O&G: rules Flashcards
Maternal risk factors
Age (less than 16 years or more than 35 years).
Low socio-economic status.
Parity (none or more than five births).
Previous pregnancy problems.
Maternal substance abuse
Drugs (teratogens)
BMI < 20 or > 30
Comorbidities - e.g, asthma, cyanotic CHD, HTN, pre-eclampsia, DM, CKD, SLE, APLS, SCD
Infections: TORCH, malaria, tuberculosis, UTI and BV
Foetal risk factors
Chromosomal abnormalities - eg, trisomies 13, 18, or 21,
Genetic syndromes - eg, Russell-Silver syndrome, Rubinstein-Taybi syndrome, Dubowitz’s syndrome, Seckel’s syndrome, Fanconi’s syndrome.
Major congenital anomalies - eg, tracheo-oesophageal fistula, congenital heart disease, congenital diaphragmatic hernia, abdominal wall defects (omphalocele or gastroschisis), neural tube defect (eg, anencephaly), anorectal malformation.
Multiple gestation.
Congenital infections (TORCH syndrome, malaria, congenital HIV infection, syphilis).
Metabolic disorders - eg, congenital lipodystrophy, galactosaemia, generalised gangliosidosis type I, hypophosphatasia, fetal phenylketonuria
Foetal distress: assessment and management
Assess - CTG, movements
Manage - ROM, IOL and CS if urgent
Active management of labour.
PROGRESS
Pain relief adequate Rate - contractions, FHR Oxytocin Glandins (PGE2) Rupture membranes Examine vagina Support (one-to-one) Sweep
Gynae malignancy:
Stages 1 - 4 (typically)
Stage 1: confined
Stage 2 - 3: local spread, local invasion
Stage 4: invasion to bowel/bladder or distant mets.
Cervical cancer
Dyskariosis to CIN
Mild ~ CIN 1
Moderate ~ CIN 2
Severe ~ CIN 3
Types of hysterectomy
- Subtotal: uterus
- Total: uterus and cervix
- TAH + BSO: uterus, cervix, tubes and ovaries
- Radical: as above, with regional lymph nodes and wide excision
Fertility preserving treatments:
a) Cervical cancer (stage 1A)
b) Endometrial cancer (stage 1A)
c) Endometriosis
d) Fibroids
a) Cervicectomy
b) Progestogens
c) Endometriata removal
d) Myomectomy
Gynae malignancy: histology
a) Ovarian
b) Endometrial
c) Cervical
a) Epithelial (most common: serous)
b) Adenocarcinoma
c) Squamous cell
Ovarian cancer:
a) Signs on USS (MASS)
b) Treatment
c) Intra-operative procedure to tests for malignancy
d) Risk of malignancy index (RMI)
a) Multilocular cyst, Ascites, Solid areas, Spread (intra-abdominal metastases)
b) TAH with BSO
c) Peritoneal washings
d) RMI = U x M x CA125
- U = USS features (score 0 - 5)
- M = menopausal status (pre = 1; post* = 3)
- CA125
- post menopausal = no period for > 1 year or >50 and had a hysterectomy
Menopause
a) Define
b) Presentation
c) Early = ? (diagnosis?)
a) Permanent cessation of menstruation resulting from loss of ovarian follicular activity
- 12 consecutive months of amenorrhoea (or onset of symptoms if hysterectomy)
b) Amenorrhoea, hot flushes, tired, irritable, vaginal atrophy, dyspareunia, urinary symptoms
c) < 40 - diagnose with low FSH on two samples a month apart
HRT
a) If hysterectomy
b) If no hysterectomy - why?
c) Types - choice? risk of DVT etc.
d) Other treatments to give for menopause
e) Duration
f) Risks
a) Oestrogen alone if hysterectomy
b) Oestrogen + progesterone if not as this reduces risk of endometrial hyperplasia/carcinoma
c) Oestrogens can be oral, transdermal, subcutaneously (implant)
d) Other things to use: tibolone, androgens (used to improve libido), vaginal oestrogens
e) Up to 51 in premature menopause, otherwise advise 5 years
f) Breast cancer (combined HRT), Endometrial cancer (oestrogen only HRT), VTE (oral > transdermal), Gall bladder disease (oral), CV disease (combined), Stroke (oral)
Investigating amenorrhoea
Bedside.
