O&G Flashcards
Hx for pelvic pain
SOCRATES
4Ps - PV bleed (+timing), PV discharge, pain, ?pregnancy
GI/urinary Sx
Gynae/menstrual/sexual Hx
Birth Hx
- outcomes
Contraceptive/smear Hx
- coil in situ
Approach to pelvic pain
I would investigate with bedside tests, blood tests and imaging.
At the bedside I would check the obs, take a urine sample for dipstick and bHCG, check the BG
I would take a full set of baseline bloods - FBC, U&E, CRP, LFTs, clotting, G&S and serum bHCG
In the first instance I would request a TVUSS, particularly looking for any evidence of a IUP, free fluid,or tubal ectopic.
Management of ectopic
Management of ectopic pregnancy is expectant, medical or surgical, according to bHCG, size, symptoms and haemodynamic status.
First I would counsel the patient on their options and provide them with a leaflet.
If HDS, with no sig pain & the fetal pole is <35mm, expectant Rx or medical Rx may be appropriate with according to bHCG, with follow up. (<30=exp, <1500=med)
If HDUS, symptomatic, or if fetal pole is >35mm, surgical management is appropriate. 1st line would be a laparoscopic salpingectomy, salpingotomy if both tubes are damaged.
Patient needs to be followed up with seriel pregnancy tests until they become negative. given advice re: not becoming pregnant for the next 3 months.
Management of miscarriage
Management of miscarriage is expectant, medical or surgical, mainly according to patient preference.
First I would counsel the patient on their options and provide them with a leaflet.
Expectant management (HDS, msd<50mm, CRL<30mm, good home suppport) • 'Waiting for the miscarriage to pass naturally" • It can take a few weeks for the miscarriage to pass and women often experience bleeding and cramps in this time • If expectant management is unsuccessful then medical or surgical management may be offered
“The process can be sped up with medication or surgery”
Medical management:
• ‘Using tablets to help the miscarriage pass more quickly’
• Vaginal misoprostol
○ Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
• Risks - haemorrhage, infection, retained tissue
• Should be given with anti-sickness and pain relief
Also, pregnancy test after 3 weeks and safety net to return if bleeding hasnt started in 24 hours or stopped in 7-14 days.
Surgical management
• ‘Undergoing a surgical procedure under local anesthetic in the clinic or general anaesthetic’
• The two main options are vacuum aspiration or surgical management in theatre. Give anti D.
Vacuum aspiration is done under local anaesthetic as an outpatient.
Management of UPSI (emergency contraception)
Options include ulipristal, levonorgestrel and the copper IUD.
Ulipristal (EllaOne) inhibition of ovulation
• single dose taken as soon as possible, no later than 120 hrs. If vomiting occurs within 3 hours, repeat dose.
• don’t use with levonorgestrel
• contraceptive pill/patch or ring should be restarted, 5 days after having Ulipristal - use barrier methods
• caution in severe asthma, better for overweight people
• ulipristal can now be used more than once in the same cycle
• breastfeeding should be delayed for one week after taking ulipristal (fine with levonorgestrel)
Levonorgestrel
• single dose taken ASAP, within 72 hrs (85% effective)
• can be used more than once in a menstrual cycle
• SEs - disturbance of menstrual cycle, breast tenderness, nausea/vomiting - if vomits within 2 hours then the dose should be repeated
Intrauterine device (IUD)
• must be inserted within 5 days (99% effective)
• 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 patient is high risk STI
Risks - pain, infection, bleeding, expulsion, migration
**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
I’d also like to counsel her on the risk of STI and invite her for a sexual health screen in 2-3 weeks time
I’d also recommend that her current sexual partner receives a sexual health screen.
I would also counsel the patient on long-term contraceptive options such as IUP, IUD, implant, depot injection.
What are the Fraser guidelines?
- she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- she cannot be persuaded to tell her parents or to allow the doctor to tell them
- she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
- her physical or mental health is likely to suffer unless she received the advice or treatment
The advice or treatment is in the young person’s best interests.
Options for contraception
*User-dependent* Hormonal - CHC - oral, patch, ring *measure BP and BMI *UKMEC - POP
Non-hormonal/barrier
- Male/female condom
- Diaphragm
- Non-user-dependent* i.e. LARC
- IUD (copper)
- IUS, implant, depot injection (progesterone)
- Male/female sterilisation
Approach to menorrhagia
Hx: 4Ps (pain, PV bleed, pv discharge, pregnancy), unscheduled bleeding (IMB/PCB), bloating, urinary Sx ?Anaemia ?FLAWS ?Hypothyroidism FHx: bleeding problems, cancers
Structural = PALM - polyps/PID, adenomyosis, leiomyoma (fibroids), malignancy Systemic = COEIN - coagulopathy, ovulatory dysfxn (?PCOS, hypothyroid), endometriosis, iatrogenic (copper coil), UNSPECIFIED DUB
I would investigate with bedside tests, blood tests and imaging.
At the bedside I would do full examination + speculum + bimanual, check the obs and take a urine sample for dipstick and bHCG. I also may take vaginal swabs for STIs and consider a cervical smear if not up to date.
I would take a full set of baseline bloods - FBC, U&E, CRP, LFTs, TFTs, and clotting.
In the first instance I would refer to gynae for a TVUSS to assess for local causes. A pipelle biopsy or hysteroscopy may be indicated following this.
