O+G 5 Flashcards
What contraceptives can be used after birth?
After giving birth women require contraception after day 21.
Progestogen only pill (POP)
- the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days
- a small amount of progestogen enters breast milk but this is not harmful to the infant
Combined oral contraceptive pill (COC)
- absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
- UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum
- the COC may reduce breast milk production in lactating mothers
- may be started from day 21 - this will provide immediate contraception
- after day 21 additional contraception should be used for the first 7 days
Lactational amenorrhoea method (LAM)
- is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
Which contraceptives inhibit ovulation and thicken cervical mucus?
Desogestrel-only pill Injectable contraceptive (medroxyprogesterone acetate) Implantable contraceptive (etonogestrel)
How does Intrauterine system (levonorgestrel) work?
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
As emergency oral contraception:
Inhibits ovulation
What are the features, investigations and treatment for mittelschmerz?
- Usually mid cycle pain.
- Often sharp onset.
- Little systemic disturbance.
- May have recurrent episodes.
- Usually settles over 24-48 hours.
- Full blood count- usually normal
- Ultrasound- may show small quantity of free fluid
- Conservative
What are the features, investigations and treatment for endometriosis?
- 25% asymptomatic, in a further 25% associated with other pelvic organ pathology.
- Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina.
- Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
- Intra-abdominal bleeding may produce localised peritoneal inflammation.
- Recurrent episodes are common.
- Ultrasound- may show free fluid
- Laparoscopy will usually show lesions
- Usually managed medically, complex disease will often require surgery and some patients will even require formal colonic and rectal resections if these areas are involved
What are the features, investigations and treatment for ovarian tortion?
- Usually sudden onset of deep seated colicky abdominal pain.
- Associated with vomiting and distress.
- Vaginal examination may reveal adnexial tenderness.
- Ultrasound may show free fluid
- Laparoscopy is usually both diagnostic and therapeutic
- Laparoscopy
What are the features, investigations and treatment for PID?
- Bilateral lower abdominal pain associated with vaginal discharge.
- Dysuria may also be present.
- Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort.
- Fever >38
- Full blood count- Leucocytosis
- Pregnancy test negative (Although infection and pregnancy may co-exist)
- Amylase - usually normal or slightly raised
- High vaginal and urethral swabs
- Usually medical management (metronidazole, doxycycline, IM ceftriaxone)
What’s the most common type of ovarian pathology associated with Meigs’ syndrome?
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
What’s the most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
What’s the most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
What are the types of benign ovarian cysts?
- physiological cysts
- benign germ cell tumours
- benign epithelial tumours
- benign sex cord stromal tumours
What causes follicular cysts and what happens to them?
- due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- commonly regress after several menstrual cycles
What is a corpus luteum cyst and how do they present?
- during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
- more likely to present with intraperitoneal bleeding than follicular cysts
What are dermoid cysts?
What’s the median age of diagnosis?
How often are they bilateral?
How do they present?
- also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
- most common benign ovarian tumour in woman under the age of 30 years
- median age of diagnosis is 30 years old
- bilateral in 10-20%
- usually asymptomatic. Torsion is more likely than with other ovarian tumours
What’s the most common type of ovarian cancer?
Serous carcinoma (epithelial in origin)
What can happen if a mucinous cystadenoma ruptures?
may cause pseudomyxoma peritonei
What is the most common benign epithelial ovarian tumour?
- Serous cystadenoma
2. Mucinous cystadenoma
What are defining features of mucinous cystadenomas?
typically large and may become massive
A 30-year-old female presents to her GP seeking contraception. She has three children and states she has completed her family. She is open to long-acting reversible contraception. After receiving advice about all options available, she opts for the copper IUD. Besides pregnancy, which of the following is it important to exclude?
Pelvic inflammatory disease
Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD.
A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?
Intrauterine system
How do you treat a woman with menorrhagia?
