O+G Flashcards
normal fundal height and major week milestones
gestational age +/- 2cm
12 weeks - pubic symphysis
20 weeks - umbilicus
36 weeks - xiphisternum
pre-eclampsia important symptoms
blurred vision or flashing lights (due to local vasospasm of the retina) severe epigastric pain hyperreflexia clonus oedema of hands, feet, face severe headache - usually frontal fetal distress- reduced fetal movements vomiting confusion / altered mental status
when do you feel fetal movements
16-25 weeks - will increase until 32 weeks and then plateu
cut off to investigate is 24 weeks
amount of vitamin D in pregnancy
400 IU daily
appointment timing
booking - 8-12 weeks - detailed history, risk assessment (community or midwife), estimation of due date but most accurate is at dating scan with CRL, heigh, weight, BMI, urine dip for asympomatic bacteriuria, bloods (anaemia, HIV, syphilis, hepB, group and save for Rh)
dating - 8-14 weeks - determines age based on CRL, detects if twins, DS (via nuchal translucency, PAPP-a, beta hCG)
anomaly - 18-20 - take pic home, gender, major structural malformations
how is DS confirmed
CVS at 11-14 weeks - 2% risk of miscarriage
amniocentesisis at 15 weeks - 1% risk of miscarriage
give anti-D in both
TOP methods
Most women have some bleeding and cramping for several days after either
method, but these usually get better day by day
surgical can be doen under LA or LA and sedation or GA - benefit w LA is going home same day and dont have to fast
wont be able to drive following sedation
beforehand - may be offered sti testing, an US to check how many weeks, chance to speak to counsellor
medical - up to 24w
mifepristone pill then 24-48 hours later misoprostol (vaginal/buccal/sublingual) - dose and amount of pills depends on how far along - e.g. <9 weeks only need one bill, 9-12 need vaginal + up to 4 doses oral
pregnancy comes out via bleeding several hours after the 2nd pill. someimtes need to take extra dose of misoprostol to get it to pass
if >10w pregnany you may need to take the second tablet at hospital
surgical
vacuum aspiration up to 14w
dilation and evacuation 14-24 w under sedation or GA
done w LA, sedation or GA/deep sedation - w both can go home say day
In very limited circumstances an abortion can take place after 24 weeks – for example, if there’s a risk to life or there are problems with the baby’s development
saftey netting = get advise if pain or bleeding that does not get better in a few days - have a temp or unusual vag discharge
comps inc needing another procedure, heavy bleeding or sepsis, injury to womb
what is needed alongside a TOP
anti-d prophylaxis for Rh negative after 10w gestation in every sort of TOP
consider for before 10 weeks for surgical TOP
for those that need thrombophrophylaxis, consider LMWH for at least a week after the abortion
NSAIDs for pain relief for either
use pads until bleeding stops
who needs to take aspirin from 12w of pregnancy
>1 of - First pregnancy - Aged >40 - Previous pregnancy >10 years ago - BMI >35 - Family history of pre-eclampsia - Multiple pregnancy Or 1 of - Hypertension or pre-eclampsia in a past pregnancy - CKD - Autoimmune disease e.g. SLE - Diabetes mellitus - Chronic hypertension
diabetes monitoring (with target values) and checkups in pregnancy
seen every 1-2 weeks by diabetes care team
type 1 and type 2 on insulin - test glucose pre-meal, one hour post meals and bedtime
type 2 on oral or conservative - same but not bedtime
target = fasting 5.3, two hours after meal 6.4 (7.8 one hour after)
timing of birth in diabetes
elective birth by induction of labour or C section if indicated between 37-38+6 weeks of pregnancy
screening for gestational diabetes + its risk factors
75g oral glucose tolerance test - wont eat for 8-12hrs before, then given some glucose, then blood measured at intervals after
fasting = 5.6, two hour = 7.8
if previous GDM pregnancy - done asap after booking, and again at 24-28 weeks if first was normal
any other risk factor - done at 24-28 weeks
risk factors include BMI >30, previous macrosomic baby, first degree relative with diabetes, south asian, black carribean, middle eastern
glycosuria of 2+ or above on one occasion or of 1+ or above on two or more occasions during routine antenatal care may indicate undiagnosed GDM. Consider further testing to exclude GDM
management of gestational diabetes
consultant led
most treated with lifestyle modifications
offer metformin to women with GDM if targets are not met within 1-2 weeks
offer insulin instead of metformin if CI - advise tho of risk of hypo- always have a fast-acting form of glucose in case
offer insulin +metformin if target not met
offer insluin straight away with or without metformin if fasting glucose >7 at diagnosis
advise give birth no later than 40+6 weeks - offer induction or c section to those that haven’t by then (a bit earlier if on treatment - 37-38w)
discontinue treatment immediately after birth
when to offer a fasting blood glucose test after birth for a women with GDM
6-13 weeks after birth
if >7 then is likely they have diabetes
gestational hypertension vs pre-eclampsia
gestational hypertension = pregnancy-induced hypertension (SBP > 140 or DBP > 90 or increase above booking readings SBP >30 or DBP > 15) that develops after 20 weeks gestation - will resolve after birth
pre-eclampsia = pregnancy -induced hypertension + proteinuria (>0.3g/24hr) and/or oedema - (most cases occur after 24 weeks but definition is after 20)
3 anti-hypertensives safe in pregnancy
labetolol
nifedipine
methyldopa - NB if this is use, switch back to pre-pregnancy anti-HTN regime within 2 days of delivery due to increased risk of post natal depression on this
definition and management of severe gestational HTN
> 160/110
admit to hosptial
start IV labetolol to keep SBP <150 and DBP <100
CTG to check on baby
test BP 4x per day and check for proteinuria once a day
discharge one BP in target range
management of mild and moderate gestational hypertension
mild - check BP and proteinuria weekly
moderate - twice weekly, and start labetalol to keep SBP <150 and DBP <100, and arrange bloods to check liver function, FBC and U+E for signs of pre-eclampsia
(nafedipine 2nd line, methyldopa 3rd line)
HELLP syndrome
haemolysis, elevated liver enzymes, low platelets
investigations for pre-eclampsia - DUCH
BP and urine dip (2+)
then confirm via urinalysis - MC+S (rule out UTI), then 24-hour urine collection or calculation of albumin:creatinine ratio (or protein:creatinine ratio)
FBC - low platelets and anaemia in HELLP
LFTs - raised transaminases
U+E - keep an eye on creatinine for AKI
coagulation profile - prolonged PT and APTT
high LDH in haemolysis
high urate - indicates worsening disease
USS - assess fetal growth and amniotic fluid volume
dopper of umbilical arteries**
CTG
use placental growth factor (PIGF) to test in those with pre-existing HTN and renal disease
management of mild and moderate pre-eclampsia (not including delivery)
mild - proteinuria with BP 140/90-149/99
moderate - proteinuria and BP 150/100 -159/109
both same
admit if concerns for mother or baby or high risk of adverse effects suggested by fullPIERS or PREP-S
monitor BP QDS if in hospital, if not every 48 hours
twice weekly bloods
anti-HTN with labetalol
carry out US and CTG at diagnosis
repeat US 2-weekly
VTE prophylaxis if in patient
management of severe pre-eclampsia (not including delivery)
severe - BP >160/110
admit
antihypertensive - labetalol oral, if not IV labetalol, or oral nifedipine, or IV hydralazine
monitor BP at least QDS (but at first, every 15-30 minutes until BP is less than 160/110)
bloods three times weekly: U&Es, FBC, LFTs
carry out CTG and US of fetus at diagnosis and if normal, repeat US every 2 weeks
repeat CTG if clinically indicated
VTE prophylaxis
delivery for pre-eclampsia
(up to this point - patients can usually be managed conservatively until 34w as long as they’re stable - then just antihypertensives, monitor +/- admit)
anti-HTN oral or IV labetolol or oral nifedipine or IV hydralazine if SBP >160 or DBP >110
magnesium sulphate if seizure concern 24 hours before delivery
fluid restriction due to pulmnoary oedema being a significant cause of maternal death in pre-eclampsia
CTG throughout
BP measurement throughout
3rd stage of labour with syntocinon (not ergometrine or syntometrine)
only offer delivery <34 weeks if severe HTN refractory to treatment or complications develop like eclampsia, HELLP, reversed umbilical diastolic flow - consider steroids and mag sulph
consider <37 weeks if inability to control BP (tried >3 classes), <90% sats, HELLP, eclampsia, non-reassuring CTG - consider steroids
from 37w onwards - initiate birth within 24-48 hours
offer IV Mg sulphate and a course of antenatal corticosteroids (if <34+6) if indicated - e.g. in severe pre-eclampsia
post-natal management for pre-eclampsia
important to monitor mother as still at risk of eclamptic seizures measure bloods 48-72 hours after delivery - FBC, U+Es,LFTs
monitor fluid balace
measure BP every day or other day for 2 weeks, reducing the anti-HTN gradually as it falls
urine dip at 6w to ensure no proteinuria
(anti-HTN may be needed for several weeks after birth)
management of eclampsia
A-E
left lateral position
magnesium sulphate 4g loading dose then infusion 1st line for fits
if further fits occur a further 2g can be given as bolus
assessment for magnesium toxicity via testing reflexes (confusion, loss of reflexes, hypotension, respiratory distress) - if low urine output consider lowering dose as it is renally excreted
anti-HTN - oral or IV
fluid restrict to 80m/hr
continuous CTG
deliver fetus once mother is stable (vaginal is fine)
manage 3rd stage with syntocinon
measure obs every 15 minutes
assess for magnesium toxicity (confusion, loss of reflexes, respiroaty distress, hypotension)
after delivery, mother will need HDU care until stable - well controlled BP, good UO, discontinuation of magnesium sulphate - usually takes a minimum of 24 hours
hyperemesis gravidarum triad
is associated w a higher incidence of SGA, multiples and premature babies - thought to be due to rapidly increasing bhcg
dehydration
electrolyte imbalance
body weight loss of more than 5% pre-pregnancy weight
(may also be ketonuria)
grading vomiting in pregnancy
PUQE score - pregnancy unique qualification of emesis
management of hyperemesis gravidarum
outpatient (PUQE = 3-12), ambulatory (PUQE>12), inpatient (complications/failed ambulatory care)
NB PUQE = pregnancy unqieu quantification of emesis
outpatient - cyclizine, promethazine, chlorpromazine or prochlorperazine with oral hydration
abulatory care - IV fluids and IV anti-emetics and oral or IV thiamine/pabrinex
in patient - same plus thromboprophylaxis with LMWH, nutritional support may be required, steroids if unresponsive to anti-emteics, TOP may be last option for intractable
management of obstetric cholestasis
weekly LFT monitoring
UDCA
vitamin K if steatorrhoea or prolonged PT (small risk of neonatal haemolytic anaemia, hyperbilirubinaemia and kernicterus)
induction 37w onwards as maternal morbidity and stillbirth increases form this point onwards
hospital birth
chages/monitoring if taking an AED and pregnant
measure maternal AED levels at each trimester to avoid fits - pregnancy can change plasma concentration
increased fetal growth monitoring
vitamin K oral from 34w
CTG tracing
5mg folic acid
