O&G PACES Flashcards
1
Q
Counselling: DVT/PE
A
- We think you have a blood clot in the leg/lung.
- It’s important to keep you and the baby safe so we want to start some treatment. We will need to admit you, teach you how to give yourself daily injections, give stockings. It’s important to stay mobile in hospital to reduce the risk of further clots. When you go home you should continue injecting yourself daily with the medication we give.
- To confirm the diagnosis, we want to give you a CTPA or V/Q scan. Both use some radiation and there is a risk of fetal exposure to it, but the risk is minimal and needs to be weighed up against the risk of the clot to you and your baby.
- Birth plan: elective induction or caesarean. Stop LMWH 24hrs before.
- I’d like you to make an appointment to see your GP in a week to discuss whether your symptoms have changed. They will also counsel you on the risk of this occurring again in subsequent pregnancies.
- Safety net: return in case of HIT (bruising, weakness, SOB), anaphylaxis, reduced foetal movements, bleeding, symptoms of VTE/PE.
2
Q
Counselling: Hyperemesis Gravidarum
A
- Nausea and vomiting in pregnancy is normal but we think you might have something called hyperemesis gravidarum which is when vomiting is severe and leads to weight loss and abnormalities of chemicals in the blood.
- It’s important to keep you and the baby safe so we want to admit you and start some treatment. This will involve some anti-sickness medications to reduce the nausea. Hopefully this will allow you to be able to keep food down. If the medications don’t stay down, we can give them via a drip or by the back passage.
- We will also give you some fluids and vitamins.
- You will also need some blood-thinning tablets to prevent clot formation while you’re in hospital.
- At home you can try ginger, acupressure and eating bland meals.
- Usually, HG resolves by weeks 16-20 but if it continues, you may need extra scans to check on the baby’s growth.
- The risk of HG is a small increased risk of preterm delivery and low birthweight, but most women’s birth plans do not change, and they deliver on time vaginally.
- The group Pregnancy Sickness Support can provide support and advice to you and your partner.
- I’d like to catch-up with you a week after you are discharged from hospital to check that the anti-sickness medication is working and discuss the risk of this happening in future pregnancies.
3
Q
Counselling: Gestational Diabetes
A
- The results show that you have developed diabetes. Do you know what this is?
- GD is high blood sugar and usually develops in the 2nd or 3rd trimester in 3 in 100 women. It happens because the body can’t produce enough of a hormone called insulin to meet the demands of carrying a baby.
- GD can pose risks for both you and the baby: for you, it can cause high blood pressure or difficult delivery due to the baby being big. For the baby it can cause low blood sugar, abnormal development in the womb and in the worst-case scenario, stillbirth.
- However, we have treatments which are very effective in reducing these risks. We recommend a balanced diet and exercise to reduce blood sugar. If these changes don’t lower your sugar enough, we will give you medication to help- this might be tablets or insulin injections.
- We will give you a blood sugar testing kit to monitor your glucose at home and we will show you how to use it.
- You will be seen in joint diabetes and antenatal clinic in 1 week and every 2 weeks after that. You will need extra US scans every 4 weeks from 28-36 weeks.
- It’s best to give birth before 41 weeks. We’d recommend an elective birth by induced labour or caesarean before 41 weeks if labour hasn’t naturally started by then. Earlier delivery may be necessary if there is concern about the baby or your blood sugar is not well controlled.
- Medication will be stopped after delivery, but the GP will follow you up to check if the sugar is still high. In most women, GD goes away after birth but women who have had it are more likely to get it again in future pregnancies and develop lifelong T2DM.
- If you plan on getting pregnant in future, ask your GP for information about the risks.
- Safety net: call 999 if you feel you might collapse because of low blood sugar. Go to DAU if you notice reduced fetal movements last more than 40 minutes.
4
Q
Counselling: Pre-Eclampsia
A
- The results show that you have developed pre-eclampsia. Do you know what this is?
