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