define types of haemorrhage within APH
minor <50
major 50-1000
massive >1000
triad of ruptured vasa previa
rupture of membranes followed by painless vaginal bleeding and fetal bradycardia
placenta praevia vs placental abruption
placenta praevia = placenta covers internal cervical os - not painful, fresh red blood
placental abruption = placenta separates from the uterus and blood separates them - painful, may be no blood or dark red
causes of APH
idiopathic placenta previa placental abruption ruptured vasa previa trauma cervical ectropion poylps infection uterine rupture (although this usually happens in labour)
management of APH
mild spotting and baby is ok can be discharged with serial growth US scans for IUGR, oligohydraminos etc (are at increased risk from APH)
if more than just spotting or ongoing bleeding then should remain in hospital until the bleeding has stopped
A-e
cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage
Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer
fluids
auscultate heart rate - if not do US
US to rule out praevia
(abruption is clinical diagnosis)
CTG
APH is a risk factor for pre-term delivery so give steroids if 24 - 34+6 weeks - BUT if small spotting which has stopped (particuarly if cause identidied like postcoital from ectropion or lower genital tract infection ) then may not need steroids
tocololysis only in very preterm and not yet completed steroids - senior decision (if fetal distress dont want to delay delivery)
if >37w and stable - induce vaginal with CTG monitroing
fetal distress then C section
3rd stage managed actively due to risk of PPH
specific management for placenta previa
A-e
cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage
Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer
fluids
CTG monitoring
minor >2cm away from os, may be able to deliver vaginally continue scanning every 2 weeks
<2cm is an indication for C section at 38 weeks (after this risk of haemorrhage increases) - early if evidence of accreta (35-37)
women with major PP who have previously bled should be admitted from 34 weeks (can be remain at home if they are close to hospital, have a constant companian and understand risks)
must avoid intercourse
should explain the risk of hysterectomy while a c section is done
note on steroisd - if bleeding is associated with pain suggestive of uterine activity or abruption then the risk of preterm birth is increased and therefore steroids may be of benefit. Women presenting with spotting that has stopped (particularly if identified cause like post-coital from a cervical ectropion or lower genital tract infection is found) and no abdominal pain, may not require steroids
management of placenta accreta
delivery should take place in a specialist centre with immediate access to blood products and adult and neonatal intensive care planned c section delivery at 35-36+6 weeks (35-37 weeks) (opening of the uterus at a site distant from the placenta)
can be performed with regional anaesthesia but risk of converting to GA should be discussed
if the mother really wants another child, then a uterus-saving approach may be tried with or without therapeutic uterine artery embolisation, surgical internal iliac artery ligation or methotrexate therapy e.g. a partial myometrial resection
but unfortunately is not often successful and can be associated with bleeding and infection and some will still need to go on to have a hysterectomy
so must consent pt for both blood transfusion and a hysterectomy
management of placental abruption
A-e - oxygen if needed
cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage
Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer
CTG monitoring and arrange USS
position in left lateral tilted position
catheter + fluids - keep SBP >100 - warmed hartmanns until blood is available if required
fetal distress - immediate C section
no distress <37 weeks - observe, steroids, regular US for growth - i.e the conservative method - a less common presentaiton
no distress >37 weeks or dead fetus - induction and labour and vaginal
for all Rh neg - give anti-D within 72 hours of haemorrhage
note on steroisd - if bleeding is associated with pain suggestive of uterine activity or abruption then the risk of preterm birth is increased and therefore steroids may be of benefit. Women presenting with spotting that has stopped (particularly if identified cause like post-coital from a cervical ectropion or lower genital tract infection is found) and no abdominal pain, may not require steroids
what to do if reduced fetal movements
try handheld dopper
if none detectable, use US
if present, do CTG for next 20 minutes to monirot
PROM vs P-PROM
prom = premature reupture after 37 weeks (at least an hour before onset of labour)
p-prom = preterm prom, occurs <36+6
investigations for PROM
speculum after woman has lied down for 30 minutes - showing amniotic fluid pooling in the vagina
swab for infection
can do a ferning test - place cervical secretion onto a slide and allow it to dry - will form fern-patterened crystals
US will show low liquor volume
temperature, MSU, bloods +/- amniocentesis to look for infection
fetal monitoring with CTG
do not perform PV exam as this increases risk of chorioamnionitis
management of PROM
evidence of chorioamnionitis - betamethasone 12mg IM, broad spectrum antibioitc cover and deliver
no evidence - then admit then depends on date
<37w (P-PROM)
erythromycin for 10 days (or until labour if this is sooner) and can go home after 48 hours of no labour - take temp every 4-8 hours and return if it spikes
also give steroids if between 24-34+6
tocolytics are generally not recommended
magnesium sulphate to prevent CP - between 24-29+6w (and consider if up to 33+6) in those in labour or a planned birth within 24 hours - bolus followed by infusion
if >34 weeks, the timing of IOL depends on risk vs benefits of delaying pregnancy further
> 37w - expectant management for no longer than 24 hours, or induce labour straight away
<37w - alert neonatal team as the preterm baby will need supprot
when to offer someone magnesium sulphate
- NICE say to offer IV magnesium sulphate for neuroprotection between 24-29+6 weeks in those in established preterm labour or having a planned preterm birth within 24 hours
- AND to consider the same for up to 33+6 weeks
- Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner)
- Monitor for toxicity - calcium gluconate to treat
when should antenatal steroids be given
between 24 and 34+6 weeks
define premature labour
contractions leading to dilation of the cervix before 37 weeks
investigations for premature contractions without water breaking
TV to measure cervical length - if >15mm then unlikely she is in pre-term labour, re-evaluate 2 weeks later
fetal fibronectin if TV US is unavailable or unacceptable - if positive then more likely to deliver
management of preterm labour
admit if likely to be true labour i.e. TV cervical length <15mm or fibronectin assay positive
steroids should be consdiered - betamethasone or dexamethasone e.g. betamethasone IM 2x doses given 24 hours apart
tocolytic drugs can be consdiered to allow time for steroids to work e.g. nifedipine
magnesium sulphate if between 24 and 29+6 (and consider up to 33+6)
can consider emergency cervical cerclage if dilated cervix and unruptured fetal membranes
delivery - IV benzylepenicillin to protect against GBS in all preterm deliveries (and if GBS postitive at term)
prevention of preterm labour
treat BV - clindamicin rather than metronidazole
progesterone reduces recurrence in high risk (e.g. previous history of late miscarriage or preterm birth) and in low risk with a short cervix - done via cream or pessary
elective (rather than rescue) cervical cerclage/sutures
active vs latent phase of first stage of labour
latent= where contractions occur at 5 and 10 minute intervals - women should go home and come back when contractions are stronger
active phase - when cervix is around 4-5cm dilated and contractions are more painful and regular
delayed first stage management
e.g. <2cm in 4 hours (remember than expected is 1cm an hour for multiparous and 0.5cm an hour for nuliparous)
when there is a delay it is recommended to commence CTG monitoring
amniotomy followed by oxytocin infusion can be offered to accelerate labour, advise the woman that this will increase pain – contractions will be stronger and more painful
if membrane is broken then consider oxytocin infusion
if full dilation is not imminent consider C section
deliver within what amount of time from starting pushing
within 3 hours of pushing in a nulliparous (start investigating after 2) – if multiparous would expect to deliver within 2 hours but start intervening after 1
management of second stage
- Half-hourly documentation of the frequency of contractions
- Hourly BP
- Continued 4-hourly temperature
- Offer vaginal examination hourly in the second stage
- Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes. Palpate the woman’s pulse every 15 minutes
- Sufficient analgesia
- Once born, the baby’s mouth and nose are suctioned, and the 1- and 5-minute Apgar scores recorded
management of third stage of labour
expectant - uterus is rubbed to stimulate contraction
active - rcommended. with IM syntocinon or IM syntometrine immediately after birth, followed by clamping umbilical cord after 5 minutes
amount of dilation during first stage expected
want 1 cm an hour for multiparous or 0.5cm an hour for a nulliparous
normal variability on ctg
10-25bpm
non-reassuring is <5 for 40-90mins
abnormal is <5 for >90 mins - should assess for fetal acidosis via fetal scalp capillary blood sample
normal amount of accelerations
> 15bpm for >15 seconds - and there should be at least 2 accelerations every 15 minutes
3 methods of inducing labour
vaginal prostaglandins - either via tablet/gel or via pessary e.g. propess - max one cycle in 24 hours (60% will start labour within that 24 hours)
amniotomy - membranes are ruptured using an amniohook which releases prostaglandins - only performed when cerxic is ripe
syntocinon infusion is given alongside
membrane sweep - insert gloved finger and rotate it against the fetal membranes to separate the chorionic membrane from the decidua
what is the bishops score
an assessment of cervical ripeness
uses cervical dilation, cervical effacement/length, cervical consistency (how soft), cervical position, fetal station
highest score = 13
<5 = labour unlikely to start without induction
>8 = labour is likely to be spontaneous / high chance of induction agents working
between these values is hard to predict one way or another
things to do before instrument delivery
mediolateral episiotomy
pudendal nerve block - usually this is sufficient analgesia
empty bladder via catheter
pre-op for c section
FBC + G+S - average blood loss is around 500-1000ml
H2 receptor antagonist should be prescribed e.g. ranitidine +/- metoclopramide (risk of Mendelson’s syndrome (aspiration of gastric contents into the lung), leading to a chemical pneumonitis. This is because of pressure applied by the gravid uterus on the gastric contents)
risk score for VTE should be calculated - anti-thromboembolic stockings +/- low molecular weight heparin should be prescribed as appropriate
anaesthesia – majority under regional, this is usually a topped-up epidural or spinal
prophylactic Abx during op and oxytocin to aid delivery of placenta
