O&G Flashcards
PCOS mx
General
weight reduction if appropriate
if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)
Hirsutism and acne
a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
if doesn’t respond to COC then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
Infertility
weight reduction if appropriate
the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins
Uss criteria for confirmed miscarriage
no cardiac activity and:
The crown-rump length is greater than 7mm OR
The gestational sack is greater than 25mm
Conditions every woman gets screened for
Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Rubella immunity Syphilis
The following should be offered depending on the history:
Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
Causes of infertility
male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15%
Investigation of infertility
semen analysis
serum progesterone 7 days prior to expected next period
Level Interpretation
< 16 nmol/l Repeat, if consistently low refer to specialist
16 - 30 nmol/l Repeat
> 30 nmol/l Indicates ovulation
Key infertility counselling points
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Miscarriage management
Expectant management:
First line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
Medical management:
Give the patient vaginal misoprostol. Advise them to contact the doctor if the bleeding hasn’t started in 24 hours. Should be given with antiemetics and pain relief. Often preferred if there is a higher risk of haemorrhage (late first trimester or coagulopathies), evidence of infection or previous adverse experiences.
Surgical management:
May involve manual vacuum aspiration under local anaesthetic as an outpatient or surgical management in theatre under general anaesthetic (previously referred to as ERPC).
Common causes of offensive vaginal discharge
Candida ‘Cottage cheese’ discharge
Vulvitis
Itch
Trichomonas vaginalis Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis Offensive, thin, white/grey, ‘fishy’ discharge
Induction indications
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
Epilepsy medication in pregnancy
aim for monotherapy
there is no indication to monitor antiepileptic drug levels
sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
Top methods
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening of gestational diabetes
women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Mx of gestational diabetes
newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
women should be taught about selfmonitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Mx of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Folic acid in pregnancy
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).
Criteria for continuous ctg monitoring
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 - this was a new point added to the guidelines in 2014
Criteria for postpartum thyroiditis
Patient is within 12 months of giving birth
2) Clinical manifestations are suggestive of hypothyroidism
3) Thyroid function tests support diagnosis
Causes of oligohydramnios
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
PPH risk factors
previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysi
Causes of increased nucal translucency
increased nuchal translucency include:
Down’s syndrome
congenital heart defects
abdominal wall defects
Causes of hyperechogenic bowel:
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