Does not require contraception
- either mefenamic acid (NSAID) 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
1st line: intrauterine system (Mirena)
2nd line: combined oral contraceptive pill
3rd line: long-acting progestogens (e.g Depo Provea)
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife notices that the umbilical cord is visibly protruding from the vagina. She is brought for an emergency caesarean section. What is the correct position for her to be in while being prepared for surgery?
on all fours, on knees and elbows, while someone pushes the presenting part of the fetus up
A woman presents to her GP complaining of bleeding after sexual intercourse. What is the most common identifiable cause of postcoital bleeding?
Cervical ectropion
What are the causes of post coital bleeding?
- no identifiable pathology is found in around 50% of cases
- cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill
- cervicitis e.g. secondary to Chlamydia
- cervical cancer
- polyps
- trauma
What’s the Bishop’s score? Below what result requires induction?
The Bishop’s score is used to predict whether induction of labor will be required.
A score of 5 or less suggests that labour is unlikely to start without induction.
What proportion of pregnancies are induced?
20%
What are the indications for induction of labour?
- prolonged pregnancy, e.g. > 12 days after estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- diabetic mother > 38 weeks
- rhesus incompatibility
What are the methods for inducing labour?
- membrane sweep
- intravaginal prostaglandins (PGE2)
- breaking of waters
- oxytocin
What is the most effective method of emergency contraception and should be offered to all appropriate women seeking emergency contraception?
Intra-uterine device. Not affected by BMI
What is thought to reduce the effectiveness of oral hormonal emergency contraceptives? What is recommended?
- reduced in patients with a high BMI.
- A double dose of levonorgestrel (Levonelle) is advised in patients with a BMI of over 26kg/m² or body weight greater than 70kg
What are the types of emergency contraceptive and how should they be taken?
- levonorgestrel
- ulipristal, a progesterone receptor modulator
- IUD
Levonorgestrel
- should be taken as soon as possible - efficacy decreases with time
- must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
- single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
- 84% effective is used within 72 hours of UPSI
- levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
- can be used more than once in a menstrual cycle if clinically indicated
Ulipristal
- a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
- 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
- concomitant use with levonorgestrel is not recommended
- Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having Ulipristal. Barrier methods should be used during this period
- caution should be exercised in patients with severe asthma
- repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
- breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
- must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
- prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
- is 99% effective regardless of where it is used in the cycle
- may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test. Which blood test is this?
Anti-Xa activity
In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) should be commenced immediately until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated.
Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE).
When is VTE risk in pregnancy assessed?
at booking and on any subsequent hospital admission
How do you treat women with risk of VTE?
A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin.
The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
- IVF pregnancy
- Gross varicose vein
- Family history of unprovoked VTE
- Immobility
- Smoker
- Age > 35
- Low risk thrombophilia
- Parity > 3
- Current pre-eclampsia
- Body mass index > 30
- Multiple pregnancy
(IVF IS A Last Point of Call for Blessed Mums)
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Which muscarinic antagonists are used to treat urinary incontinence?
- oxybutynin
- solifenacin
- tolterodine
How do you treat a 30-year-old woman presents with an offensive ‘fishy’, thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5?
Oral metronidazole for bacterial vaginosis
What criteria is used to identify bacterial vaginosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
How do you treat a 27-year-old woman who complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation?
Oral metronidazole
The ‘strawberry cervix’ is actually quite rare outside of examinations - some studies suggest only 2% of patients with Trichomonas vaginalis have this finding.
How do you treat a 22-year-old woman who presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus.
(neisseria gonorrhoea)
ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections
What causes vaginal discharge?
Common causes
- physiological
- Candida
- Trichomonas vaginalis
- bacterial vaginosis
Less common causes
- Gonorrhoea
- Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
- ectropion
- foreign body
- cervical cancer
What’s the diagnosis?
‘Cottage cheese’ discharge
Vulvitis
Itch
Candida