woman positioned with a left lateral tilt of 15 degrees
3 types of cord prolapse and its treatment
overt - cord through cervix and vagina past presenting part
occult - is alongside presenting part but not passed it
funic - cord is between presenting fetal part and fetal membranes but has not passed the opening of the cervix
treat with emergency c section
management of shoulder dystocia
mcroberts - hyperflex maternal hips (knees to chest) to widen pelvic outlet
suprapubic pressure - pressure behind anterior shoulder
can try episotomy to make access for following manoeuvres easier
posterior aim - insert hand posteriorly and grasp posterior arm
internal rotation/corkscrew manoeuvre - put pressure with 2 fingers on posterior shoulder and rotate it until it becomes anterior
if all fail, patient on all fours then repeat
last resort = symphisiotomy, zavenelli moevre (return head and c section), fracture clavicle
3 types of breech presentation
frank/extended (majority) - knees extended upwards
complete - knees are flexed
footling - one or both thighs are extended, feet downwards
management of breech
<36w - may turn spontaneously
ECV (external cephalic version) done at 36 for nulli and 37 for multi
- 50% success rate (higher in muliparous) - can be increased by tocolytics like salbutamol that relax the uterus - either electively or if first attempt fails
- 2-3% chance of baby turning back to breech after a succesful ECV
- painful
if fails/CI - planned C section has lower risks of perinatal death - however in most cases vaginal is safe with monitoring and in hospital (some women may not favour this tho e.g. large baby, previous C section…)
CI to ECV _RAM
where C section is required APH in last 7 days abnormal CTG ruptured membranes multiple pregnancy
complications of ECV
transient fetal heart abnormalities persistent fetal bradycardia DDH PROM and premature labour cord prolapse traumatic injuries like Erb palsy placental abruption
risk of woman needing emergency c section is 1 in 200
4Ts in PPH
tone - atony - most common - where uterus fails to continue to contract after birth and clamp placental artereis shut to reduce bleeding which continues for a few weeks
trauma - e.g. due to instrumentation, incision from c section, from baby itself, uterine rupture
tissue - retained placenta (prevents contractions and leads to uterine atony)
thrombin - pre-existing coagulopathy e.g. VWD or eclampsia leading to a DIC preventing clot formation and thus –> bleeding
causes of uterine atony
multiple pregnancies, fatigue from prolonged labour, induction of labour, magnesium sulphate and nifedipine can also interfere with uterine contractions
management of primary PPH
communicate and alert relevant professions
resuscitae with a-e, oxygen, IV access, fluids via bolus in minor, blood transfusion in major (in meantime use 2L of warmed Hartmann’s)
monitor and investigate - bloods from cannula; FBC, coagulation, U+E, LFT, crossmatch 4u, monitor obs
stop bleeding
atony - empty bladder, fundal massage, oxytocin slow IV injection or IM ergometrine or IM syntometrine
second line - IM carboprost (Hemabate), rectal misoprostol, oxytocin infusion
adjuncts with IV tranexamic acid or factor VIIa
surgery if medical fails - balloon tamponade, B-lynch suture, arterial ligation/embolisatio or hysterectomy last option
trauma - compress and suture tears
tissue - manual removal of placenta if placenta has separated. if not the exam under anaesthesia
primary vs secondary PPH
primary = within 24 hours secondary = 24 hours - 6 weeks
causes of secondary PPH
endometritis - risk factors include C section, PROM, meconium stained liquor, long labour with multiple exams
retained products of conception - elevated fundus that feels boggy
when can you start COCP again after giving birth - breastfeeding vs nonbreastfedding
non-breastfeeding >3 weeks
breastfeeding >6w - same as for patch or ring
nb iud is within 48 hours - if not after 4 weeks
immediately after birth = any progesterone method
LAM becomes unreliable when:
other foods or liquids are substituted for breastmilk
your baby reaches 6 months old
you have a period
contraception options for <21 days non breastfeeding or <6 months breastfeeding
progesterone only (POP, injection, implant)
barrier
IUD or IUS can be inserted within 48 hours of giving birth - if not in this time then have to wait until 4 weeks after birth
urinary symptoms vs bowel symptoms are associated with what sort of prolapse
urinary with anterior compartment prolapse
this includes urethrocele and cystocele
bowel with posterior prolapse which includes rectocele (constipation, tenesmus, need to digitally evacuate stool, incontinence)
management of prolapse
conservative - pelvic floor exercises, weight loss
medical - vaginal pessary (inserted into the vagina to relieve pressure on bladder and bowel - are changed every 6m)
surgical
anterior vault prolapse - colporrhaphy (fixation of anterior vaginal wall) or colposuspension (fixation of bladder bass to pelvic side wall)
uterine prolapse - hysterectomy, sarcospinus fiaxation (fixation of uterus to sacrospinus ligament)
vaginal vault prolapse - vaginal sacrospinous fixation with sutures or with mesh to attach it to sacrum
treatment for overactive bladder
conservative
medical - antimuscurinics like oxybutynin, darifenacin, solifenacin, tolterodine, or beta3 agonist ; mirabegron
surgery - augmentaiton cystoplasty (small piece of intestine is added to the bladder wall to increase its size) or urinary diversion (ureters are re-routed to outside the body)
causes of overflow incontinence
where there is detrusor underactivity or bladder outlet obstruction resulting in retention and leakage of urine
e.g. due to neurological disease, urethral obstruction, medications that decrease contractiliy e.g. ACEi, antidepressants, antimuscurinics, antihistamines, antiparkinsonian drugs, CCBs, opioids, sedatives
causes of urge incontinence
idiopathic in most
can be associated with neurological conditions like PD, MS or injury to pelvic/spinal nerves
comorbidites like obestiy, T2DM and chronic urinary tract infection can increase urgency symptoms
drugs such as antidepressants
exacerbated by caffine or alcohol
investigations for incontinence
LL neuro exam
ask about bowel habit
examine abdomen for a palpable bladder
perform a pelvic exam - do bimanual and ask woman to contract her pelvic muscles
ask woman to cough with full bladder and observe for urethral meatus leakage
test for UTI
U+E - AKI may be present if urinary obstruction is present
ask patient to keep a bladder diary
ask about use of pads to determine severity
post-void residual volume measurement with US or catheter
urodynamic studies - can measure pressures with bladder outlet behaviour during filling and voiding
management of stress incontinence
conservative - reduce caffine, avoid excessive fluid intake, weight loss, stop smoking (cough), make adaptations to get to toilet quicker, at least 3 months of pelvic floor muscle training (minimum of 8 contractions performed at least 3 times a day - vaginal cones can be used to help, or electrical stimulation)
surgery - colposuspension - bladder neck is lifted upwards via stiching lower part of vagina to ligament behind pelvic bone, or intramural urethral bulking agents e.g. with collagen or silicone, retropubic mid-urehtral mesh sling or rectus fascial sling
medical with duloxetine (anticholinergic) if doesnt want surgery
management of urge incontinence
conservative - reduce caffeine, monitor fluid (too much or too little will make it worse), offer referral for bladder training (at least 6 weeks, where you hold for 5 mins for a week after urge kicks in, then extra min the next week if you dont lose continence with 5) which can be combined with pelvic floor training if mixed
medical - antimuscurinics with oxybutynin, tolterodine or darifenacin OR beta 3 agonist with mirabegron (if am is CI e.g. if concerns about frailty in elderly) - can take 4 weeks to work (SE constipation and dry mouth)
if these fail - botulinum toxin into bladder, percutaneous sacral nerve stimulation, percutaneous tibial nerve stimulation, augmentation cystoplasty and urinary diversion
indwelling catheter for intractable symptoms
management of postnatal psychosis
- Most need to be treated in hospital – ideally in a mother and baby unit
- Medication -antidepressants, antipsychotics to help with manic and psychotic symptoms like delusions and hallucinations (most antipsychotics are secreted in breastmilk but there is little evidence of it causing problems - avoid clozapine) -mood stabilizers like lithium (but should be encouraged not to breastfeed)
- CBT
- ECT – only rarely used. If very severe depression or mania
3 stages of the menstrual cycle
proliferative phase - oestrogen stimulates repair and growth of functional layer
secretory phase - once ovulation has occured, progresterone creates a more welcoming environment for embyro to implant
menstrual phase - decreased progesterone due to corpus luteum degeneratio leading to breakdown of endometrial tissu
causes of primary amenorrhoea
SECONDARY SEXUAL CHARACTERISTICS PRESENT
constitutional
pregnancy
imperforate hymen - complains of intermittent abdominal pain, palpable lower abdominal swelling, bulging, bluish membrane at vagina
mullerian agenesis - painless, where there is a missing uterus with variable degree of vaginal hypoplasia
testicular feminisation syndrome (aka complete androgen insensitivity syndrome) - may have ambiguous genitalia
high prolactin- due to pituitary tumour, hypothyroidism, medicaition (chlorpromazine antipsychotic)
SECONDARY ABSENT
ovarian failure - chemo, iraddiation, Turner’s
hypothalamic - stress, anorexia, exercise
failure of hypothalamic-pituitary axis - tumour, infarction, injury, Kallmann’s (anosmia, unilateral renal agenesis, cleft)
congenital adrenal hyperplasia - classic severe (salt losing or not-salt losing/simple virulizing) which presents with ambigious genitalia or salt losing crisis in boys, or non-classic/late-onset form which presents with early pubarche in men or amenorrhoea or infertility in women
causes of secondary amenorrhoea (no periods for 6 months)
pregnancy
PCOS
high prolactin - hypothyroidism, pituitary tumour, medication (chlorpromazine antiemetic/antipsychotic)
primary ovarian insufficiecny aka premature ovarian failure
thyroid disease
hypothalamic amenorrhoea - stress, anorexia, trauma, tumour
causes of raised FSH and LH in amenorrhoea
Turner's ovarian failure (because no oestrogen inhibiting)
causes of post-coital bleeding
infection
cervical ectropion - where the columnar epithelium from the inside of the cervix is on the outside and is weaker and prone to bleed - COC, puberty and pregnancy are risk factors so can manage by stopping COC, or if persists then cryotherapy or ablation or can go away by itself
cervical or endometrial polyps
malignancy in vagina or cervix
trauma
vaginal atrophy - usually occurs after menopause, is due to lack of oestrogen
causes of intermenstrual bleeding
ectopic pregnancy gestational trophoblastic disease spotting may occur with ovulation vaginal adenosis - presence of glandular tissue within vagina, is benign vaginal tumours vaginitis infection ectropion polyps fibroids endometrial hyperplasia endometritis adenomyosis following smear missed COC
management of menorrhagia
IUS
second line = tranexamic acid or mefenamic acid (better tolerated), COC
