O & G Flashcards
Antenatal Clinic History
PC - 4 questions: PV Bleeding/ Discharge, Abdominal pain, Fetal Movements, Rupture of membranes
HPC:
i) Previous Pregnancies - Number, Birth method, Complications, BW, Post-natal complications
ii) LMP
iii) Preference for delivery
iv) Maternal Factors - HTN, DM, Maternal Age, GDM, PET, Obesity, PMH, FH - SFD, GDM, previous scans, clinics, hyperemesis gravidarum, folic acid
DH - Any medications, any allergies, latex and penicillin
FH - Anything, miscarriage, SFD
SH- Alcohol, Smoking, Drugs, Domestic Abuse, Other children
Small For Dates Management
Small for Dates: <10th Centile for gestation / 2.7kg at term
Investigations
SFH - SFD (Follows own trajectory) or IUGR ( Drops along the centiles)
Uterine Artery Doppler (most sensitive at 23 weeks) - Look for reversal of blood flow in diastolic waveform
Fetal MCA (most sensitive at 23 weeks)
Ultrasound: Amnotic Fluid, Fetal MCA, Tone, Breathing Movements, Limb Movements
SFH
Screen for infections (amniocentesis)
Karyotyping
Mx
Re-check fortnightly for fetal growth if SFD/ Re-check twice a week for IUGR
CTG - continuous/intermittent
No intervention required - for normal umbilical artery doppler.
If abnormal - Umbilical artery doppler is abnormal —> admit and if pre-34 weeks steroids and prepare for delivery with constant monitoring
Admit for neonotal care postpartum
Fetal measurement paramaters
6-13 weeks - CRL
14-20 weeks - BPD
>24 weeks - SFH
Risks of SFD
Risks of IUGR
SFD
- Constiutional (Maternal height, weight, asian, female)
- Materna Disease (renal, autoimmune)
IUGR
- Maternal pregnancy complications - PET
- Mutiple pregnancy
- Substance abuse/ smoking/ alcohol
- Infection - CMV
Focused Gynae History
i) Pregnancies
ii) Discharge
iii) Bleeding - normal, abnormal, clots, flooding
iv) Dyspareunia
vi) Pain
vii) PCB, IMB, PMB, Cyclical Pain, Dyspareunia
viii) Smear history - abnormal smears + treatment
Sex History - Sexual partners in the last six months, STI?, Partners had STI? Barrier Protection? STI Screening?
PMH - Autoimmune, Cancers, Menorrhagia, Dysmneorrhoea, Gynae procedures etc.
PSH
FH - Genital breast cancers, gynaecological concerns
SH - Alcohol, Smoking, Psychological
Offer - STI Screening, Contraception and Leaflets
Smear Counselling
Colposcopy Management
i) Punch
ii) LLETZ
iii) Cone biopsy
Smears: 25-49 = 3 yearly. 50-64 = 5 yearly. 65< only offered if haven’t had smear in last 10 years/ if last smear test was abnormal or if currently symptomatic/clinical suspicion
Borderline/ Mild Dyskaryosis - HPV Negative = Discharge to routine recall
Borderline / Mild (CIN1) - HPV Positive = Colposcopy within 8 weeks
Moderate (CIN2) = Colposcopy within 4 weeks
Severe Dyskaryosis (CIN3) = colposcopy within 2 weeks
Colposcopy
i) This involves using a small camera to have a look at the cervical opening. Small sample will be taken might be painful
ii) Acetic Acid stains the abnormal cells and iodine stains normal cells
ii) There might be some bleeding, advised to not have intercourse for 2 days after and avoid strenuous exercise
LLETZ
- Sever Dyskaryosis at smear. CIN II/III at punch biopsy.
- Uses a small electrical instrument to remove part of the cervix.
