O&G Flashcards
30 year old, previously regular 30 day cycle presents with 3 months of no periods
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
Normal LFTs, TFTs, FBC raised FSH ( > 35 iu/l), LH levels (> 20 mIU/l) (but low oestrodiol - ( < 100 pmol/l))
Premature Ovarian Failure
= onset of menopausal symptoms in <40yrs + elevated gonadotrophin levels
CAUSES: Idiopathic (MOSTLY), chemo/radio, autoimmune
Primary amenorrhoea (no menses by 16yrs) causes?
Turner’s syndrome
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of the genital tract
Secondary amenorrhoea (previous reg cycles, but now stopped >/=6mnths) causes?
EXCLUDE PREGNANCY FIRST
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis/hypothyroidism
Sheehan’s syndrome (pituitary gland is damaged during childbirth - low BP or haemorrhage)
Asherman’s syndrome (intrauterine adhesions)
Ix for Amenorrhoea?
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
Mx for secondary amenorrhoea (esp POI)?
Conservative:
symptomatic relief (e.g. lubricants)
herbal
lifestyle (reg exercise, stop smoking, alcohol)
Medical:
Non-hormonal (Alpha-adrenergic agonists - clonidine; BBlockers - propanolol; Bisphosphonates - Raloxifene, Denosumab; SSRIs, Gabapentin)
HRT - PO/TD/ring/IUD; continuous combined regimen (no periods)
Testosterone supplementation
Topical vaginal oestrogen (dryness)
Gamete donation
Psych:
CBT (low moods, anxiety)
Primary PPH (<24hrs, >500ml blood loss) causes + RFs? **NB: secondary PPH (>24hrs-12 wks) usually due to retained placental tissue/endometritis)
Causes 4 Ts: Tone (MOST COMMON -uterine atony), Tissue (retained placenta), Trauma, Thrombin (coag abrnormalities)
RFs: Previous PPH, previous CS, prolonged labour, Pre-Eclampsia, Incr maternal age, polyhydramnios, multiparrity, emergency CS, placenta parevia, macrosmonia, ritodrine (used for tocolysis)
Primary PPH Mx?
ABC approach Call for help Vaginal exam + remove placenta if still present Rub up a uterine contraction Admin bolus of syntocin/syntometrine Insert 2 large bore cannulae 14 gauge Take FBC, clotting, X-match Consider catheterisation
MEDICAL: IV syntocin 10 units/IV ergometrine 500mcg IM carboprost (prostaglandin)
SURGICAL (2nd line): Intrauterine balloon tamponade (if uterine atony)
B-Lynch suture
Ligation of uterine/internal iliac arteries
**HYSTERECTOMY IF SEVERE, UNCONTROLLABLE BLEEDING (Life-saving)
37 weeks pregnant with nausea, severe itching and lethargy. On examination she is clinically jaundiced but observations are normal. Normal Hb, platelets, WBC, LFTs incr - obstructive
Diag + Mx?
Obstetric Cholestasis
MATERNAL:
Monitor LFTs weekly
Conservative (loose clothing, emollients)
Medical - Antihistamines, Ursodeoxycholic acid, Cholestyramine, Vit K
FOETAL + LABOUR:
CTG, Doppler, IOL at 37wks (incr risk of pre-term, still birth & meconium)
**Measure LFTs 10 days PN.
NB: Acute Fatty liver has non-specific symptoms (pre-eclampsia-like + abdo pain) + incr ALT (>500) –> DELIVER ASAP (ICU Emergency)
Uterine Fibroids (Afro-caribbean, asymp OR menorrhagia, lower abdo pain, bloating, urinary freq, subfertiity) Mx?
TVUSS
Mx =
1st line - IUS (levonorgestrel-releasing)
Tranexamic acid, COCP
GnRH short term (reduce size)
If large fibroid - myomectomy (preserves fertility) OR hysteroscopic endometrial ablation/hysterectomy, uterine artery embolisation
Induction of labour (IOL) indications?