Rx: treat the cause
MEDICAL - If needs contraception - IUS – COC
If not - tranexamic acid, mefenamic acid (NSAID)
SURGICAL - endometrial ablation, myomectomy, hysterectomy
Approach to postmenopausal bleeding
Hx: 4Ps, unscheduled bleeding (IMB/PCB), bloating, urinary Sx/bowel Sx
**oestrogen exposure - birth Hx, menstrual Hx, PMHx incl cancers, HRT
?Anaemia
?FLAWS
FHx: bleeding problems, cancers
> /= 55 + PMB - REFER FOR 2WW TVUSS
Approach to the menopause
Sx:
irregular periods - amenorrhoea
vasomotor - hot flushes, night sweats (disturbs sleep)
urogenital - dryness, itching, dyspareunia
psychological changes - dec mood/libido, irritable
Management
Conservative - lifestyle measures (exercise, relaxation), self-help, stop smoking, reduce alcohol
psychological support, increased lubrication
Medical
- HRT Normally O+P, cyclical if peri menopausal, transdermal patch if obese. SE’s= breast tenderness, nausea, headaches, fluid retention, mood swings.
Risks= VTE, stroke, CHD, breast and ovarian cancer
- vaginal creams if predom vaginal sx
- Non hormonal treatments include clonidine for flushing, beta blockers for palpitations, ssri’s for depression and bisphosphonates for osteoporosis)
Approach to suspected ovarian Ca
Red flags ? persistent bloating/IBS ? early satiety/loss of appetite ? pelvic/abdo pain ? inc urinary freq/urgency FLAWS
I would investigate with bedside tests, blood tests and imaging.
At the bedside I would do full examination + speculum + bimanual, check the obs and take a urine sample for dipstick and bHCG. I also may take vaginal swabs for STIs and consider a cervical smear if not up to date.
I would take a full set of baseline bloods - FBC, U&E, CRP, LFTs, and CA125 (if 35 IU/ml or greater, I would refer to gynae for ultrasound scan of the abdomen and pelvis).
Approach to suspected cervical Ca
Sx: routine screening, bleeding (PCB), dyspareunia, bloody discharge, foul smelling, pelvic pain.
FLAWS
DDx: ectropion, polyp, cervicitis, pregnancy
At the bedside I would do full examination + speculum + bimanual. check the obs and take a urine sample for dipstick and bHCG. I also may take vaginal swabs for STIs.
If the appearance of the cervix was suspicious for cancer, I’d refer this patient to colposcopy clinic on a 2WW. Here they have a magnified view of the cervix, use acetic acid to stain and take a biopsy.
If Dx is confirmed, the patient will sent to the gynae cancer MDT. Further imaging, CT CAP +/- MRI.
Surgery, chemo, radio
? fertility preservation - trachelectomy - cervix and upper vagina
radical abdominal hysterectomy + BSO + vaginal + lymph nodes
Approach to NVP
DDx: GI causes - cholecystitis, appendicitis, pancreatitis - gastroenteritis UTI DKA Drug reaction
*NVP* RFs - multiple preg - molar preg - obesity - nulliparity
Hyperemesis triad
- > 5% wt loss
- electrolyte disturbance
- severe dehydration/ketonuria
I would investigate with bedside and blood tests.
At the bedside I would do full examination & assess fluid status, weigh the patient, check the obs and take a urine sample for dipstick and bHCG. I would take a full set of baseline bloods - FBC, U&E, CRP, LFTs. I would consider an USS ?molar ?multiple.
PUQE score and assess wellbeing
3-12 + no comps - community antiemetics (cyclizine), lifestyle
>13 + no comps - ambulatory care with hydration, antiemetics, thiamine
if complications - inpatients + MDT Rx, VTE prophylaxis, ?steroids
Complications
Maternal - electrolyte abn, GORD, Wernicke’s, MW tear
Foetal - SGA
Incontinence
stress? urge? or mixed?
In history ask for age, no of vaginal deliveries?forceps, obesity, pelvic surgery, smoking, diabetes
Ix- urine dipstick at bedside, ask pt to keep a bladder diary, uss bladder and post micturition scan (?retention) Gold standard= urodynamic studies. May consider CT urogram with methylene dye contrast to assess urethral integrity
Urge
C- 1st line- Lose weight, avoid caffeine or artificial flavours. Limit fluids to 1.5l/day. Bladder retraining for 6 wks to increase intervals between voiding.
M- Oxybutynin/ Tolterodine. Mirabegron if worried about anticholinergic side effects.
S- Botox injections, PTNS(percut tibial nerve stim) or SNS (sacral nerve stim)
Stress
C- 1st line- Pelvic floor training (8 contrac, tds for 3 months)
S- 2nd line- retropubic mid-urethral tape procedure, Burch colposuspension
M- 3rd line/unwilling or unsuitable for surgery- Duloxetine
Subfertility
In Hx ask about
- how long have they been trying? How often do they have sex per week? Any difficulties i.e. vaginismus or dyspareunia
- Periods regular? menorrhagia? dysmenorrhea? previous STI’s, previous pelvic surgeries or chemo? miscarriages or terminations? any children with previous partners? discharge or pain?
Ix- bimanual and speculum examination.
Bloods- Day 2 FSH and Mid luteal prog (day 21), AMH, TFTs, prolactin, testosterone
Imaging- TVUSS, tubal assessment with hysterosalpingogram
Semen analysis
Mx- wait for 2 years of regular sex. Medical- clomiphene for ovarian stimulation Intrauterine insemination Donor insemination IVF Donor egg with IVF
Surgical- for structural causes e.g. adhesions, endometriosis, fibroids, ovarian drilling (PCOS),