- Pre-eclampsia is a condition affecting some pregnant women in the 2nd trimester. It happens in 6% of pregnancies and is when you have high blood pressure and protein in the urine.
- High blood pressure can pose risks for both you and the baby: for you, it can affect your blood vessels and decrease blood to your organs. It might also cause poor growth for the baby and in the worst-case scenario, stillbirth. The complication we’d really like to avoid is eclampsia; this is a type of seizure caused by the high blood pressure which can be dangerous for you both.
- However, we have treatments which are very effective in reducing these risks and we’d like to admit you to take them. We recommend a balanced diet with low sodium and exercise to reduce blood pressure. We will also start you on some medication to reduce blood pressure- these are safe in pregnancy. The target BP is 135/85.
- The only way to cure eclampsia is to deliver the baby but if your blood pressure comes down you can go home until delivery. You will be seen in antenatal clinic every 2 weeks and will have some extra scans at 28, 32 and 34w. You will need to come back for blood tests twice every week.
- You can give birth vaginally if your blood pressure is well controlled but if it’s not or the baby is having problems, you might need to delivery earlier by caesarean or induction. You should keep taking the blood pressure medication in labour and your BP will be checked hourly. It will also be monitored afterwards. You may need extra treatment in delivery in you have eclamptic fits but these are rare.
- You should be offered an appointment with the GP 2 weeks after birth to check if you need to continue treatment- most women do not. You will again be checked at 6 weeks after birth. You will also be told about the risks of having high blood pressure in a future pregnancy.
- Pre-eclampsia can be difficult to manage so support can be found at Action on Pre-eclampsia.
- Safety net: ask someone to call 999 if you experience blurred vision, severe headache or are seizing.
5
Q
Counselling: Gestational Hypertension
A
- The results show that you have developed high blood pressure.
- High blood pressure can happen in pregnancy in the 2nd trimester in 2 in 100 women. We don’t exactly know why but it’s a combination of several genetic and lifestyle factors.
- High blood pressure can pose risks for both you and the baby: for you, it can affect your blood vessels and decrease blood to your organs. It might also cause poor growth for the baby and in the worst-case scenario, stillbirth. The complication we’d really like to avoid is pre-eclampsia; this is high blood pressure that can cause seizures which be very dangerous for you both. You should take 75mg aspirin daily to reduce this.
- However, we have treatments which are very effective in reducing these risks. We recommend a balanced diet with low sodium and exercise to reduce blood pressure. We will also start you on some medication to reduce blood pressure- these are safe in pregnancy. The target BP is 135/85.
- You can give birth vaginally or by caesarean if your blood pressure is well controlled. You should keep taking the blood pressure medication in labour and your BP will be checked hourly. It will also be monitored afterwards.
- You should be offered an appointment with the GP 2 weeks after birth to check if you need to continue treatment- most women do not. You will again be checked at 6 weeks after birth. You will also be told about the risks of having high blood pressure in a future pregnancy.
- Safety net: call 999 if you experience blurred vision, severe headache or pain under the ribs.
6
Q
Counselling: Varicella Zoster Infection in pregnancy
A
- We think you might have chickenpox. Do you know what this is?
- Chickenpox can cause complications for both you and the baby such as an itchy rash, pneumonia and birth defects caused by varicella syndrome.
- We are going to give you something called VZIG since you haven’t had chickenpox before. These are antibodies to fight the virus. They will pass through the placenta to your baby.
- If she presents <24h after rash and ≥20w: we are going to give you antiviral medicine. It doesn’t cure chickenpox but makes symptoms like fever less severe and reduces the risk of complications.
- You can also buy some calamine lotion OTC to help with itching.
- You can normally give birth vaginally but if you go into labour in the next 7 days, you should have a caesarean to reduce the risk of giving the baby chickenpox.
- Your baby may also be given antibodies after birth if he is born in the next 7 days or develops a rash within 7 days of birth.