- Risks - preterm delivery, infection, haemorrahge
- Six month follow up - test of cure: review LLETZ biopsy histology and repeat cervical smear again + HPV
- Three outcomes :
i) Biopsy shows clear margins, no dyskaryosis and no HPV then goes back to routine follow up.
ii) Not clear excision then back to LLETZ.
iii) Clear excision but new SMEAR has HPV/ dyskaryosis then back to colposcopy
Cone Biopsy
Used to treat 1 a i) –> Removes ectocervix + some of endocervix
-Risks - preterm delivery, infection, haemorrahge
always offer To Take Away information (leaflets)
Different types of swab
a) Endocervical
b) High Vaginal
c) Vulval
a) Endocervical - Involves LBC for Chlamydia, Gonorrhoea and Smear testing
b) High Vaginal - BV and Trichomonas
c) Vulval - BV and Trichomonas
Dyskaryosis
vs
CIN
Dyskaryosis - The finding of abnormal cell types in LBC
CIN - Tissue sample finding of dysplasia in situ (I: 1/3 , II: 2/3 and III: 3/3)
STI Management
+
partner tracing
PID Protocol
14 Days - Oral Oflaxacin + Oral Metronidazole
IM Ceftriaxone + 14 days Oral Doxy + Oral Met
Syphyllis
Benpen/ Gent / Doxy
Gonorrhoea - Ceftriaxone + Azithromycin ( 1 Dose + 1 Pill)
Chlamydia - Azithromycin/ Doxy
BV + Trichomonas - Metronidazole
CA 125
Sensitivity
Specificity
Sensitivity - 81%
Specificity - 75%
Ovarian Cancer Management
Examination - Pelvic + Bi Manual +/- SPeculum
Investigations - Blood Tests: CA-125, AFP + HCG - Germ Cell, LDH
Imaging - USS
Surgery - Stages 1a and 1b surgery no chemo. Stages 1c and above surgery and chemo
Pelvic Inflammatory Disease
Hx
Rx
Hx
Discharge, pain : SOCRATES, quantify discharge or blood
Long term partner/ casual partners: how many how long
Have you ever had sex with someone knowing they have an STI/ HIV/ Hepatitis
Have you had sex with a sex worker
Have you had an STI Check before (and partner)
Have you ever felt pressured into having sex
PMH, PSH, SH - Smoking, Alcohol, FH, DH - Pill, In Situ devices.
Rx
Oral Oflaxacin + Met (14 Days)/ IM Cef (once) + Met and Doxy for 14 days
Contact Tracing - 6 months - any woman, men with upper genital tract invovlement. 4 weeks - asymptomatic men or urethritis.
Abstain from sex until treatment course completed.
Barrier protection and contraception
Safety Net - if experiencing gynaecological or psychosexual issues.
Risks of PID - Common - pain, discharge Severe - ectopic and infertility
Placenta Praevia
Hx
Mx
VIVA
Hx
- Gravida/ Parity
- Gestational Age/ LMP
- Quantify Bleeding if present
- Discharge, pain, recent intercourse, Waters broken, other complications
- Fetal Movements
HPC - Scans, past appointments, STIs, previous period questions (IMB, PCB, Dyspareunia, menorrhagia etc)
PMH , PSH, Drug History, SH (alcohol, drugs), FH
Mx
- ABCDE, Admit, Call Senior
- Abdo examination, urine dip, BP
- CTG/ Pinnard/Doppler
- IV Access - FBC, G&S, U&E, LFT, Clotting, Rhesus, Ultrasound Scan
- Serial Scans - Long term Management, Safety Net, Discuss delivery plans
VIVA
Placenta Praevia Grading
I - Near os
II- Partly covering os
III- Completely covering os
IV - completely covering os even when dilated
What to give to pre-term mothers/ neonates
Steroids
Antibiotics
MgSO4 (Consider)
Immediately to NICU especially if before 34 weeks (24 hours)
DVT/PE Pathway
ABCDE, FBC, Clotting Studdies, Us and Es, LFTs, NOT D DIMER. ECG, ABG, CTG
i) Venus Duplex Scan - If positive —> Start management immediately. If negative–>
ii) CXR —> Abnormal –> CTPA / Normal —-> VQ Scan, if VQ Scan is abnormally CTPA
Management:
LMWH - Subcut (enoxiparin/clexane) - Titrated against women’s booking weight. Continued for entire pregnancy and stopped when she goes into labour
Restarted after labour then continued for six weeks or until three months. Not contraindicated in breastfeeding.