third line = progestogens like oral or injected, or oral norethisterone
in secondary care - a 3 or 4 month course of GnRH analogue (SC every 28 days) may be offered but if using >6m then add back therapy will be needed
surgery - hysterectomy if doesnt need uterus, or endometrial ablation if no desire for future fertility ideally >45 (is less effective <35 and although pregnancy is unlikely, it can be associated with life-threatening complications)
classification of fibroids
intramural - within the uterine wall
submucosal - in the submucosa and protrude more into the uterine cavity - these may be pedunculated
subserosal - grow outwards from the uterus
investigations for fibroids
pregnancy test
fbc for anaemia
pelvic/trans-vaginal us
endometrial sampling, MRI or hysteroscopy with biopsies if leiomyosarcoma is suspected
MRI may be done if myomectomy is being considered or if suspicious of adenomyosis or adenomyomas
management of fibroids
medical - IUS, NSAIDs like ibuprofen or mefenamic acid taken 3x a day from first day of period until bleeding stops/mangeable level, tranexamic acid 3-4x a day for up to 4 days, COCP, GnRH agonist (max 6m), ulipristal acetate (only prescribe for occassional use if surgery/non-surgical procedures like UAE not suitable)
surgical
laparascopic myomectomy (+/- GnRH agonist before - goserelin injection) (2-3% recurrence rate)
uterine artery embolisation (via femoral - not so much surgery - not if pregnant)
hysteroscopy w myomectomy for removal for submucosa if closer to cevrix
endometrial ablation (for very small fibroids in womb lining)
hysterectomy
MRI-guided transcutaenous US is a new treatment
types of endometrial hyperplasia
hyperplasia without atypia - risk of progression to carcinoma is <5% over 20 years
atypical hyperplasia - pre-malignant condition - 28% risk over 20 years
investigations for endometrial hyperplasia
transvaginal US- >3-4mm then further investigations needed in postmenopausal women (in premenopausal is less useful due to cyclical changes but can be used to identify things like polyps)
pipelle biopsy - definitive diagnosis is with biopsy and histology
hysteroscopy and biopsy should be considered as a more accurate method of diagnosis
management of endometrial hyperplasia
hyperplasia without atypia
address any risk factors e.g. hormonal medication like tamoxifen or obesity
in asymptomatic - watchful waiting as it may return to normal on its own
progesterone treatment is the usual management - IUS first line, second is continuous progesterone treatment for 6m (everyday)
with either; follow-up biopsies is an option -6montly until 2 are negative, then annually if higher risk e.g. BMI >35
hysterectomy option if women wishes, change to atypia, regression has not occured despite a year of progesterone treatment
with atypia
total hysterectomy with bilateral salpingo-oophorectomy in addition for postmenopausal women
women who wish to preserve fertility, progestogen options may be used as above, with regular monitoring by three-monthly endometrial biopsy, and advice to have a hysterectomy as soon as potential fertility is no longer required
tubo-ovarian abscess - what is is and what does it result in
late manifestation of untreated PID
is a cause of secondary dysmenorrhea
can result in adhesions, tubal blockage and infertility
causes of dysmenorrhea
endometriosis adenomyosis chronic PD tubo-ovarian abscess IUD fibroids pelvic adhesions including Ashermann's syndrome where scar tissue forms due to trauma e.g. surgery to remove fibroids ovarian cysts
dysmenorrhoea management
conservative - locally applied heat, tea (regular, chamomile or mint), massage, stop smoking, some evidence for TENS
medical
analgesia paritcuarly NSAIDs, mefenamic acid, COC, IUS, POP, people can become amenorrhoeic within a year of depo-provera
surgery - laproscopic uterine nerve ablation (LUNA) in refractory cases - insufficient evidence
hysterectomy
management of endometriosis
analgesia like NSAIDs
hormonal treatment like COC, depo-provera, IUS, POP, implant - all same efficacy says NHS (by stopping ovulation you decrease the amount of endometrial thickening - help w cyclical pain but may not help w adhesion pain)
norethisterone
danazol - not used commonly due to androgenic SEs
GnRH for 6 m (cyclical pain stops w menopause - but can experience menopausal symptoms)
GnRH agonists for 3m can be used before surgery (induce a temporary menopause by decreasing oestrogen secretions)
surgery - ablation of endometrial lesions, adhesiolysis, ovarian cystectomy for endometriomas
hysterectomy last resort - ovaries removed at same time means less chance of it coming back but will require HRT if doing this (but may not work and is quite drastic)
infertility - with surgical methods above (endometrial cyst may cause infalmmation in ovary, adhesion may block egg) or IVF
NB periods will stop while taking goserelin
management of adenomyosis
- Can do nothing if symptoms are mild
- Conservative options include yoga
- Pain relief with NSAIDs if mild
- Tranexamic acid and mefanamic acid can help bleeding and pain
- Hormonal medications - IUS, COC, POP
- GnRH agonists via injections - but only short term (SC injection every 28 days for max of 6m)
- Danazol - but use is reduced due to androgenic side effects
- Uterine artery embolisation– by reducing blood supply there is insufficient oxygen for the adenomyosis to grow and spread
- Or endometrial ablation (only if completed childbearing)
o Not used as much as although it reduces bleeding, not so much the pain - Hysterectomy is definitive treatment
o Removal of ovaries as well is not necessary unless they also have endometriosis in which case removing ovaries means less chance of recurrence
early vs premature menopause
early = before 45 premature = before 40
how long are women fertilie for after menopause
one year if >50, 2 if <50
symptoms of menopause
may start while still menstruating or not until more than a year after their last period night sweats hot flushes menstrual irregulatiry leading up to it dyspareunia vaginal dryness UTIs urinary incontinece sleep disturbance mood changes- anxiety, irritability, difficulty concentrating loss of libido other - brittle nails, thinning of skin, hair loss, aches and pains
investigations for menopause if in doubt
FSH >30iu/l
TFTs - thyroid symptoms may be confused with menopause
BMD if siginificant risk factors for osteoporosis
management of menopause
conservative - lose weight to improve flushes, same with caffeine, light clothing
HRT helps with symptoms and bone loss
HRT alternatives
CBT for mood symptoms, SSRIs /clonidine/gabapentin for vasomotor symptoms (night sweats and hot flushes), SERMs e.g. tibolone (if period more than 1 year ago), herbal - oestrogen derivatives found in food like nuts, soy, wholegraines, oil of primrose for breast tenderness
CI to HRT
current, past or suspected breast cancer
known or suspected oestrogen-sensitive cancer
past VTE - unless already on anticoagulant treatment
undiagnosed PV bleeding
raised LFTs - any active liver disease
untreated HTN
pregnancy
be cautious with - fibroids, migraines, epilepsy, endometriosis, starting >60, FHx breast cancer
risks of HRT
VTE - 2/3x baseline risk
ischaemic stroke
oestrogen alone increases risk of endometrial cancer so only given to those without uterus
breast cancer with combined only (1 extra case per 1000)
increased risk of IHD if taken more than 10 years after menopause
HRT preperations
oral
patch - preferred if bowel disorder than affects absorption or lactose sensitivity - do not increase clot risk - placed on thigh - oestrogen only or combined
gel - same reasons as patch - but only comes in oestrogen so need to take additional pill if wanting progesterone as welll
HRT implant into abdomen or an IUS - reserved for those where nothing else has worked - oestradiol has to be monitored to avoid tachyphylaxis
vaginal oestrogen cream if only problem is dryness - can use even if still have womb as does not carry extra risks
testosterone gel for libido if not improving with HRT alone
who can you give oestrogen only HRT to
wihtout a uterus
o BUT if ovaries are removed as well, may also want to consider giving testosterone to bring up sex drive
o BUT if subtotal – got to check there is no endometrial tissue left around cervical stump – so do 2 progesterone challenges – bleeding after this means positive and needs combined, no bleeding is negative and means is ok for oestrogen only
types of combined HRT preparations
sequential aka cyclical - LMP within 1 year - gives a monthly bleed - monthly (take on last 14 days of cycle) or 3 monthly regimens available
continuous - LMP >1 year or >54 years - gives no period - takes every day without a break
side effects of HRT
fluid retention bloating breast tenderness leg cramps headaches vaginal bleeding - breakthrough - continuous combined, <6m indigestion cancers - encourage self examination of breasts and attendance of screening with combined
usually all transient – usually settle within 3-4 months – if not change preparation or dose
when to stop HRT
trial withdrawal should be suggested with asymptomatic for 1-2 years or been on HRT >5 years
comes down to
- Patient choice
- No arbitrary time limit
- Main issue with combined HRT is the breast cancer risk
time until effective - COC
- If you start on the 1st day of the period up to and including the 5th day then you are protected straight away
- If on any other day, 7 days condoms
cancers increased in COC
cervical
breast
2 missed COC pills or start new pack 2 days late
take last pill you missed now
use extra contraception for 7 days
you may also need EC if you have missed 2 or more pills in the first week of a pack and had unprotected sex in the previous 7 days
- If there are 7 or more pills left in the pack after the last missed pill – finish the pack, take your 7-day pill-free break as normal
- If there are less than 7 pills left in the pack after the missed pill – finish the pack and start a new pack the next day; this means missing out the pill-free break
time until effective POP
- Taken during first 5 days of period, will work straight away
- If not, then need additional contraception for 2 days
missed POP pill
- <3 or <12 hours - take now then take next pill at usual time
- If >3 hours or >12 hours - take a pill asap - only take 1 (even if you have missed more than 1)
- Then take next pill at normal time (this may mean taking 2 on the same day)
- Need extra contraception for next 2 days, or do not have sex
- If you have unprotected sex from the time that you miss your pill until 2 days after you start taking it reliably again, you may need emergency contraception
types of progesterone injection
IM dep-provera - 12 weekly
SC sayana-press - 13 weekly
IM noristerate - 8 weekly max of 2 injections so only for short-term use e.g. waiting until their partners vasectomy is effective
time until injection effective
if during first 5 days fine
if not then extra contraception for 7 days
disadvantages of progesterone injection
delay in return of fertility - up to 1 year
menstrual irregularity - nearly half with be amenorrhoeric at 1 year
decreased bone mineral density - will recover once injections are stopped
weight gain - up to 3kg in one year
small hormonal side effects like COCP
IUS time until effective
if fitted in first 7 days then protected
any other time need 7 days of protection
IUD time until effective
instant