- Height and weight
- Pregnancy test
Bloods.
- FSH/LH levels , Prolactin levels
- Total testosterone/sex-hormone binding globulin levels
- Thyroid function (if clinically indicated)
Imaging.
- Pelvic USS if PCOS suspected
Menorrhagia management
a) Trying to conceive
b) Not trying to conceive
a) TxA, NSAIDs (mefenamic)
b) IUS (Mirena) - 1st line
Dysmenorrhoea management
a) Trying to conceive
b) Not trying to conceive
a) NSAIDs (ibuprofen/mefenamic)
b) COCP - also regulate cycle
Investigating dysmenorrhoea
- Examination (abdo, speculum, bimanual)
- swabs if STI risk,
- pelvic US,
- diagnostic laparoscopy
Investigating abnormal PV bleed
- Assess effect of blood loss- FBC
- TFT/clotting
- FSH/LH levels if menopause suspected
- Cervical smear if required
- USS of uterine cavity (Endometrial biopsy if abnormal)
- Beta-hCG (ectopic, miscarriage)
Pelvic ligaments
Broad
Round
Suspensory
Ovarian
Fibroids.
a) Risk factors
b) Protective factors
a) Oestrogen (nulliparous, early puberty), Afro-Caribbean descent, Family history
b) COCP, parity, late menarche, breastfeeding
Uterine abnormalities
a) Result from…?
b) Example
a) Results from differing degrees of failure of fusion of Müllerian ducts
b) Bicornuate, arcuate
Investigating suspected endometrial Ca
Transvaginal US scan (PMB)
Endometrial biopsy (hysteroscopy/ Pipelle)
- Indications:
Endometrium >4mm thick on TVUS if post menopausal
Endometrium >10mm thick on TVUS if premenopausal
Multiple episodes of PMB
PCOS:
a) Rotterdam criteria (PCO)
b) Ix
c) Rx if wishing to conceive
d) Rx if not wishing to conceive
e) Complications
a) Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
Clinical and/or biochemical signs of hyperandrogenism
Oligo-ovulation or anovulation.
b) LH:FSH ratio, testosterone and SHBG, USS ovaries, lipids and glucose
c) Conservative, COCP, metformin, co-cyprindrol (for hirsutism and acne)
d) Conservative, Clomifene, metformin
e) Infertility, miscarriage, menstrual issues, weight gain, T2DM
Ovarian cyst
a) Most common types in i) 40 - 50, ii) 20 - 40
b) Presentation
c) Ix
d) Rx - 1st line? 2nd line? Torsion
a) i) Serous cystadenomas, ii) Mucinous cystadenomas
b) Asymptomatic, pressure symptoms, dyspareunia, acute (torsion, rupture)
c) Pregnancy test, urinalysis, FBC and CRP
TVUS, CA125 (in older women), AFP (if complex and worried about germ cell tumour)
d) Watchful waiting, then surgery if persisting.
Torsion - oopheropexy or salpingo-oopherectomy if severe/necrotic
Prolapse
a) Three types
b) Degrees of uterine prolapse
c) Presentation
d) Causes
e) Investigation and management
a) Anterior wall (cystocele), posterior wall (rectocele), uterine prolapse
b) - 1st (cervix into vagina),
- 2nd (cervix to level of introitus),
- 3rd (cervix outside vagina, i.e. below introitus),
- 4th (whole uterus outside vagina - complete procidentia)
c) Dragging, dyspareunia, stress incontinence
d) PROLAPSE: o Pregnancy o Race (Caucasian) o Oestrogen low/ obesity o Labour o Age/ anatomy o Pelvic surgery o Strain (cough, constipation) o Elastin/collagen (e.g. EDS)
e) - Sims’ speculum to assess
- Conservative (weight loss, stop smoking, pelvic floor exercises),
- vaginal pessary
- surgical repair + vaginal mesh
CTG interpretation (DR C BRAVADO)
- Define Risk - maternal (GDM, smoking), obstetric (pre-eclampsia, induction of labour, IUGR, PROM, foetal abnormalities, etc.)