> 41-42 wks or >12 days after due date
PROM
Diabetic >38wks
Rhesus incompatibility
Methods of IOL?
Intravaginal prostaglandins
Membrane sweep
Oxytocin
Artificial ROM
Pregnant mother presents with exposure to chickenpox <10 days ago, unsure if she has had it as a child - Mx?
Check VZ Antibody status (IgG and IgM)
If negative, give VZIG (effective for 10 days post-exposure)
Oral acyclovir if presenting within 24hrs of rash
Oligohydramnios (<500ml at 32-36 weeks and AFI <5th percentile) causes?
PROM Renal agenesis IUGR Post-term pre-eclampsia
RFs and Ix for Ovarian cancer?
BRCA1/2 gene mutations, early menarche, late menopause, nulliparity
CA125 levels (>35 IU/mL) If raised, Abdo/pelvis USS
Diagnosis & Mx for ovarian cancer?
Diagnostic laparotomy
Surgery with platinum-based chemotherapy
Which conditions are routinely screened for in pregnancy?
Hep B
HIV
Syphillis
Blood group, Rhesus status, anti-red cell Ab
Down’s syndrome
Fetal anomalies
Neural tube defects
Anaemia
Bacteruria
Risk factors for pre-eclampsia
Which conditions are NOT screened for routinely in antenatal care?
Bacterial vaginosis Chalmydia CMV Fragile X syndrome Hep C!!! GBS Toxoplasmosis
Emergency contraception for high BMI?
Copper coil (IUD) - not affected by BMI
Fitted within 5 days of unprotected sex
Inhibits fertilisation/implantation
99% effective
can be left in as long-term contraception
53-year-old female presents with 2 months of PV bleeding. Passed through the menopause at 49-years-old, BMI is 34kg/m² and drinks 18-units of alcohol/week. One sexual partner her whole life and no pain during sex or post-coital bleeding. Most likely diagnosis?
ENDOMETRIAL HYPERPLASIA (can develop into endometrial cancer) - intermenstrual bleeds, post-menopausal, menorrhagia, irreg bleeds + HIGH BMI
Types = simple, complex, simple atypical, complex atypical
Mx for typical = high dose progestogens with repeat sampling in 3-4months AND/OR levonorgestrel IUS
Mx for atypical = hysterectomy
Not:
Cervical cancer - requires more than 1 sexual partner. Has intermenstrual/postmenopausal bleeds
Vaginal atrophy - post-menopausal, pain during sex, dryness, some post-coital bleeds
Mx for atrophic vaginitis (PM bleeds, vaginal dryness, dyspareunia, occasional spotting)?
Topical oestrogen (restore vaginal mucosa) + lubricants, moisturisers (adjunct)
How long to use contraception for after menopause?
> 50 yrs - for 12months after LMP
<50 yrs - 24mnths after LMP
Mx for maternal GBS infection at 34 weeks?
Oral benzylpencillin + offer IV benzylpenicillin at start of labour and at 4hr intervals
(IV antibiotic prophylais (IAP) indicated if prev GBS, pyrexia >38 during labour, late-onset GBS, PROM, premature labour)
Most common cause of CYCLICAL secondary dysmenorrhoea?
Endometriosis
What is the score that can be used to classify the severity of nausea and vomiting in pregnancy?
PUQE score
Pregnancy-Unique Quantification of Emesis
Most common cause of recurrent miscarriages?
APL syndrome
Screening tools for post-natal depression?
The Edinburgh Postnatal Depression Scale (score >13 out of 30 indicates depression)
(also PHQ-9 form)
Most common reason for short episodes of decreased variability on CTG? (<40min)
Foetus is asleep
Normal foetal HR = 100-160bpm (normal variability = 5-25bpm; abnormal <5bpm)
> 40 min –> cause of concern (maternal drugs e.g. benzos, opiods, methyldopa; foetal acidosis due to hypoxia; prematurity <28wks; foetal tachy >140bpm; congenital heart abnormalities)
HRT suitable for perimenopausal women?