Signs of pulmonary embolism
Pleuritic Chest Pain
Leg Pain
Breathlessness
Prolapse Stages
I - Cervix drops into the vagina
II - Cervix out of the vaginal opening
III - Cervix is outsode of the vagina
IV - Procedentia
Incontinence
Dx
Mx
Rx
Dx - Urge (Can’t make it) vs Stress (Leaks)
Bladder Diaries first line
If first line treatment fails then urodynamic studies
What are urodynamic studies:
- Fill bladder and vagina or rectum with fluid –> pressure probe ( Detressur pressure = Bladder - rectal pressure)
- Look for unsynchronised detrussor contrations = Detrussor Overactivity
- Look for leak when cough and NO detrussor contraction = Urodynamic Stress Incontinence
Post micturation ultrasound volume (stones, anomalies). FIlling and voiding studies.
Mx/Rx
Urge - Bladder Retraining —>
Conservative —->
Oxybutynin, Tolterodine —->
Sacral Nerve Stimulation / Clam Ileocystoplasty
Stress- Pelvic floor muscles (8 contractions ,3 times a day for 3 months) + Conservative +
—> Medical: Duloxetine
—>Surgery (TVT, TOT and plication)
GDM
Hx
Dx
Mx
Cx
Hx:
Dates etc.
Previous clinics - BP readings, glucose readings, SFH
Sx - polyuria and polydypsia
Dx:
16 week GTT is warranted if: if past history of GDM or Macrasomia
28 week GTT with RFs: obesity, FHx DM, Stillbirth, Race, Macrosomia
or Urine dip: 2x + or 1 x ++
USS - look for polyhdramnios
Mx:
2 weekly monitoring
Target <7.8 post prandial
Measure glucose: morning, before meals and after meals
Fasting: <7.0 - diet and exercise, then metformin then insulin ( 2 weeks reviews)
Fasting: >7.0, start insulin)
Hba1c?
Teams : Dibaetic nurse, dietician,
Intrapartum - CTG, Maternal BMs, IV insulin pump, induction (39 weeks)
Postpartum - Stop IV Insulin, Subcutaneous Insulin after birth, Paediatrics team
Neonatal hypoglycaemia: 2x<2.6/ <1.6
Cx: Pre-Ecclampsia, Macrsomia, PPH, Shoulder Dystocia, Diabetes (30%),
Vomiting in early pregnancy
DDX
History
Dx
Mx
DDx - Pregnancy related (hyperemesis gravidarum) + Molar Pregnancy / non related vomiting
History - Excessive vomiting, ask for LMP, contraception, blood in vomit, triggers for vomiting
Dx - Clinical Examination (Assess for hydration status), Urine test (pregnancy and ketones), FBC, U&Es, B HCG, USS (if thinking about molar pregnancy), Repeat B HCg if worried about ectopic if no findings on ultrasound scan.
Mx - Psychosocial management, Dehydrated - IV Fluids, Vitamins - Thiamine, Steroids.
Counsel regarding the pregnancy
ROM/ PROM/ P-PROM
Hx - Sudden gush, Pink Plug, Lots of fluid, Maybe associated with contractions, what were you doing at the time, whe ndid it happen, sexual intercourse history, gynae history, can be due to - infection, pre-eclampsia, placenta praevia, placental abruption.
Extra questions - blood, fever, fetal movements, pregnancy up-to-date, previous scans, exclude vasa praevia and placenta praevia. No contractions!