- Contractions - duration and intensity (over 10 mins)
- Baseline RAte - normal (110 - 160)
- Variability - normal (5 - 25)
- Accelerations - present (normal), absent (only normal if no other abnormal CTG features)
- Decelerations - early (may be physiological), late (pathological), prolonged (pathological)
- Overall impression - reassuring, non-reassuring or abnormal
CTG: baseline rate
a) Normal range
b) Tachycardia (causes?)
c) Mild bradycardia (causes?)
d) Severe bradycardia (causes?) - treatment?
a) 110 - 160
b) > 160: hypoxia, chorioamnionitis, hyperthyroid, anaemia
c) 80 - 100 (for > 3 mins): post-term gestation
d) < 80 (for > 3 mins): FOETAL HYPOXIA - prolonged cord compression, cord prolapse, maternal seizures. If cause not found/treated - immediate delivery
CTG: variability
a) Why is it good?
b) Causes of reduced variability - 1 normal, 4 pathological
c) If reduced variability and late decelerations - likely cause?
d) Sinusoidal pattern
a) Foetus adapting to environment well with every beat
b) Foetus sleeping (should last < 40 mins), foetal acidosis, drugs (opiates, MgSO4), prematurity
c) Foetal acidosis secondary to hypoxia
d) Indicates severe foetal hypoxia. Poor outcome, requires immediate CS
CTG: accelerations
a) Define
b) Presence of accelerations good?
a) Abrupt increase of FHR > 15 bpm for > 15 seconds
b) Yes. If absent, but other features in CTG normal then this is okay.
CTG: decelerations
a) Define
b) Early - due to…?
c) Late (causes?)
d) Prolonged (management?)
e) Variable decelerations
f) If late decelerations present - what investigation should be done? If this is abnormal, what should be performed?
a) Abrupt decrease of FHR > 15 bpm for > 15 seconds
b) Normal physiological response to maternal contractions causing raised foetal ICP and increasd vagal tone. Resolves once uterine contraction ends
c) Begin at peak uterine contraction and recover after the contraction has ended. Indicate uteroplacental insufficiency (e.g. pre-eclampsia, maternal hypotension) causing foetal hypoxia and acidosis
d) > 3 mins: emergency CS
e) Usually caused by umbilical cord compression
f) Foetal blood sampling. If acidosis - emergency CS
Gynaecological history.
a) Pain history - key things to ask (SOCRATES)
b) Bleeding types
c) Other gynae symptoms
d) Systemic symptoms
e) In a gynae history, what 3 things MUST you ask?
f) Elaborate on these 3 components
g) PMHx/ PSHx
h) Obstetric history
i) DHx
j) FHx
k) SHx
a) - Cyclical pain? (coincides with period),
- Types: dyspareunia, pelvic pain, dysmenorrhoea
- Radiation to shoulder tip (?ectopic)
b) - Normal period (?dysmenorrhoea, menorrhagia)
- Inter-menstrual bleed (IMB) - STI, ?malignancy
- Post-coital bleed (PCB) - ?cervical Ca, STI
- Post-menopausal bleed (PMB) - ?endometrial Ca
c) - PV discharge - ?STI, malignancy (ask about colour, blood, smell, sexual hx)
- Vulval skin changes - ?infection, lichen sclerosis
d) - Urinary/bowel - ?pressure effects (eg. fibroid), prolapse, bloating/IBS (?ovarian)
- Systemic - fever (?PID), shock (?bleed, ectopic), weight loss (?malignancy), tiredness/SOB (?anaemia)
e) - LAST MENSTRUAL PERIOD (LMP),
- CONTRACEPTION, and
- CERVICAL SMEAR
f) Menstrual hx.
- Duration (ave: 5), frequency (ave: 21 - 35), menarche, menopause, flow (flooding?), associated symptoms
Contraception hx.
- type, barriers?, sexual partners, need for emergency
Cervical smear hx.
- last smear, any abnormal results?, HPV vaccine status?
g) - PMHx - pregnancies, ectopics. miscarriages, STIs, malignancy, bleeding disorders, VTE, migraine w. aura
- PSHx - abdominal/pelvic, LETZ, hysterectomy, CS
h) - Gravidy, parity
- Current pregnancy? - symptoms, scans, plans
- Previous pregnancies - dates, deliveries, complications
i) - Hormonal - HRT, contraception, etc.
- Other - TB drugs (affect COCP), recent ABx (?thrush)
j) - Malignancy - ?BRCA - ovary, endometrial, breast
- Bleeding disorder/ thrombophilia (?VTE)
k) - Smoking (>35 + 15/day = no COCP), alcohol, obesity (?PCOS)