Systemic Combined (oestrogen and progesterone) CYCLICAL HRT
Preferred as: produces predictable withdrawal bleeding, whereas continuous cause unpredictable bleeding
Mx of PPROM in 32+0 who is otherwise well?
Admit for 48hrs + reg obs
Abx (10 days oral Erythromycin; to prevent chorioamnionitis)
corticosteroids (promote lung maturity, otherwise risk of pulmonary hypoplasia)
consider delivery by 34wks
Ix and Mx for woman presenting with menorrhagia?
Ix = Examination, FBC (anaemia?), TVUSS, hysteroscopy
Mx - depends on if they want contraception or not
If they require:
CONTRACEPTION –> IUS (1st line - total 52mg leveonorgestrel, released at 20 mcg/day + kept in for 5 years), COCP, long-acting progestogens
NO-CONTRACEPTION –> Tranexamic acid 1d TDS
or Mefenamix acid 500mg TDS (also helps w/dysmenorrhoea)
[start both of first day of period]
+ short term relief = Norethisterone 5 mg tds
What secretes hCG and when can it be detected by?
Secreted by synctiotrophoblast into maternal bloodstream (maintains prod of progesterone by corpus luteum)
Detected ~8days after conception, doubles every 48hrs in first few weeks and peaks at 8-10wks
Causes of bleeding in pregnancy in each trimester?
T1 - Spontaneous abortion, Ectopic preg, Hyatidiform mole (mole assoc. w/ exaggerated symptoms of pregnancy e.g. hyperemesis; large for date uterus + V high hCG)
T2- Spontaneous abortion, Hyatidiform mole, Placental abruption (shock, tender + tense uterus, normal lie + presentation & distressed fetal heart)
T3- Bloody show, Placental abruption, placental praevia (abnormal lie, non-tender uterus), vasa praevia (ROM followed by PV bleeding)
CTG mnemonic - DR C BRAVADO - stands for?
DR- define risk: why is this patient on a CTG monitor? e.g. pre-eclampsia, antepartum haemorrhage, maternal obesity, maternal ill health
C- contractions. Look at the bottom of the trace, each contraction is shown by a peak. In established labour you would expect 5 contractions in 10 minutes. Each large square = 1 minute duration, so count the number of contractions in 10 squares.
BRA- baseline rate. The fetal baseline rate should be approximately 110-160 beats per minute. Each large square = 10 beats and each small square = 5 beats. A fetal bradycardia is below 110 beats per minute and a fetal tachycardia is above 160 beats per minute.
V- baseline variability. The fetal heart rate should vary between 5 to 25 beats per minute. Below 5 beats per minute, the variability is said to be reduced.
A- accelerations. Are there accelerations in fetal heart rate? Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions.
D- decelerations. Are there decelerations in fetal heart rate? These are a reduction in fetal heart rate by 15 beats or more for at least 15 seconds. Decelerations are generally abnormal and should prompt senior review. In particular, late decelerations, which are slow to recover are indicative of fetal hypoxia.
O- overall impression/diagnosis. As a medical student it is important to be aware of two features- terminal bradycardia and terminal decelerations. A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a ‘pre-terminal’ CTG and are indicators for Emergency Caesarean section.
Anti-D Ig to be given asap (within 72hrs) in which situations?
- Delivery of Rh+ve infant (even if stillborn)
- Any termination of pregnancy
- Miscarriage if gestation >12wks
- surgically manged ectopic (NOT if medically)
- ECV
- APH
- Amniocentesis, CVS, FBS
- Abdo trauma
Which tests are done for babies born to Rh-ve mothers?
NB: ALL babies born to Rh-ve mums have cord blood at delivery tested for FBC, blood group & direct Coombs test
- Coombs test - direct anti-globulin demonstrates Abs on RBCs of baby
- Kleihauer test - (done in T2/3 + large dose of anti-D given) shows proportion of fetal RBCs present; add acid to maternal blood, fetal cells are resistant
Complications for Rh sensitisation affected fetus? And Tx?
