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