- You should stay away from other pregnant women and babies for the next month.
- Safety net: go to DAU if you develop chest problems, headache or nausea, vaginal bleeding or a severe or bleeding rash. These might be complications of chickenpox.
7
Q
Counselling: Herpes
A
- We think you might have herpes. Do you know what this is?
- Herpes isn’t harmful to you but there is a small risk your baby could develop a serious illness called neonatal herpes. This can be fatal, but most babies recover with antiviral medication.
- We are going to give you antiviral medicine. It will reduce outbreaks in pregnancy and during birth. You should take in 3x a day (if ≥28w) to protect the baby.
- Most women with herpes will have a vaginal delivery but you may be offered a caesarean if you go into labour in the next 6 weeks. You may be given antivirals intravenously during labour.
- Safety net: in the month after birth, call your GP immediately if your baby is irritable, not feeding, has a fever or develops a rash on the skin, eyes or mouth.
8
Q
Counselling: Preterm Labour
A
- The symptoms you’ve been experiencing might be signs of early labour. This happens to 8 in 100 babies.
- We will check to see if your waters have broken and if there may be an infection. We will also record any contractions and the baby’s heartbeat.
- If your waters have broken, there is an increased risk of infection and you’ll be given antibiotics. It doesn’t mean you’ll definitely go into labour, but you should stay in hospital for a few days. You might be given steroids to help the baby’s lung develop in case he comes early and allowed to go home.
- If your waters haven’t broken, we will check your contractions and do a vaginal exam to check the baby’s head and position. We might try and stop labour in some cases and give steroids. Sometimes it might be safer for the baby to be born- e.g., if you have an infection or you’re bleeding. Your baby might need to stay in hospital for a few days/weeks after birth.
- Safety net: call your maternity unit if you have regular contractions, fluid from your vagina or unusual backache before 37w. Also call if you have a fever, notice green/smelly fluid from the vagina or notice a chance in your baby’s movements.
9
Q
Counselling: Vaginal Birth after Caesarian
A
- It’s a common myth that you can’t give birth vaginally after having a caesarean. As long as your baby is face down and you have had 1 prior LSCS, it is clinically safe.
- The current success rate for VBAC is about 75%- this is higher if you have had a previous vaginal delivery and even higher if you’ve had a successful previous VBAC.
- VBAC can be complicated by factors such as multiple pregnancy, large baby or advanced maternal age.
- Now it’s not very nice to talk about, but I have to inform you of the possible complications of VBAC and ERCS to help you make an informed choice about delivery.
- The advantages of VBAC are that if it is successful, you will have a shorter hospital stay and recovery. It also means that you have a good chance of successful future VBACs. However, there is a small risk of HIE to the baby during delivery and there is a 1 in 200 risk of uterine rupture. The absolute risk of birth-related death with VBAC is comparable to first time mums delivering vaginally.
- The advantages of ERCS are the smaller risk of HIE and the no risk of anal sphincter injury as you will not be pushing. There is no risk of uterine rupture but there is increased risk of placental problems and adhesion formation. ERCS also means that you are likely to require caesareans in future. The risk of maternal death is also higher with ELCS than VBAC.
- If you choose to have a VBAC and don’t go into labour by 39w, your obstetrician will probably recommend a ERCS to minimise the risk of complications.
- I know it’s a lot of information, but I will write this down for you to take away with you. You don’t have to make a decision now and can think about it before your next appointment. Are there any questions you have for me at the minute?
10
Q
Counselling: Ectopic Pregnancy
A
- The symptoms you’ve been experiencing are signs of an ectopic pregnancy. Do you know what this is?
- An ectopic pregnancy is when the fertilised egg implants outside of the womb, usually the tubes connecting the ovaries to the womb. It’s an emergency as it’s a risk to your health if the pregnancy continues. It’s not possible to save the pregnancy so it has to be removed using medicine or an operation.