when can the IUD be used for emergency contraception
up to 5 days after sex OR up to 5 days after the earliest time you have ovulated (even if the UPSI was then >5 days ago)
e.g. if UPSI occured 7 days ago and ovulation was 3 days ago then can be used
when can ellone be used for EC
up to ovulation and 5 days after UPSI
when can levonelle be used for EC
within >48 hours before ovulation and within 72 hours of UPSI
threatened miscarriage vs inetiable miscarriage
threatened - bleeding and abominal pain but pregnancy still continues with fetal hr present, cervical os is closed and theres a fetal heartbeat. 25% will go on to have a miscarriage (not very much bleeding)
inevtiable - cervical os is open and fetal hr present - will lead to an incomplete or complete miscarriage (heavy bleeding) (if US - fetal heartbeat may be present but a miscarriage is a bout to occu - unlike incomplete where no heartbeat usually)
missed vs incomplete vs complete miscarrage
missed = fetus dead but retained and os is closed - suspect a missed miscarriage in pregnant women who do not have bleeding or pain but have resolving symptoms of pregnancy (often no bleeding at all)
incomplete = partially expelled products of conception, os is open - some products still retained (bleeding still ongoing)
complete = os is closed, US shows empty uterus
differentials for bleeding in early pregnancy
miscarriage
ectopic
implantation bleed - light bleeding or spotting that occurs between 7 and 14 days after fertilisation
cervical polyp or ectropion
gestational trophoblastic disease - most develop bleeding in first trimester and undergo uterine evacuation at about 10w
investigations to confirm a miscarriage
NB risk increases with age - 10% in 20s to 50% in 40s
other risk factors = infection, multiple preg, assissted conception, fibroids, uncontrolled diabetes
transvaginal ultrasound - if empty then either is an ectopic, too early to see or a complete miscarriage (if CRL <7mm and mean sac diameter <25 then could just be too early)
but if a woman has had a previous scan confirmed pregnancy and is now empty - miscarriage is confirmed
serum hCG if PUL on US - two tests taken 48 hours apart
• ≥63% increase suggests ongoing intrauterine pregnancy (rescan in 7-14 days to determine location - ectopic isn’t necessarily ruled out yet)
• Fall by >50% indicates failing pregnancy and potential miscarriage (should do pregnancy test 14 days later and return if positive)
• Fall <50% OR fail to rise >63% should be reviewed in EPAU to exclude ectopic
rare causes of raised hCG should also be consdiered like gestational trophoblastic disease or germ cell tumour
if woman is <6w, bleeding but no pain can also consider expectant - tell her to repeat pregnany test in 7-10 days and return if postive or symptoms worsen
miscarriage management
complete - just support
incomplete, inevitable or missed
expectant - allow miscarriage to progress naturally - cant do this if increased risk of haemorrhage (e.g. pregnancy in late first trimester or coagulopathy) or has infection - should complete in 2w and in most cases resorption of fetal tissue occurs without much bleeding but this can vary, then take preg test in 21 days - if still positive then medical or surgical (saftey net - any unusal signs of infection like discharge)
medical - misoprostol pessary or oral - then preg test in 21 days - can take 2-8w to resolve - can be more pain and bleeding than surgical but advantage is avoids GA
w analgesia and antiemetics
surgical - manual vacuum aspiraton under LA or surgically under GA - always done if haemodynamic compromise or suspected molar or GTD - offer anti-D if Rh negative - risk is uterine perforation or asherman’s
once miscarriage occurs, recomened to send products to lab to rule out ectopic (choiroinc vili present) and molar
investgiations for recurrent miscarriage
endocrine - TFTs, HbA1c, and investigate for PCOS
antiphospholipid antibodies
inherited thrombophilia screen - factor V leiden, prothrombin/protein s/protein c mutation
USS of uterus - fibroidsm malformed uterus, e.g. bicorunate
hysteroscopy for ashermans
karyotype woman and partner
kartotype products of conception
managemnet of antiphospholipid syndrome to prevent recurrent miscarriages
usually is warfarin but women will be switched to heparin while trying to conceive
then heparin with low-dose aspirin during pregnancy
ranges within gestational trophoblastic disease
ranges from molar pregnancies (benign) to malignant conditions like choriocarcinoma
premalignant = hydratiform mole
- complete hydatiform mole
- partial hydatiform mole
malignant
- invasive mole - a complete mole that has invaded the myometrium
- choriocarcinoma - can metastasise to lungs - most often follows a molar pregnany which is why is important to monitor these pregnanies
- placental site throphoblastic trumour
- epithelioid trophoblastic tuomur
what makes a complete vs partial molar pregnancy
complete = all comes from father - 46 chromosomes - 2 sperm fertilising empty ovum - will be no fetal tissue - 15% go on to develop persistent gestational trophoblastic neoplasia
partial = 2 sperm fetilise one ovum - 69 chromosomes - usually evidence of fetal tissue and embryo may be present at start - 0.5% go on to deveop persistent gestational trophoblastic neoplasia
features of molar pregnancy
bleeding in first trimester +/- abdominal pain
may end on its own by a miscarriage
hyperemsis
abnormal uterine enlargement (larger with soft, boggy consistency)
hyperthyroidism - due to the high hCG (similar shaped to TSH)
anaemia
respiratory distress
pre-eclampsia
investigations for molar pregnancy
urine and blood hCG - excessively high
US - complete looks like bunch of grapes or snowstorm - partial may be viable with signs of early growth restriction
histology from conception for definitive
suspicion of metastatic = pelvic US, CT, MRI
management of molar pregnancy
complete - surgical evacuation via suction curettage by experienced surgeon
oxytocin may be required alongisde due to haemorrhage risk but is associated with risk of tissue dissemination leading to metastasis so should be avoided until uterus is evacuated if possible
chemotherapy may be required after evacuation if hCG level does not fall (is measured fortnightly) - risk of requiring chemo is 15% after complete and 0.5% after a partial
partial - surgical evacuation unless v small and can do medical
chemotherapy may be required after evacuation if hCG level does not fall
persistant gestational trophoblastic disease - chemotherapy +/- surgery
hCG levels should be checked at 6w and 10w after each subsequent preg
following a normal hcg on the fortnightly tests, urine hCG is requested at 4-weekly intervals until 1yr post-evacuation, then every 3mths in the 2nd year of follow-up
usually you will be advised not to become pregnant until your hCG tests have been normal for six months after a molar pregnancy, and for a year after finishing chemotherapy
Indications for chemo
- Serum hCG levels >20 000IU/L at 4wks after uterine evacuation
- Static or rising hCG after uterine evacuation in absence of new pregnancy
- Persistent symptoms, e.g. uterine bleeding and/or abdominal pain
- Evidence of metastases
- Histological diagnosis of choriocarcinoma
when do ectopic pregnancies present
6-8 weeks after last normal period
diagnosis of ectopic pregnancy
abdominal exam - if pain then admit to EPAU, if not then pelvic
pelvic exam - if cervical motion tenderness or pelvic tenderness admit to EPAU, if none and >6w pregnant then refer to EPAU
if no pain or anything and <6w pregnant then do expectant and advise to repeat test in 7-10 days then return if positive
pregnancy test positive, do urine dip to rule out UTI, bloods include FBC, crossmatch, G+S if thinking rupture
transvaginal US - if too small can look for free fluid in pouch of douglas or adnexae
serum hCG - >63% suggests ongoing (rescan in 7-14 days), fall by 50% indicates failing + miscarriage (redo preg test 14 days later), fall <50% to rise <63% could mean ectopic and need clinical review
management of ectopic pregnancy
expectant - stable, asymptomatic/minimal symptoms, hCG <1500 IU, no fetal activity on TV USS, mass <35mm, willingness to attend for follow-up
requires serum hCG every 48 hours until repeated fall then weekly until less than 15IU
medical - stable, minimal symptoms, hCG <1500IU, no fetal cardiac activity on TV USS, mass <35mm, willingness to attend follow-up
methotrexate IM as a single dose
hCG levels should be measured at 4 and 7 days post-methotrexate and another dose can be given if drop is <15%
they will need reliable contraception for 3-6m after due to teratogenicity
surgical - significant pain, adnexal pain >35mm, fetal heartbeat on US, hCG >5000IU/L, unable to return follow-up
laparoscopy is preferred (laparatomy may be done if particulary unstable)
laparascopic salpingectomy is commonest, if other tube not ok then salpingotomy
anti-D should be given if Rh negative to those that have had surgery
if haemodynamically unstable then 2 large bore IV lines and fluids, crossmatch 6u of blood then emergency laparotomy once resuscitated
how long to wait until investigating for not being able to get pregnant
not concieved within 1 year
can offer earlier referral for consultation to discuss other options where >35 years or where there is a known clinical cause of infertility
nice advise a couple to try for a total of 2 years (which can include up to 1 year before their fertility investigations) before IVF will be considered
everyday things that can affect fertility
atypical antipsychotics like chlorpromazine can increase prolactin levels
NSAID use is associated with luteinized unruptured follicle syndrome
antidepressants and erectile dysfunction
smoking, drugs, obesity
chemotherapy
surgery and radiotherapy to pelvic area
systemic disease can interfere with the hypothalamic-pituitary axis - SLE or rhumatoid, CKD, DM, anorexia
mumps in men
causes of female infertility
in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not
hypothalmic amenorrhoea - low BMI, excessive, kallman’s syndrome
pituitary tumours
sheehan’s syndrome
hyperprolactinaemia - high prolactin inhibits GnRH
PCOS
premature ovarian failure - idiopathic, chemo, autoimmune
turner’s
testicular feminisation syndrome
damage to tubes due to pid/infection
significant distortion of uterine cavity by fibroids or adhesions
endometrioris causing tubal infertiliy
problems with cervical mucus - hostility to sperm
investigations for female infertiliy
exam for signs of PCOS, bimanual for PID
mid-luteal progesterone to assess if ovulation occurs as it is produced by corpus luteum so must have ovulated - done 7 days after ovulation/7 days before next anticipated period (<3ng/ml means no ovulation, if normal then points to fallopian tube obstruction or uterine abnormality - can repeat if low - may have not ovulated that month)
FSH and LH - high suggests poor ovarian function and low suggests central
testosterone for pcos
prolactin
US genital tract for abnormalities
HSG for tubal patency (or laparascopy with dye test if cormorbdities like PID or endometriosis) - must do sti check beforehand
ovarian reserve testing with total antral follicle count via US, AMH level (high means more reserve), FSH level on day 2-5 (high if fewer follicles)
causes of male infertilty
in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not
high prolactin
