidarum?
Triad:
5% pre-pregnancy weight loss AND dehydration AND electrolyte imbalance
What’s the incidence of hyperemesis gravidarum and when is it most likely to occur?
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels.
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks and in very rare cases beyond 20 weeks.
What is hyperemesis gravidarum associated with?
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
Smoking is associated with a decreased incidence of hyperemesis!
How do you manage hyperemesis gravidarum?
- antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
- ondansetron and metoclopramide may be used second-line
- ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration
Complications of hyperemesis gravidarum
- Wernicke’s encephalopathy
- Mallory-Weiss tear
- central pontine myelinolysis
- acute tubular necrosis
- fetal: small for gestational age, pre-term birth
What’s the most common cause of short periods of decreased variability on CTG? After how long is it a cause for concern?
Fetus is asleep
40 minutes
How is a decrease variability in foetal heart rate on CTG defined and what are the causes?
< 5 beats / min
- Fetus is asleep
- maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol)
- foetal acidosis (usually due to hypoxia)
- prematurity (< 28 weeks)
- foetal tachycardia (> 140 bpm)
- congenital heart abnormalities.
What does CTG stand for?
Cardiotocography
Normal fetal heart rate?
100-160 / min
How is baseline bradycardia defined and what are the causes?
Heart rate < 100 /min
- Increased fetal vagal tone
- maternal beta-blocker use
How is baseline tachycardia defined and what are the causes?
Heart rate > 160 /min
- Maternal pyrexia
- chorioamnionitis
- hypoxia
- prematurity
What are early decelerations and what causes them?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually an innocuous feature and indicates head compression
What are late decelerations and what causes them?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Indicates fetal distress e.g. asphyxia or placental insufficiency
What are variable decelerations and what causes them?
Independent of contractions
May indicate cord compression
Which cancer is linked to PCOS?
Endometrial
Which contraceptives inhibit ovulation?
- levonorgestrel (as an emergency contraceptive)
- implantable contraceptive (etonogestrel)
- desogestrel-only pill
- injectable contraceptive (medroxyprogesterone acetate)
- ulipristal (as an emergency contraceptive)
- combined oral contraceptive pill
Which contraceptives thicken the mucus plug?
progestogen-only pill (excluding desogestrel)
Early menarchy is a risk factor for which cancers?
breast cancer
ovarian cancer
endometrial cancer
Elevated LH:FSH ratio and raised testosterone level is a stereotypical…..
PCOS
Which drugs lengthen the QT interval?
ciprofloxacin
antipsychotics
amiodarone
What does a pearl index of 1 mean?
if 100 women were using the contraceptive then 1 would get pregnant in a year
What proportion of UK 16 year olds have had sex?
1/3
What proportion of 13-15 year olds get pregnant?
1%
Which pill is associated with loss of bone density?
DepoProvera. Do not use under 18
What contraception should be used for women with IBD?
Not oral
Patches
Progesterone only injectables and implants
Intra-uterine and vaginal methods
Not DepoProvera as already at inc risk of osteoporosis
Is breastfeeding an effective form of contraception?
If women are fully breastfeeding, amenorrhoeic and less than 6 months postpartum, breastfeeding is >98% effective.
If she has intercourse 21 days postpartum she does not need emergency contraception.
What pill affects breast milk volume? What can be used instead?
COCP. Avoid before 6 weeks post partum and ideally up to 6 months.
Progestogen- only methods have no effect on milk production
IUD can be inserted from 4 weeks
Do postmenopausal women need contraception?
Women under 50 are advised to continue contraception for at least 2 years after the last period.
Over 50 for 1 year
What does the mini pill contain?
Progestogen only tablet
Give examples of progestogens given as a depot
Nexplanon
Depo-Provera
levonorgestrel-containing IUS
What contains both oestrogen and progestogen?
COC (mono, bi or triphasic)
Transdermal patch
Vaginal ring
Action of COCs
- Negative feedback
- inhibit gonadotrophin release and inhibit ovulation
- thin endometrium
- thicken mucus plug
Typical compound in COC
synthetic oestrogen ethinyloestradiol
Qlaira contains oestrogen oestradiol valerate which is metabolised to oestradiol
Can you take the pill back to back?
Yes but increase the irregular spotting can occur.
What is a monophasic pill?
The same dose of oestrogen and progestogen are taken every day
What is Qlaira
- Type of COC
- oestradiol valerate with synthetic progestogen dienogest
- 4 phases over 26 days then 2 pill free days
Risk of pregnancy when taking COC
0.2 per 100 women
What is a low dose COC?
20mcg ethinyloestradiol
Progestogenic side effects
- depression
- postmenstrual tension-like symptoms
- bleeding, amenorrhoea
- acne
- breast discomfort
- weight gain
- reduced libido
Oestrogenic side effects
- nausea
- headaches
- increased mucus
- fluid retention and weight gain
- occasionally hypertension
- breast tenderness and fullness
- bleeding
What should you do if you vomit after taking the pill?
If within 2 hours, take another
If you are on the COC and antibiotics what should you do?