- There are 3 options for management of an ectopic. You can be carefully monitored, or you can have an injection to assist the passage of the pregnancy. Afterwards, you should take things easy for a few days and expect vaginal bleeding and minor cramping for up to 2 weeks. You can also choose to have keyhole surgery to remove it with the affected tube if you don’t want to wait. The options depend on your US results. All carry a small risk of infection and excessive bleeding.
- An ectopic pregnancy does not affect your likelihood of a successful pregnancy in future. However, some treatments may reduce your chance of natural conception so I will have a senior colleague discuss this with you if you are concerned.
- You should wait until you’ve had 2 periods after treatment before trying again for a baby when you and your partner feel physically and emotionally ready. 65% of women achieve a successful pregnancy 18 months after an ectopic. Let your GP know as soon as you are pregnant to get early scans.
- An ectopic pregnancy can be difficult to cope with; you and your partner might benefit from counselling or support from the Ectopic Pregnancy Trust.
- Safety net: call 999 if you experience, sharp, intense tummy pain or feel very dizzy or faint.
11
Q
Counselling: Emergency Contraception
A
- There are 3 options for emergency contraception. There’s the copper IUD, levonorgestrel (‘the pill’) and ulipristal acetate.
- We’d recommend the IUD first as it has a longer window of action and provides ongoing contraception beyond the last UPSI. Discuss risks and benefits.
- Levonorgestrel: risks and benefits.
- Ulipristal acetate: risks and benefits.
- After taking the emergency contraception, you should take a pregnancy test if your next period is more than 5 days late.
- We’d recommend a form of long-acting contraception to prevent pregnancy in future. There are intrauterine devices/systems, injections, patches, implants and pills. We can talk about the benefits and side-effects of each: do you have a preference?
- You should also use condoms to protect against STIs.
- We’d recommend an STI screen now and then another in 12 weeks as some infections don’t show up on tests immediately.
12
Q
Counselling: Menorrhagia
A
- Heavy periods happen in around half of women with menstrual bleeding and may or may not have an underlying cause.
- Before we discuss the options, could I ask if you are planning to begin trying for a baby soon?
- No identified pathology: we would recommend trialling a type of hormonal contraception called LNG-IUS with is a progestogen hormone that regulates periods and can make them lighter. They last 3-5 years and can be removed at any time if you want to conceive without a delay in return to fertility. The other option is using normal painkillers like ibuprofen or a medication called tranexamic acid that reduces bleeding. Both of these are non-hormonal methods.
- Fibroids >3cm: I’d like to refer you to Gynaecology for additional investigations. In the meantime, you can use normal painkillers like ibuprofen, or a medication called tranexamic acid that reduces bleeding. Both of these are non-hormonal methods. We can also think about hormonal treatments like the pill or surgical options if you’d like.
- We’ll check your iron levels, and you might need supplements if you’re anaemic.
13
Q
Counselling: Subfertility
A
- What you’ve described sounds like it might be subfertility which is where couples have difficulty conceiving. This affects 1 in 7 couples. There are many possible causes and problems can affect either partner. In 25% of cases, it’s not possible to identify the cause.
- I’d like to refer you to Gynaecology for some more tests and possible treatment. They will test both you and your partner for specific hormones and may perform minor procedures to look at your reproductive organs.
- You may be offered medical treatment that helps with regular ovulation or surgical procedures to repair reproductive organs. You might also get assisted conception such as IVF or IUI depending on the cause of the problem and what’s available from your local CCG. There is no guarantee that treatment will be effective. It might also carry risks of multiple pregnancy or an ectopic, where the fertilised egg implants outside of the womb.
- In the meantime, we’d advise regular unprotected vaginal sex every 2-3 days and for you and your partner to ideally stop drinking alcohol and smoking. We have services to help with this. It’s also important to avoid putting pressure on yourselves to conceive as this can make it harder to do so.
- Resources and support can be found at RESOLVE, an association for people experiencing subfertility.