pituitary tumour
kallman syndrome
hypothalamic - head trauma, radiation
testicular - cryptochidism, varicoele, tumours, trauma, orchitis, radiotherapy, chemotherapy, Kleinfelter’s
problems with genital tract - CF (absence of vas), previous STI thats caused scarring, damage from trauma, surgery or cancer, ejaculatory dysfunction, retrograde ejection
investigations for male infertility
in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not
examine - look for presence of varicoele, epididymal thickening, scrotal swelling
semen analysis (repeated 3m later if abnormal to complete one cycle of spermatozoa, but repeat asap if gross deficiency) (need 3 days of abstinence before)
FSH and LH - low is central, high in testicular abnormalities like kleinfelters, crytochidism, normal is ejaculatory dysfunction and retrograde ejaculation
testosterone
prolactin
genetic testing for kleinfelts
US genital tract
testicular biopsy to see if sperm present in men with non-obstructive azoospermia - these can then be used in treatment
teratozoospermic
low sperm morphology - <4% of sperm with normal morphology
cryptozoospermia
so few sperm in the ejaculate that they are identified only after concentration and centrifugation
management of male infertility
obstructive azoospermia - end to end anastomosis or surgical sperm retrieval
non-obstructive azoospermia - ICSI (selects sperm w best morphology and motility then injects it directly into an egg), donor sperm, if secondary to central cause than gonadotropins (hCG IM or recombinant FSH), varicocelectomy, microTESE (microsurgical testicular sperm extraction - done under GA, sample is taken from testes) or ICSI for Kleinfelters with genetic counselling beforehand
motility issues - ICSI or can do intra-uterine insemination where high-quality sperm are injected into uterus but unclear as to whether this is any better than normal intercourse
central - hCG via IM or gonadotrophins like recominant FSH
prolactinoma - cabergoline or bromocriptine (all other benign tumours should be removed by transphenoidal resection)
retrograde ejaculation - sympathomimetic meds that close bladder neck or ICSI/IVF
management of female infertiliy
In polycystic ovary syndrome, abnormal hormone levels prevent follicles from growing and maturing to release egg cells. Instead, these immature follicles accumulate in the ovaries. Affected women can have 12 or more of these follicles
central - avoid excessive exercie/normal BMI, hCG via IM or gonadotrophins like recominant FSH
prolactinoma - cabergoline or bromocriptine (all other benign tumours should be removed by transphenoidal resection)
PCOS - weight loss, then clomiphene (encourages ovulation), then ovarian induction with gonadotrophins (recombinant FSH and hCG - but mighter risk of multiple pregnancies), laparascopic ovarian drilling by laser or diathermy (destroyes the tissue that is producing androgens and has been found to increase fsh levels)
metofrmin can be used to lower blood sugar levels in pcos which may help - used off liscense in uk
letrozole can also be used instead of clomiphene off label
ovarian failure - donor eggs
tubal - surgery can be considered for adhesiolysis or salpingotomy, IVF if not
how are ovaries stimulated
suppress pituitary with GnRH agonist or antagonist
then give clomiphene to suppress natural oestrogen release and therefore neg feedback on the pituitary
FSH will then increase (or exogenous FSH can also be given)
this will increase number of mature follicles
ovulation can be triggered 36 hours prior to egg harvesting via hCG
what is gamete intrafollipian transfer (GIFT) vs ZIFT
egg and sperm put back into the fallopian tube via laparascopy but not fertilised yet, needs more eggs so higher risk of mlutiple = GIFT - e.g. if couple has religious reasons about not wanting to have fertilisation done outside of the body
mix egg and sperm then inject fertilised egg back into the fallopian tube via laparascopy = ZIFT
e.g. used in unexplained infertility after trying IUI
relationship between tamoxifen and taking a biopsy with endometrial hyperplasia
even if <4mm - if the patient has taken tamoxifen in the last year then this is an indication for biopsy due to it increasing the risk of endometrial cancer
investigations for endometrial cancer
speculum to rule out other causes of PMB
TVUS - 4mm or around that as cut off for biopsy
pipelle biopsy via vagina
or hysteroscopy and biopsy (some women may require GA for this)
or can do hysteroscopy with dilation and curettage under GA
CT for staging in those with suspected advanced disease
management of endometrial cancer
TVUS >4mm, then pipelle or hysteroscopy and biopy or hysterosocpy w dilation and curettage under ga
CT for staging
2 week wait referral for >55 with PMB
stage 1 - total hysterectomy with bilateral salpingo-oophorectomy (if wish to preserve fertility then can be hormonal treatment with progestogens)
stage 2- total hysterectomy with bilateral salpingo-oophorectomy with pelvic node clearance
stage 3 and 4 - maximal debulking surgery with radiation and chemo
other
o Unfit for surgery - options include vaginal hysterectomy (regional anaesthesia), pelvic radiotherapy or hormonal therapy with progestogens or aromatase inhibitors
o Chemoradiotherapy - may be combined with surgery - can be given before to shrink - options dependent on stage, grade and risk of recurrence
o New immunotherapies and biological therapies
commonest symptoms of cervical cancer
vaginal discharge
post-coital bleeding
intermenstrual bleeding
late signs = haematuria, PR bleeding, urinary/bowel symptoms, dyspareunia
signs on examination = unusual appearance of cervix on speculum, or bulky masses on bimanual PV
investigations for cervical cancer
bloods - FBC, UE, LFTs diagnosed via biopsy at colposcopy STI screening may be done prior to this to rule out cervicitis staging via CT, PET, CXR, cystoscopy etc pelvic lymph node sampling
management of cervical cancer
- 1A1
o Large loop excision of the transformation zone (LLETZ) or cone biopsy - simple hysterectomy can also be considered particularly if preserving fertility is not an issue - IA2 - IIA (early-stage disease)
o <4cm - gold standard is radical hysterectomy +/- lymph node clearance
o >4cm - chemoradiation is preferred
o If wanting to preserve fertility
• Depending on stage, a cone biopsy with negative margins or local excision can be performed
• Or depending on exact staging and growth, cervicectomy (aka trachelectomy) - IIB - IVA (locally advanced disease)
o Chemoradiation is first line - IVB (metastatic)
o Combination chemotherapy is the treatment of choice
o Alternatively, single agent therapy and palliative care may be suitable
how is cervical screening performed
done using liquid based cytology from the squamocolumnar junction (junction of ectocervix and endocervix) (theres a move away from pap testing where the sample is smeared on a slide)
HPV status and dyskaryosis status are both tested during screening
age group for cervical screening
25-49 every 3 years, then 50-64 every 5 years
women >65 are invited if one of 3 recent cervical cytology samples is abnormal or if they have not had a test since 50 and request one
women who are HIV positive should be screened annually due to them being at increased risk of CIN
if pregnant - wait until 12 weeks post partum
outcomes of cervical screenin g
borderline/low grade changes - only if HPV positive
mild dyskaryosis = grade 1 CIN - only if HPV positive
moderate dyskaryosis = grade 2 CIN - colposcopy - will be seen quicker within 2w rather than a month
severe dyskaryosis = grade 3 CIN - colposcopy
negative follow up as normal
indadequate - repeat sample in 3 months
if HPV positive but cytologically normal, repeat in 12 months (keep doing this until 3rd test then coloposcopy if still HPV positive)
how is colposcopy performed
- Speculum is inserted then a microscope is used to look at cervix
- The cervix is cleaned with acetic acid followed by iodine to identify the abnormal areas (will stain them yellow)
- Abnormal cells in the cervix that are identified at colposcopy are removed by large loop excision of the transformation zone
in some cases treatment like diathermy, laser therapy or larger excision may be undertaken but this will generally only be after discussion of biopsy results
whole things takes 20 mins
fine to return to work same day - warn of small amount of blood of discharge
bring pad - avoid sex and tamponds until bleeding stops
biospy results usulaly avaible in a week
may be an association between treatment of the cervic and preterm labouir
treatment of CIN
done at same time as colposcopy but may have to wait for biopsy results (colposcopy doesnt hurt but may cause cramping - take pain killer 30mins before and bring pad to wear after in case of bleeding)
most common treatment is large loop excision of the transformation zone (LLETZ) with a thin heated (with electric current) wire loop – LA is injected into cervix first
cone biopsy is done less – a cone-shaped piece of tissue is cut out – done if a large area of tissue needs to be removed. Cannot be done at same time as colposcopy - done under GA
other treatments include cryotherapy (only used to treat minor cell changes), laser treatment, cold coagulation, hysterectomy (if abnormal cells found more than once and dont want children)
after treatment - another screening test 6m later - if HPV or cytology changes found then another colposcopy
NB after a cone biopsy - generally wont affect fertility however there is a small chance or miscarriage and preterm labour (and a small chance that there will be cervical stenosis in which case sperm wont be able to get through)
subtotoal vs total hysterectomy
total = removes cervix
RMI for ovarian cancer
US score (number of findings on scan) x menopausal score (1= premenopausal, 3 = post) x Ca 125
investigations for ovarian cancer
two-week wait referral is recommended in any woman with ascites ± pelvic mass that is not obviously fibroids
baseline investigations - urine pregnancy test (exclude ectopic and uterine pregnancy as a cause of symptoms), FBC
CA125 - >35 then arrange pevlic and abdominal US
then consider CT of pelvis and abdomen if US is suggestive
then do RMI (risk malignancy index)
if RMI >200-250 then refer to MDT for laparotomy
in women <40 measure AFP and hCG as well to exclude rarer tumours
can also consider doing AFP, CA19-9 and CEA
final diagnosis is often obtained during surgery after appropriate MDT discussion. In cases where cytotoxic chemotherapy is proposed prior to surgery a histological sample is normally attained before treatment is commenced. This is ideally by percutaneous image-guided biopsy
management of ovarian cancer
standard - surgery followed by chemo - surgery is via midline incision with goal to remove as much as possible - will usually involve a hysterectomy, removal of both ovaries and fallopian tubes and the omentum
the chemotherapy after surgery isn’t necessarily required for very early stages
at earlier stages there can be discussion of fertility preserving surgery but this has risks associated
in advanced, may also have neoadjuvant chemo
radiotehrapy for palliative
investigatinos for ovarian cysts
the vast majortiy of ovarian cysts are benign and may not need treatment and go away on their own
folliciluar cyst is the commonest type
syptmos - dull ache in abdo or back (may be intermittent or only w sex)