Oedematous, jaundice, anaemia, hepatosplenomegaly
HF, kernicterus (brain damage)
Tx = Transfusions, UV phototherapy
What factors make up the bishop score and which score indicates SVD is likely?
Cervical position, consistency, effacement and dilation + fetal station
<5 = unlikely to start labour without induction >9 = SVD likely
Classification of OHSS?
Mild = Abdo pain, bloating Mod = + Nausea, vom, USS evidence of ascites Severe = + CLINICAL evidence of ascites, oliguria, Haematocrit >45%, Hypoproteinaemia Critical = + Thomboembolism, ARDS, anuria, TENSE ascites
Tx of OHSS?
Fluid replacement and thromboprophylaxis (LMWH; AVOID DOACs and WARFARIN)
Most common benign tumour in under 30s?
Germ cell: Dermoid cyst/ Cystic teratoma
Most common benign EPITHELIAL tumour?
Serous cystadenoma (looks like serous carcinoma)
**2nd most common is mucinous cystadenoma (RUPTURE –> psuedomyxoma peritonei)
Causative organisms for:
- “cottage cheese” discharge, vulvitis, itch
- offensive, yellow/green frothy discharge, vulvovaginitis
- offensive, watery white/grey “fishy” discharge
- Candida albicans (thrush)
- Trichomonas vaginalis
- Bacterial vaginosis (+ pH > 4.5, positive whiff test, clue cells on microscopy - stippled vaginal epithelial cells)
Tx for the following infections:
- Bacterial vaginosis
- Trichomonas vaginalis
- Gonorrhoea
- Candida albicans
- Chlamydia Trachomatis (MOST COMMON STI IN UK)
- Oral metronidazole 400mg BD 5-7days
OR topical 0.75% 5 days
OR clindamycin - Oral metronidazole
- IM ceftriaxone 1g OR Ciprofloxacin 500mg PO
[both = one off dose] - Topical clotrimazole cream 10% OR pessary 500mg stat PV
OR itraconazole 200mg PO bd for 1 day/fluconazole 150mg PO stat
[[**RISK OF DRUG INDUCED HEPATITIS W/ ITRACONAZOLE]]
IF PREG –> TOPICAL imidazole 7days
- Oral doxycycline 100mg BD 7 days
If PREG –> azithromycin/erythromycin/amoxicillin
Most common identifiable cause of post-coital bleeding?
Cervical ectropion (33%)
**50% unidentifiable cause; also cervicitis (secondary to Chlamydia), cervical cancer, polyps, trauma
Most common site of ectopic pegnancy?
Ampulla of fallopian tubes
other sites = isthmus -MOST DANGEROUS!!, infundibulum, cornula, cervix
Common long-term complications of vaginal hysterectomy?
Enterocoele, vaginal vault prolapse
urinary retention is ONLY acute, not chronic
Tx for PCOS (specific to infertility)?
Lifestyle changes (BMI, stop smoking, alcohol, etc)
1st:
CLOMIFENE (antioestrogen) - 50mg/day –> 100mg/day –> 150mg/day
Metformin (but lower live birth rate; can be given with clomifene)
2nd:
Ovarian diathermy, Gondatrophin induction (daily SC injec of recombi/purified urinary FSH and/or LH) + USS monitoring –> artificially stimulate ovulation with hCG/LH once follicle >17mm
LAST LINE = IVF
Presentation of threatened miscarriage present?
PAINLESS bleeding (less than menses)
<24wks (usually 6-9wks)
CLOSED CERICAL OS
**complicates 25% of ALL preg
Presentation of missed/delayed miscarriage?
Gestational sac w/ dead foetus WITHOUT symp of expulsion (or light beed/symp of preg disappear)
<20wks
CLOSED CERVICAL OS
Gestational sac >25mm + no embryonic/fetal part seen in it
Presentation of inevitable miscarriage?