Dx - Clinical, ROM-Test (if not likely), FFT (if not ruptured but looking for risks)
FBC, WCC (look for infeciton as high cause of ROM), CRP, G&S/ Cross match - PPH
Abdominal examination, Cusco speculum examination (looking for pooling of fluid, consider sterile speculum), Kleihauher Test (If Rh Negative/ or can prophylactically give 500 iu Anti-D),
Fetal monitoring - CTG
If >36 weeks
Induce if not in labour after 18 hours
If >34 weeks
Admit, and if 18 hours elapse and no spontaneous labour consider inducing. Sometimes wait and monitor for signs of infection or fetal distress at which point delivery is considered to allow fetal maturation.
24-34 weeks
Steroids + Antibiotics ( Erythromycin)
Cervical Length (If more than 15mm do an FFT. If positive FFT/ or cervical length less than 15mm then –>
+ Tocolytics (If going into labour (FFT/ Cervical Length)
If Choriamionitis/ Fetal distressed is suspected —> C Section
Placental Abruption
Hx
Dx
Mx
Hx - Painful abdomen, PV Bleeding (might be concealed so no bleeding), Fetal Movements reduced, ++ Fetal Haemorrahge can lead to haemodynamic instability, Rhesus status (Kleihauher Test), what was she doing, elicit history of (drug, smoking, alcohol use, pre eclampsia)
Bleeding - when, how much, how long
Dx- ABCDE Management, Iv Fluid resuss, CTG, Abdominal Exam (tender, tense abdomen), Cusco Speculum (pool of blood),
USS to confirm and assess viability. Emergency –> Mention you would involve a senior obstetrician as soon as possible to discuss expediting delivery.
FBC, WCC, CRP, Blood Cultures ( think about infection), G and save/ Cross match for maternal haemorrhage
Mx - Emergency. ABCDE management. Senior obstetrician for emergency c section. IV Fluid recussitation. Analgesia, Anti- D if required.
If <34 weeks - consider Betamethasone, antibiotics + (MgSO4)
Pre-Ecclampsia
Hx: Headaches/Random finding/ High blood pressure finding/ Epigastric Pain/ Reduced fetal movements/ Pre-existing HTN/ DM/ GDM/ Anti phospholipid syndrome etc.
Rarely - seizures, muscle weakness
Dx: 0.3g/24hour urinary collection of protein/ ++ once or + on multiple occasions on urine dip/ >30 PCR/ Hyperreflexia/ Maybe SFD/ Oedema/ Mild: >140 Moderate: >150 Severe: 160
Mx: On presentation - Admite for a period monitorin (usually 24 hours). Then administration of Anti-HTNives (i) labetalol ii) Nifedipine iii) methyldopa iv) hydralazine. Aim for <140. Screen for HELLP Syndrome
Monitoring - twice weekly for blood pressure and urine .
23 week - Potential screen for IUGR with Uterine artery doppler (reversed diastolic flow) / MCA doppler (raised peak systolic flow)
Consultant led birth plan - needs to be in hospital, consider epidural due to the hypertension.
Higher likelihood of PPH - so needs active management of third stage of labour
If Ecclamptic - MgSO4 to neuroprotect mother and baby. Needs to be delivered by c section as an emergency. Consider pre-term birth protocol
If >160 (or high) : C - Section due to unwanted effects of maternal effort. Once again consider pre-term birth protocol
Menorrhagia / Abnormal Bleeding
Hx
Dx
Management
Hx: Cycle length
How long do you bleed for,
Clots/Flooding
How many pads
When did it start
Pain
Discharge
Screen for anaemia
Screen for STI risk
Psychosocial impact
Contraception
Pregnant?
Smears?