cyclical pain suggests chocolate cysts
palpable mass
pressure effects on bladder or bowel
ascites - meig’s syndorme (ovarian tumour, ascites and effusion)
pregnancy test
FBC - infection, haemorrhage
US - simple vs complex (simple is fluid only, complex can be irregular and contain solid material, blood or have separations or vascularity)
CA-125 - be aware it can be rasied in endometriosis, diverticulosis, liver cirrhosis, menstruation and pregnancy - it does not need to be done in premenopausal women who US shows simple cyst
LDH, AFP and hCG for germ cell tumours
calculate RMI - >200 = high risk and shoudl be discussed for staging laparotomy, 25-200 - do MRI to further evaluate
CT and MRI if US not definitive
diagnostic laparoscopy or fine-needle aspiration cytology may be used to gain histological evidence that a mass or cyst is benign
BUT - RCOG said that aspiration of the cyst is associated with a high rate of recurrence and increased spillage into the peritoneal cavity, which may disseminate possible malignant cells
- Therefore cystectomy may be preferred over aspiration
meig’s syndrome
triad of ovarian tumour, ascites and pleural effusion
mangement of ovarian cysts
<5cm and without complications, follow up not required as is likely physiological and almost always resolves in 3 menstrual cycles
if >5cm then observe with annual US to monitor for possible malignany
if the cyst persists, or enlarges, either further imaging (MRI) or surgery is recommended if the cyst is >70mm or symptomatic
o In children and younger women wishing to preserve maximum fertility, cystectomy may be preferable to oophorectomy
investigations + management of complication of ovarian cysts (torsion, rupture, haemorrhage)
A-E
cannulate, take bloods including FBC and G+S
fluids as needed
pregnancy test to exclude ruptured ectopic
pelvic or transvaginal US
(can do doppler for torsion - however doppler flow isnt always even absent in torsion)
CT or MRI if diagnostic uncertainty
immediate surgical intervention = usually laparascopically with uncoiling and oophoropexy for torsion
and removal of the cyst
salpingo-oophorectomy may be indicated if severe vascular compromise, peritonitis or tissue necrosis
in cyst rupture, IV broad spectrum antibiotics
how long do you give inflation breaths over
5 inflation breaths over 30 seconds
rate of ventilation breaths
30-40 per minute (1-2 seconds each)
(after your 5 inflation breahts, if HR increases but baby does not breath then you would now do your ventilation breaths until it breaths by itself)
when to start compressions in neonatal rescitation
- If the heart rate remains slow (less than 60 beats per minute) or absent following 5 inflation breaths, despite good passive chest movement in response to your inflation efforts, start chest compression
- Give 3 compressions to one inflation breath
APGAR meaning
appearance - colour
pulse - >100 scores 2 points
grimace/reflex irritability in response to a pinch
activity - muscle tone
respiration - absent, weak or strong cry
7-10 is normal
<3 is critically low
is taken 1 and 5 minutes after birth
timing of heel prick test
5-8 days
timing and types of hearing test for neonates
4-5 weeks
automated otoacoustic emission - probe in the ear that emits clicks and acoustic energy will be produced in response if the cholcea is normal (detects echoes)
automated auditory brainstem response - done if the baby doesn’t have a clear repsonse to the first - uses electrodes to detect brainstem responses
babies who have spent more than 48 hours in a Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) are regarded as high-risk and are screened using both AOAE and AABR tests
SGA baby define
birth weight <10th centile or 2 standard deviations from norm
(whereas IUGR described baby that hasn’t reached its growth potential due to genetic or environmental factors)
risk factors for SGA
- Minor risk factors o Maternal age ≥35 years o IVF singleton pregnancy o Nulliparity o BMI <20. o BMI 25-34.9 o Smoker - 1-10 cigarettes per day o Low fruit intake pre-pregnancy o Pregnancy interval <6 months o Pregnancy interval ≥60 months - Major risk factors o Maternal age >40 years o Smoker - ≥11 cigarettes per day o Paternal or maternal SGA o Cocaine use o Daily vigorous exercise o Previous SGA baby o Previous stillbirth o Chronic hypertension o Diabetes with vascular disease o Renal impairment o Antiphospholipid syndrome o Heavy bleeding similar to menses o Pregnancy associated plasm protein-A (PAPP-A) <0.4 multiples of the median (MOM)
investigations for SGA
plot symphysis fundal height
if <10th centile then can do US for fetal size
or women with major risk factor should have serial US and umbilical artery doppler from 26-28 weeks
women with 3 or minor risk facotrs should have uterine artery doppler at 20-24w - if this is abnormal (pulsitility index >95th centile) – should be referred for serial US measurement of fetal size with umbilical artery Doppler at 26-28 weeks
where uterine artery doppler shows reversal or absent diastolic flow, delivery of fetus is indicated
can do karyotyping is detected before 23 weeks
some causes of IUGR
placenatal most common - pre-eclampsia, abruption, accreta, previa
maternal - malnutrition, low BMI, substance abuse, chronic disease, hypertensive disease, anti-phospholipid syndrome, extremes of ages
fetal - chromosomal abnormalities, congenital abnormalities, congenital infections, multiple pregnancy
3 types of IUGR
symmetrical - mostly due to chromosomal abnormalities
asymmetrical - cause of IUGR later in pregnancy, most often placental insufficiency, head circumference will be normal - but abdominal circumference will be decreased
mixed - when early IUGR is affected further by placental causes in late pregnancy
scanning when at risk of IUGR
every 2 weeks from 28w gestation to asses fetal head circumference, liquor volume (oligohydramnios occurs in IUGR as there is shunting of blood to the head to protect the developing brain. This deceases renal perfusion, lowering urine output)
uterine artery doppler- where this shows reversal or absent diastolic flow, delivery of fetus is indicated
when is meconium aspiration seen vs transient tachypnoea of newborn vs newborn respiratory distress syndrome
meconium aspiration usually seen in term or post term - will see patchy infiltrations and atelectasis on cxr
transient tachypnoea usually seen in term or near term infants usually after a c section (as is due to delay in resorption of lung fluid, thought to be due to decreased levels of catecholamines from c section) - resolves fully within first day of life - HF type patten on CXR (interstital oedema and pleural effusions - but normal size heart which distinguishes it from heart issue)
NRDS in premature - respiratory distress which worsens over next few days - diffuse ground glass lung with low volumes on CXR
causes of neonatal seizures
most common = HIE (hypoxic ischaemic encephalopathy) - presents in first 24 hours with fetal distress, need for resuscitation at birth and decrease coscious level
group b strep and e coli are commonest infective causes and present from end of 1st week onwards
cerebral infarction often presents with focal seizures at 24-72 hours in an otherwise well infant
remember IUGR babies are at risk of hypoglycaemia
materanl substance abuse = neonatal abstinence syndrome
benign neonatal sleep myoclonus – presents from 5 days with myoclonic jerks only during sleep
management of neonatal seizure
- Monitor breathing – may be compromised during seizures and following anticonvulsant administration
- Start an anticonvulsant if there are: prolonged desaturations, haemodynamic instability, seizure lasting >5 minutes, or brief but frequent seizures >3 per hour
o First- line: phenobarbital ‘full’ loading dose (20 mg/ kg IV) - Commence antibiotics and add aciclovir if there is any suspicion of herpes infection (maternal infection, rash, abnormal LFTs)
management of ttn
- Observation – if symptoms are related to TTN they will improve within mins-hours (whereas if due to pneumonia for example will get worse)
- Additional oxygen may be required
cause of meconium aspiration
usually secondary to fetal hypoxia which causes increased peristalsis, relaxation of anal sphincters and reflex gasping
so is a sign of fetal distress
management of meconium aspiration
observation over 12 hours
therapeutic interventions include airway suctioning, oxygen delivery, ventilatory support
surfactant replacement can be beneficial as meconium will deactivate the actvity of rsurfactant causing a rise in surface tension
antibiotics if suspicious of infection
prevent hypothermia with incubator if needed (hypothermia inhibits surfactant production)
continuous monitoring
serum electrolytes should be measured in babies with MAS because perinatal stress can lead to inappropriate antidiuretic hormone (ADH) secretion syndrome and acute kidney injury
resp distress usually subsides in 2-4 days
management of respiratory distress syndrome
manage in NICU
surfactant replacement therapy given via endotracheal tube
oxygen via a hood
supportive therapy including presvention of hypothermia (may need incubator), IV nutrition
antibiotics after obtaining cultures - discontinue after 3-5 days if cultures are negatiev
antibiotic for group b strep prophylaxis
benzypenicillin
- Maternal IV antibiotic prophylaxis should also be offered to women in preterm labour regardless of their GBS status
when is neonatal jaundice pathological
if develops before 24 hours or if conjugated or if unconjugated and lasts >14 days or symptomatic or raised >220
causes of unconjugated hyperbilirubinaemia
breast milk jaundice - after 7-10 days due to substances in breast milk - should keep breastfeeind regardless
breastfeeding jaundice - presents within first 7 days - due to insufficient feeding - decreased milk volume slows down GIT
infection
haemolytic anaemia
hypothyroidism
gilbert’s
cephalohaematoma
usually not a problem, but unconjugated bilirubin is fat soluble and can cross BBB –> kernicterus
causes of conjugated hyperbilirubinaemia
liver disease leading to cholestasis
o Bile duct obstruction e.g. biliary atresia, choledochal cyst
o Alpha-1-antitrypsin deficiency
o Galactosaemia
o Cystic fibrosis
o Neonatal hepatitis syndrome
o Intrahepatic biliary hypoplasia e.g. Alagille syndrome, Down syndrome
investigations for neonatal jaundice
transcutaneous bilirubinometer if >24 hours old and >35 weeks gestation
serum if <24 hours or <35w or if transcutaenous was high at >250
total and conjugated levels to decide if conjugated or not
haemoglobin levels = if llow could be a collection outside vessels like cephalohaematoma
LFTs for cholestatis or liver disease
infection screen for TORCH
look for sources of infection
investigate for haemolysis - reticulocyte count, LDH, direct Coomb’s (see if mothers antibodies are attacking baby’s RBCs due to Rh or ABO incompatibility), blood film and red cell enzyme assay, electrophoresis
US, HIDA scan for cholestatic jaundice like biliary atresia
management of neonatal jaundice
differentials include - hypothyridism, haemolytic anaemia
- Infants with jaundice will have their bilirubin levels plotted on a graph against age since birth, with adjustment for prematurity. The graph has two lines, marking treatment threshold
- The lower line is the threshold for treatment with phototherapy (stop once >50 below treatment lines, recheck in 12-18 hours after stopping)