HEAVY BLEEDS
CLOTS
PAIN
OPEN OS
Presentation of incomplete miscarriage?
Not all products expelled
pain
bleeding
OPEN OS
What is a whirlpool sign on imaging associated with?
Ovarian torsions
What are the following Mx options for miscarriage:
Conservative
Medical
Surgical
FORST LINE = Conservative: expectant Mx for 7-14days
Medical: Vaginal misoprostol (or oral) + antiemetic + analgesia
RETURN IF NO BLEED WITHIN 24hrs
Surgical: vacuum aspiration/suction curettage OR ERCP (under GA in theatre)
Mx for endometrial cancer? (Stage I or II)
Total abdominal hysterectomy with bilateral salphingo-oopherectomy
+/- radiotherapy after
OR if elderly/unsuitable for surgery - progestogen therapy (PROVERA - medroxyprogesterone acetate)
NB: if Stage IIB: Wertheim’s radical hysterectomy (inc LN removal)
Ix for HMB?
FBC (the only routinely done blood test!)
TVUSS
Hysteroscopy if US (LA/GA/or none if OPD) is inconclusive +/- biopsy
MOA of Tranexamic acid?
Anti-fibrinolytic
40% reduction in flow BUT non-hormonal and no/few SE
What are the surgical options for HMB:
- for DUB
- for Fibroids
for DUB: Endometrial ablation (if bleeding affects QoL, ONLY if finished family, uterus 10-12wks size, fibroids <3cm)
= CREATES Asherman’s syn; prevent regen of endometrium (so need high skill)
Novasure device used (looks like a fan, delivers electrical energy) - safe, low perforation risk
Hysterectomy
Fibroids:
TCRF (submucosal)
Uterine Artery Embolisation (esp if intramural or MANY fibroids)
Myomectomy
Which SSRI should be avoided in post-natal depression (+ which ones given)?
Fluoxetine (long half-life)
**Sertraline and Paroxetine given (low milk:plasma ratio)
What are the types of placenta accreta (hih risk after prev CS or placenta praevia)?
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium
Tx for simple endometrial hyperplasia & how its different for atypical?
SIMPLE : High dose progestogens + repeat sampling in 3-4mths
ATYPICAL: Total hysterectomy with bilateral salpingo-oophorectomy
What is the triad for Vasa praevia?
ROM, painless vaginal bleeding (following that), fetal bradycardia
hCG has a structural similarity to which endocrine hormone?
TSH
Which drugs should be avoided in pregnancy?
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
What is the clinical sign most associated with pre-eclampsia?
Brisk tendon reflexes
Gold standard Ix for diagnosis of endometriosis?
Laparoscopy
When would you use continuous CTG monitoring during labour?
Fever >38 (suspected chorioamnionitis/sepsis)
Severely high BP> 160/110
Oxytocin use
presence of significant meconium
FRESH PV bleed during labour (placental rupture? causing APH)
Tx of acute suspected DVT/PE in pregnancy and what should be monitored?
LMWH - no routine measurements unless obese/underweight (>90kg or <50kg) then measure anti-Xa activity
**APTT measured for UNFRACTIONATED heparin
Folic acid deficiency leads to what kind of anaemia?
macrocytic, megaloblastic anaemia
+ neural tube defects in baby
What conditions are assoc w/ a raised AFP in pregnancy? (and which ones present with low AFP?)
HIGH AFP = Omphalocele, NTDs, multiple preg
LOW = Down’s, Edward’s, maternal DM + obesity
How often CTG done in stage 1 and 2 of a normal pregnancy?
First stage - every 15 min
Second stage - every 5 mins
Most common type of ovarian cyst causing ovarian torsion?
Dermoid
ONLY definitive (surgical) tx for adenomyosis?
Hysterectomy
Medical tx for:
- Non-keratinised genital warts
- Keratinised warts
- Trichloroacetic acid/Podophyllotoxin
2. Imiquimod 5% topical cream (Works for both) NB: WILL REDUCE CONDOM EFFICACY