14
Q
Counselling: Incontinence
A
- Urinary incontinence is when you unintentionally pass urine. There are several different types, and you might have a mix of types. It affects millions of people. Though it isn’t dangerous, it can have a serious impact on a person’s life and daily activities.
- The first step is to keep a diary about how much fluid you drink and how often you have to urinate. You should also cut down on caffeine and alcohol and use incontinence products in case you leak. Losing weight can also help.
- Stress incontinence: this is usually caused by increasing age and pregnancy and vaginal birth as these things weaken the pelvic floor. We’d recommend 3 months of pelvic floor exercise which a physiotherapist will teach you to do. You should do 8 of these 3x a day for 3 months. If that doesn’t help, we can consider a medication called duloxetine. Surgeries may also help but these carry risks- we can discuss this when I next catch-up with you in a few weeks.
- Overactive bladder incontinence: this is due to overactivity of the muscles controlling the bladder. We’d recommend 6 weeks of bladder training where you learn ways to wait longer between needing to urinate and passing urine. If that doesn’t help, we can consider medications or surgery, but these carry side effects and risks- we can discuss this when I next catch-up with you in a few weeks.
- If you develop burning or stinging when you urinate or the urine smells bad, come back to the GP as this might be a urine infection and it needs antibiotics.
- Pelvic organ prolapse: this occurs when one of the pelvic organs slip down and bulge into the vagina. I’d like you to avoid heavy lifting and constipation, as these can worsen prolapse. We’d recommend supervised pelvic floor muscle training for 4 months. If there are signs of the muscle around the vagina shrinking, we can offer vaginal oestrogen which is a hormone that can help. Surgery is a last resort, but we can discuss this when I next catch-up with you in a few weeks.
15
Q
Counselling: menopause
A
- The symptoms you’ve been experiencing sound like the menopause. Do you know what this is?
- Menopause is a natural part of ageing that occurs between 45 and 55 and can involve the symptoms you’ve told me about (recall symptoms). These symptoms begin before your period and can last around 4 years after your last period.
- Vasomotor symptoms: you can use hormone replacement therapy to reduce the symptoms you’ve described. This is a combination of oestrogen and progesterone that mimics your body’s normal hormones. There is a slightly increased risk of blood clots and breast cancer, but it protects you against osteoporosis. You might get unscheduled bleeding in the first 3 months with this- let me know if this happens.
- Psychological symptoms: we’d recommend CBT to discuss your thoughts with a therapist. HRT may also help.
- Altered sexual function: HRT can help. If it doesn’t, we can consider testosterone which is the hormone that is responsible for libido.
- Urogenital atrophy: you can use vaginal oestrogen or systemic HRT for this.
- I’d like to catch-up in 3 weeks to discuss your symptoms.
16
Q
Counselling: Endometriosis
A
- The symptoms you’ve been experiencing sound like endometriosis. Do you know what this is?
- Endometriosis is a condition where the tissue lining the womb starts to grow in other places, such as the ovaries and fallopian tubes. It affects 10% of women across all ages and we don’t know why it happens.
- Endometriosis is a long-term condition that can impact life, but there are treatments which can help:
- Pain: there are 2 types of medication we can use to control the pain. You can try non-hormonal methods like paracetamol and NSAIDs. You can also try hormonal methods like the COCP - this regulates your cycle and reduces bleeding and pain. We’ll explain in more detail how exactly to take the pill, but it’s important to know that it might cause side effects like headache, nausea and breast tenderness for a few months. It also slightly increases the risk of blood clots and breast cancer. If medication doesn’t work, we can discuss referring you to Gynaecology for more tests.
- Fertility: do you plan on having more children? Endometriosis can make it harder to get pregnant. Surgery can improve the chance but there is no guarantee. It can also sometimes cause further problems.
- Psychological: receiving a diagnosis of a long-term condition can be difficult, physically and emotional. You’ll receive ongoing support from us but can also contact Endometriosis UK for detailed advice and support.