- The higher line is the threshold for treatment with exchange transfusion
- if below both lines - >50 below do nothing, <50 below then repeat level in 18-24 hours depending if baby has risk factors present or not
IV immunoglobulin can be used as an adjunct to phototherapy in Rh or ABO haemollytic disease
when should anti-D prophylaxis be given to rh negative women that have not already been sensitised
as two doses of anti-D immunoglobulin of at least 500 IU at 28 and 34 weeks or as a large single dose of 1500 IU at 28 weeks’ gestation
management of breast milk jaundice - prsents in first 2 weeks of life and can persist for as long as 12 weeks
can be diagnosed in a healthy thriving infant w food weight gain where haemolysis has been ruled out
this is the commonest form of prolonged jaundice in term infants *uncongjugated
benign process
no real identifiable cause and is relatively common
up to 10% of breast-fed infants can remain jaundiced up to one month of age
treatment depends on bilirubin levels and may include increasing number of feeds per day, interrupting feeds w formula solution or even phototherapy
placentra previa on exam
soft uterus
abnormal lie
typical age of presentation for fibroids
30-50
tranexamic vs mefenamic acid
Tranexamic acid (anti-fibrinolytic) – ~50% reduction in blood loss and is used during or just before the period. Particularly effective in fibroids. 3-4x a day for up to 4 days Mefenamic acid (NSAID) – ~30% reduction in blood loss, particularly useful if dysmenorrhoea is also present. take 3x a day from first day of period until it stops/is mangeable
norethisterone
You’ll usually be prescribed 3 norethisterone tablets a day, starting 3 to 4 days before you expect your period to begin
norethisterone does not act as a contraceptive when used in this way, so you could still get pregnant
when is combined vs quadruple done
combined at datings scan - 8-14 weeks
quadruple at 14-20 weeks and is only for DS
notes for DS counselling
nb high bmi can make it hard to measure nuchal translucency
DS is most common conegnital abnormality - 1 in 1000
main cause of early mortality is congenital heart disease - despite this many will live happy and fulfilling lives
risk increases to about 1 in 100 at 40 years
presents w low tone, increase reflexes, intellectual disability, developmental delay, diabetes, short stature, obestiy, 50% have congenital defects (AVSD, ASD, VSD), asthma, duodenal atresia
combined - 8-14 (beta hCG, PAPP-A and nuchal translucency)
quadruple - 14-20
is considered positive if risk is greater than 1 in 150 and these women are offered diagnostic testing
CVS - 11-14
amniocentesis - 15-18
both have infection risk and may have to be repeated
both take 10 mins, results in 3 days
both test for other things too
will need anti-D
termination of pregnancy investigations
confirm pregnancy w urine dip
USS to assess pregnancy including dating - however this is no longer considered to be an essential prerequisite of abortion in all cases (an alternative would be estimation of gestation via examination)
screen for STIs
discuss future contraceptive needs
check rhesus status
determine if smear has been done within recommended time - if not should be offered within the abortion service
Counsel the patient and give options and advice but also remember that RCOG guidelines state that: the earlier in pregnancy an abortion is performed, the lower the risk of complications
meaning of twin types
dichorionic diamniotic = separate amniotic membranes and placenta
dizygotic means 2 eggs fertilised by 2 sperm
monochorionic monoamniotic = same sac and same placenta
monochorionic diamniotic = different sac same placenta
complications and diagnosis - twin pregnancy (NB identical twins dont run in fam, IVF can increase risk)
DIAGNOSTIC SIGNS
hyperemsis gravidarum
uterus larger
two fetal hearts may be heard on ausculation
BUT not really relied upon - mostly picked up at dating scan (twin peak or lambda sign)
COMPLICATIONS
MATERNAL - diabetes, pre-eclampsia, hyperemsis, APH, PPH (a hormone drip will be started after birth to reduce this), placentra previa, anaemia
FETAL - pre-term (40%), miscarriage (particuarly with mono), IUGR, congenital anomalies (particuarly w mono e.g. cardia, neural tube), vanishing twin syndrome (one twin being resorbed), twin twin transfusion syndrome in mono (only occurs in twins sharing same placenta)
precautions for a twin pregnancy
consultant led
should all have more frequent growth scans from 20 weeks
routine use of iron and folate can be considered for anaemia risk
aspirin 75mg if one additional risk factor for pre-eclampsia e.g. first baby or FHx
more frequent check ups due to pre-eclampsia risk
offer delivery at 37-38 weeks via induction for normal birth or c section (ealier for monozygotic monochorimnotic at 32 weeks)
NB dizygotic have much less risks and dont need as much scanning
more than half of twins (around 60%) in uk are born by c section - will need if first twin is breech, placenta is low lying or if they share placenta
if previous baby was c section then will recommend c sec
NB if twins are dizygotic then you may not be able to find out for certian if identical - a third are non-identical
can reduce risks of these with a healthy lifestyle - no alcohol and smoking
presentation of fibroids
most are asymptomatic
menorrhagia local pressure effects causing abdo pain dysmenorrhoea dyspareunia 30-50 years may have palpable abdominal mass signs of anaemia enlarged, often irregular, firm, non-tender uterus palpable on bimanual pelvic examination
- Submucosal and intramural fibroids are linked to infertility and increased risk of miscarriage
- 5% of pregnant women noted to have fibroids experience acute pain during the pregnancy, due to fibroid degeneration - red degeneration
- May have urinary or bowel symptoms
- Torsion of a pedunculated fibroid can present with acute abdominal pain
endometriosis pahthohysiology
blood outside uterus also respond to the hormones
so causes a cyclical - dull heavy or burning pain around the same time as menstruation
if depsotis in bladder or bowel can lead to bleeding in stools and urine duein tmenstruation
localised bleeding and inflammation can lead to adhesions - scar tissue can attach different organs together
adhesions leads to non-cyclical pain - sharp, stabbing pulling in nature - pt feels quite sick when happenng
diagnosis of endometriosis
histroy - cyclical pain
speculum - may show deposits in vagina
bimanual - fixed urterus or cervix, tender on deep, adnexa tender
pelvic US may show large endoemtriomas or choc cyst - but often normal
MRI useful for mapping pre-surgery and may show some deposits
laparascopic surgery is gold standard
NB can stage from 1-4 by severity
blood tests (e.g. FBC), urinalysis and MC&S, cervical swabs (MC&S, chlamydia testing) and beta human chorionic gonadotrophin may be helpful in excluding some important differentials
cerical ectropion notes
occurs when the columnar epithium of the endocerxic extends out to the ectocervix
will be visible on speculum
more common in younger, coc, pregnany (associated w high oestrogen levels)
asymptomatic, post coital bleeding, vaginal discharge, pain in sex
problematic bleeding is an indication for treatmen
manage w nothing if asymptomatci
stopping pill
ablation w silver nitrate, cold cyrotherapy
this will result in some vaginal bleeding until it is healed
P1+1 meaning
+1 could be miscarriage or ectopic
questions to ask in history
w bleeding - any tissue, clots
any treatment to the cervix before
counselling points w colposcopy
speculum is inserted, then cervix is cleaned and stained to highlight abnormal cells
will then take a biopsy - most do not have LA but can if want to
the biopsy taken is the size of a grain of rice
wait until and bleeding or discharge stops before you have sex, swim or use tampons
is generally painless but may cause cramping, discomfort and bleeding in some women
your doctor may suggest taking a pain killer 30 minutes before
bring a sanitary pad before to wear after in case of bleeding
HPV is a common virus that 8 in 10 will get and does not cause problems in most people but in some can cause genital warts or cancer
hyperemesis gravidarum investigations
examine for signs of dehydration obs urine dip - uti is a differential and check for ketones - can be raised due to starvation ketosis UE, LFTs blood glucose - exclude dka abg amylase tfts US to exclude multiple or molar pregnancy do PUQE score
induction of labour counselling
ask about allergies
RISKS W POST DATES BABY
malnutrtiion, chest related complications and meconium aspiration
INDICATIONS
1 in 5 need induction
= stimulation of uterine contraction with or without a ruptured membrane
should be offered between 41-42 weeks
and for PROM >37w
or maternal of fetal complications like obstetric cholestasis
RISKS
increased risk of needing c section
excessive uterine contractions –> fetal distress or uterine rupture
uterine atony and PPH
METHODS
if cervix is not favroubale:
vaginal prostaglandins - ripen the cervix - either as a tablet or as a pessary called propess - 60% will go into labour after 24 hours - some will need repeat dose - may be able to go home to give it time to work
if the cervix is favourable:
amniotomy + oxytocin infusion - amnihook is used to rupture membranes - this releases prostaglandins to speed up labour, given w oxytocin to increase contractions - only performed if cervix is ripe
adjunct:
membrane sweep - insert gloved finger into cerivx and rotate it against fetal membranes to cause separation - this releases natural hormones to speed up labour - fot this there needs to be some dilation of cervix - risk of this is small amount of bleeding after and could be uncomfrtable - no risk of infection to baby
if membranes ruptures - iv syntocinon
BISHOPS
an assessment of how ripe the cervix is and likelihood labour will start and how successful induction methods will be
TESTS
prior to induction of labour, a reassuring fetal heart rate must be confirmed by CTG
if syntocinin/hormone drip is used then baby will need constatn monitoring w ctg
IUGR history
any high bp - ask about med conditions previous obstetric CERVICAL SMEARS pmh of kidney disease or clotting disorders good nutrition? medication during a prior to pregnancy smoking, alcohol and substance abuse
notes on rhesus counselling
15% are neg
explains that if the newborn baby is positive - then a small amount of the babys blood may enters the mothers blood stream and because it is a different blood group - the mothers body can produce a protein known as an antibody against the babys blood cells
the mums antibodies can then destroy the babys blood cells - not necessarily harm first baby but may be dangerous for subsequent
explain that blood is most likely to mix during childbirth but also termination or pregnancy, miscarriages, amniocentesis
the reason why it will affect the next baby is because the mothers cells will keep this memonry and produce more in future
can cause haemolytic disease of newborn - baby becaomes jaundice, v ill or stillbirth
to prevent this we give anti-d injection that prevents mum from making these antibodies
offered at 28 and 34 weeks
kleihauer test will be taken after birth
anti-d is safe for the mum and baby - rarely you may have allergic reaction so may be monitored for 20 mins before going home