PCB, IMB, Dyspareunia, PMB
DDx: Dysfunctional Uterine Bleeding, Fibroids, Platelet Dysfunction, Infection, Malignancy, Polyps (older women)
Examinations: Abdominal (Enlarged uterus, tenderness), Pelvic Examinations (Bimanual and speculum) , Swabs
Investigations: Urine Dip, Pregnancy Test, Temperature, FBC, CRP, ESR, Rapid antigen tests for organisms, USS?, Laproscopic with fimbrial biopsy for treatment resistant PID
Testing for bleeding/ platelet disorders in primary menorrhagia
Mx:
Dysfunctional Uterine Bleeding -
Fertility sparing - Tranexamic Aid, NSAIDS.
Non- fertilty sparing - LNG-IUS (with endometrial biopsy first), COCP, GnRH, Injectable progesterones,
surgical - hysterectomy, uterine artery emboliation, ablation
Fibroids - See fibroid card.
STI - See STI Card
Malignancy - see malignancy card. USS and Hysteroscopy + Endometrial Biopsy
Ovarian Ca
Hx
Dx
Mx
Hx
>50
Bloating, early satiety, pelvic pain, urinary symptoms, bowel sx, weight loss, recent UTIs (obstructioN)
RFs: FH (BRCA1, BRCA2), Oestrogen Exposure (nulliparity, early menarche, late menopause, HRT, tamoxifen)], not breastfeeding
Dx:
Examination: abdominal, bimanual
Investigations: CA125 (>35) (epithelial), (CEA (mucinous))
If <40 - bHCG (embryonal, choriocarcinoma), AFP( endodermal sinus, embryonal), Inhibin ( granulosa cell), LDH (dysgerminoma),
FBC, ESR, U&Es, LFTs (metastatic spread)
USS
RMI - post menopausal = 3 x Worrying features x CA-125
Staging:
1: a) One ovary - capsule intact b) Both ovaries - capsule intact c) capsule not intact
2: a) uterus/ fallopian tubes. b) other pelvic tissues c) a or b + in peritoneal fluid
3: to peritoneum + lymph nodes
4: outside of pelvis and abdomen
Mx:
Stage 1: Surgical management: oopherectomy/ excision. If high grade = carboplatin six cycles
Stage 2-4: Surgical management: resection of all cancerous tissue + paclitaxel
Antenatal
Hx
Dx
Questions for antenatal consultation:
Gravida and parity
Gestational Age/ LMP (Nagle’s Rule)
Fetal Movements
Discharge, bleeding, pain, hyperemesis, ROM (bloody show)
Booking Visits?
BP? Urine Dip? GDM Risk?
Screen for psych
PMH,PSH, DH (folic acid, penicillin allergy, latex allergy), FH (pre-term, pre eclampsia, HTN, DM, miscarriage) SH (Domestic abuse, alcohol, smoking, drug use)
Examination:
Pregnant Abdo exam + Doppler/ Pinnard
BP,
Urine Dip,
USS if indicated
Speculum + swabs if indicated
Ectopic
Hx
Dx
Mx
Hx
Abdominal pain, severe, peritonism, shoulder tip pain, diorrhae, Amenorrhoea (LMP)
RFs- Coil, uterine abnormalities, smoking, Previous gynae surgery, Previous history of ectopic, PID, STIs, Assisted Conception
Dx - Avoid abdo exam due to rupture risk
ABCDE. Observations.
Pregnancy Test
If worried about rupture - Fast Scan, ABG and cross match
TVUS, FBC, CRP, ESR, B-HCG (serial B-HCG to make sure it decreases)
Most commonly in the ampula of the fallopian tube
Mx
Surgical Indications: >35mm, pain, haemodynamically unstable, Beta HCG >1500, fluid in the pouch
Medical Indications: Serial HCG monitoring, 15% require second dose and some people require surgery.
Make sure they can come back to hospital for another pregnancy test.