- I’d like to catch up in 3 months to review your symptoms on the new medication. If, in the meantime, the pain gets worse, please make another appointment to see us.
17
Q
Counselling: Fibroids
A
- The symptoms you’ve been experiencing sound like fibroids. Do you know what this is?
- Fibroids are non-cancerous growths that develop in or around the womb. They’re made of muscle and fibrous tissue and vary in size and cause the symptoms you described. They’re been linked to the hormone oestrogen, so they usually develop during reproductive years.
- There are 2 avenues of treatment: do you plan on having any more children?
- Contraception: hormonal medication can help shrink fibroids. The LNG-IUS is a small medication that is placed in the womb and releases a progestogen hormone. It lasts 3-5 years. The COCP can also be used instead. Both can cause side effects such as headache, acne and breast tenderness. It also slightly increases the risk of blood clots and breast cancer.
- Conception: since you are trying to conceive, we should avoid contraceptive methods. We’d recommend tranexamic acid, to reduce bleeding, or mefenamic acid for pain relief.
- I’d like to catch up with you in 3 months to see if the medication is improving your symptoms. If they aren’t, there are some other medications we can consider, and I can refer you to Gynaecology for more testing and to discuss possible surgery. If, in the meantime, the pain gets worse, please make another appointment to see us.
18
Q
Counselling: PCOS
A
- We think you might have a condition called PCOS. Do you know what this is?
- PCOS is a condition that affects how the ovaries works and can cause the symptoms you’ve described. The exact cause is unknown but something it runs in families. It’s also related to insulin, the hormone that controls sugar levels.
- There is no cure for PCOS, but the symptoms can be managed. There are 2 avenues for treatment: do you plan on having more children?
- Contraception: we’d recommend using hormonal medication such as the COCP to regulate periods and help with the high testosterone. It can cause side effects such as headache and breast tenderness. It also slightly increases the risk of blood clots and breast cancer. You can also try a special cream to reduce facial hair.
- Conception: since you are trying to conceive, we should avoid using hormonal contraception. We can try a medication called clomiphene that helps with ovulation to increase the chance of conception. If this isn’t effective, we can refer you to Gynaecology for a simple surgical procedure called laparoscopic ovarian drilling. With treatment, most women with PCOS can get pregnant.
- Glucose tolerance: as PCOS involves the hormone insulin, it can sometimes cause high blood sugar. This may mean you have to take a sugar lowering drug called metformin to reduce the risk of developing diabetes. We’d also recommend regular exercise, losing weight, and a diet high in protein and fruits/vegetables and low in fat. All of these things will also make it easier to conceive.
19
Q
Counselling: Bacterial Vaginosis
A
- It sounds like you may have an infection called BV. This is a common cause of unusual vaginal discharge, but it is not an STI. We don’t fully understand why it happens.
- It is treated with antibiotic tablets or gels or creams used for up to 7d. It’s important to treat as it can reduce your natural defences against STIs.
- It is common for BV to come back, usually within 3m. You’ll need longer treatments if it comes back several times.
- To relieve symptoms, we’d recommend using water and plain soap to wash the genital area and taking showers instead of baths. Avoid perfumed soaps, vaginal washes or strong detergents in underwear.
- Your partner does not need to be treated (unless same-sex).
- Avoid sex for the next 7d and if symptoms persist beyond then, make another appointment to see us.
- The best way to prevent BV and is to have safer sex. This is best done using a condom.
20
Q
Counselling: Trichomonas
A
- It sounds like you may have an infection called TV. This is an STI caused by a tiny parasite and is a common cause of unusual discharge.
- It is treated with antibiotic tablets for up to 7d. It’s important to treat as it is unlikely to go away otherwise.
- You should inform any sexual partners from the past month to also see their GP for treatment.
- Avoid sex for the next 7d and if symptoms persist beyond then, make another appointment to see us.
- The best way to prevent TV and is to have safer sex. This is best done using a condom.