Continue taking the pills but use condoms during and for 7 days after the antibiotic course
If you miss a pill of standard-strength ethinyloestradiol what should you do?
Standard strength is 30-35ug. One or 2 missed anywhere in the cycle is not a problem
If you miss a pill of low dose ethinyloestradiol what should you do?
Low dose is 20ug
Take it as soon as you notice it’s missed. Continue packet as normal. In 3rd week continue with next pack with no break.
COC with a planned surgery?
Stop 4 weeks before
Complications of COC
MI
VTE
- Cerebrovascular accidents
- Focal migraine
- Hypertension
- Jaundice
- Liver, cervical and breast carcinoma
When is COC contraindicated?
Absolute
- BMI > 40
- Smokers age > 35 and smoking > 15/day
- Diabetes with vascular complications
- Active/chronic liver disease
- History of VTE
- History of cerebrovascular accident, ischaemic heart disease, severe hypertension
- Migraine with aura
- Active breast/endometrial cancer
- Inherited thrombophilia
- Pregnancy
- major surgery with prolonged immobilisation
Relative contraindication
- BMI 35-40
- Smokers
- Chronic inflammatory disease
- Renal impairment, diabetes
- Age >40 years
- Breastfeeding up to 6 months postpartum
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
What is Evra? How is it taken?
A transdermal adhesive patch that releases ethinyloestradiol (34ug) plus the progestogen norelgestromin.
A new patch is applied weekly for 3 consecutive weeks and then replaced
What is Nuvaring? How is it used?
A combined vaginal ring. The latex-free Nuvaring releases a daily dose of 15ug of ethinyloestradiol and 120 ug of the progestogen etonogestrel to inhibit ovulation.
Insert into vagina and leave for 3 weeks. Take out for 7 days (withdrawal bleed). Insert a new ring.
Leave in during intercourse.
Take out for max 3 hours
What does the mini pill contain? How should it be taken?
Progestogen only 350mg norethisterone (Micronor)
Must be taken at the same time every day (+/- 3hrs) without a break.
If pill is missed then another should be taken asap and condoms used for 2 days.
OK to use with broad spectrum antibiotics.
Failure rate of POP
1 per 100 woman years
How does the mini pill work?
Makes cervical mucus hostile to sperm.
Inhibits ovulation in 50% of women
What is cerazette?
- POP that has a higher dose of 3rd generation progestogen desogestrel.
- Inhibits ovulation in over 95% of cycles.
- Longer window (12 hours) in which to take.
Which contraceptive is given by injection every 3 months? What advice should women be given?
Depo-Provera
- failure rate <1 per 100 woman years
- irregular bleeding in the first weeks but usually followed by amenorrhoea
- prolonged amenorrhoea may follow cessation
- bone density decreases over first 2-3 years, then stabilizes and is regained after stopping
Which contraceptive is injected every 8 weeks and when is it appropriate to use?
Noristerat
When a short-term interim contraception required. e.g waiting for a vasectomy to become effective
Which contraceptive device is inserted in the upper arm subdermally and can last for 3 years? What is the failure rate? Do women bleed?
Nexplanon (40 mm rod containing progestogen etonogestrel)
<1 per 100
Irregular bleeding in the first year
What are the types of morning after pill? When should they be taken? How effective are they? How does it work? Anything to be aware of?
- levonelle
- ideally within 24 hours, no later than 72 hours after intercourse
- 95% within 24 hours, 58% within 72 hours
- affects sperm function and endometrial receptivity and if taken just before ovulation can prevent follicular rupture
- vomiting plus menstrual disturbances in the following cycle - Ulipristal (ellaOne)
- up to 120 hours (5 days)
- at least as good as levonelle
- prevents or delays ovulation and may reduce implantation
- blocks action of progesterone so women taking progesterone contraceptives should use condoms until next period
What is Ulipristal?
A selective progesterone receptor modulator (SPRM) like mifepristone
What is a type of emergency contraceptive that you can take later than 5 days?
IUD. Can be inserted up to 5 days after sex or 5 days after expected ovulation
Failure rate of condoms
2 (perfect) -15 (typical) % but best protection against diseases
When should diaphragms or caps be inserted?
What’s the failure rate?
Advantage
- Before intercourse and must remain in situ for at least 6 hours after.
- 5 (perfect use) 15 (typical use) per 100 woman years
- protects against PID but not HIV
What are the 2 types of IUDs?
Copper containing
Hormone containing
How often does the mirena coil need to be changed?
Every 5 years
How does the copper coil prevent pregnancy?
Toxic to sperm
Blocks implantation
What is Essure?
Trans cervical sterilization involving the hysteroscopic placement of microinserts into the proximal part of each tubal lumen. The inserts expand and cause fibrosis and occlusion of the lumen which is confirmed 3 months later with a hysteosalpingogram.
Reversal unavailable on the NHS
Risk of failure of female sterilisation
1 in 200 lifetime risk
Risk of failure of vasectomy
1 in 2000 lifetime risk after 2 negative semen analyses which may take up to 6 months to achieve.
What can be done instead of a vasectomy revrsal?
Surgical sperm retrieval followed by IVF