70% go onto have another successful pregnancy
Complications: Immediate - risks of surgery, perforation, loss of fallopian tube, infection
Long term - adhesions, damage to abdominal organs, incontinence, subfertility, risk of ectopic pregnancy
CTG Findings
Pathological
>3 minutes bradycardia
Reduced variability for more 90 minutes
Late decelerations >30 minutes
Suspicious
Baseline rate high (160-180)
Baseline variability <5 (30-90 minutes)
Variable decelerations or late decelerations for less than 30 minutes
TOP
Abortion Act
PC: Hx, Screen for non-consensual, for risk, for abuse, Previous TOPs, clotting disorders, IUD in place, endocrine problems
Before (medical and surgical) :
Scan to assess pregnancy- Rule out miscarriage and ectopic
Counsellor involved because can be long term traumatic effects
Contraception -Can be inserteid while doing termination
Bloods - RhD Negative given anti-D
Prophylactic antibiotics
During:
Medical: <13 weeks
Mifipristine and Misoprostol.
Surgical: >13weeks
Dilatation and vacuum/suction (before 14 weeks)
Dilation and evacuation (after 15 weeks)
If >22 weeks:
Fetacide (potassium chloride)
Complications:
Common - bleeding (safety net for severe bleeding) , infection
Rare - failure, prolonged bleeding, uterine perforation, miscarriage,
Contraindications:
Chronic Adrenal Failure
Clotting Disorders
IUD in place - must be taken out before TOP
Ectopic
Abortion act:
<24 weeks: harm to mother, harm to fetus (physical, psychological harm to mother, fetus or any existing children)
>24 weeks: grave danger or injury to the fetus or the mother
Emergency Contraception
Fraser:
Do you understand why im talking about contraception?
Cannot be persuaded to inform parents?
Likely to continue having intercourse?
Physical/mental health liely to suffer?
Extra:
Talk about boyfriend, age and consensual.
<13 with someone >16 is crime.
Currently on contraception?
Ovulation Inhibitors (95%)
Ulipristal Acetate - can only be used once in a cycle. 120 hours. Progresterone receptor modulator. Breast pain, N&V
Levonorgestel - N&V, Breast Pain. Can take another one if vomited out within 3 hours. 72 hours
Fetacidal (thickens cervical mucus)
Copper COil (99%)
- contraindicated in ectopic history, current PID,
-120 hours
Four extra things
safety net - for fever, bleeding, abdominal pain
Offer long term contraception
screen for STIs
Test of pregnancy - 2 weeks time
Rhesus D
On Anti - D antibody testing at booking and at 28 weeks:
>4 iu/ml = moderate risk
>15 iu/ ml = severe risk
If deteted before 28 weeks testing should occur every 4 weeks until 28 weeks and then every 2 weeks thereafter
Cord blood taken at birth to assess for anti-D antibodies.
Cell saver - 1500 iu anti-D
Sensitising Events: Give anti -D within 72 hours
250 iu 12-20 weeks
500iu >20 weeks + kleihauher test
medical interventions (chorionic villus sampling, amniocentesis or external cephalic version)
terminations
late miscarriages
antepartum haemorrhage
abdominal trauma
Secondary Amennorhea
DDx -
Physiological - menopause, breastfeeding, pregnancy
Hypothalamic - low weight, exercise
Pituitary - hyperprolactinaemia (can be secondary to hypothyroidisM), pituitary failure, sheehan’s
Adrenal - CAH, virilising tumours
Ovarian - PCOS, premature menopause, virilising tumours
Outflow - Asherman’s, Cervical stenosis , endometrial surgery
Dx:
21 Day Progesterone ( 7 days before start of new cycle) - If <30 then consider anovulation
FSH/ LH - Day 3 - if low then pituitary failure, if high then ovarian failure
TFTs
Pituitary Function testing
Testosterone - if high PCOS
Oestrogen - If low suggests premature ovarian failure
Primary Amenorrhoea
Hypothalamic - Low weight, exercise , consitutional delay
Adrenal - CAH
Congenital - Turner’s, Kallman’s (GnRH deficiency)
Outflow - Imperforate hymen, Transverse Vaginal Septum, Rokitansky’s syndrome (failure of mullerian duct development resulting in missing uterus and variable degrees of vaginal hypoplasia )
