OBG Flashcards
What contraceptives should not be given in women < 20?
Why?
What complications/ side effects ?
Guidance?
Depo-provera = IM medroxyprogesterone acetate
= risk of young age osteoporosis
IUS/ Mirena
Both cause bleeding more days than usual initially + vaginal spotting between cycles
Most females amennorhoeic after use for 1 year
= reassure + advise to come if unscheduled bleeding is problematic
What do you if bleeding becomes problematic after IUS Mirena or Depo use?
COCP for 3 months (while still on depo)
Or
Mefenamic acid or trance mix acid for 5 days
What method of contraception is safe for under 20s?
Nexplanon = etonogestrel implant
COCP
POP
What contraception would you give in a female with learning difficulties?
NO PILLS = COCP POP
- may forget to take them
What are the contraindications of COCP use? (7)
Smoking
Obesity
Thromboembolism hx
Learning difficulty
Postpartum- if breastfeeding CI for 6 mo, if not 6 weeks.
Migraine with aura
HTN - even if well controlled (DONT GIVE)
What are long term methods of contraception?
When should they be avoided?
MIRENA + nexplanon
Avoid if woman has intentions to get pregnant within the next 6 months / nears future
What contraceptive is safe for use while breastfeeding?
POPs - given orally
Short term contraception
How long after delivery are contraceptive methods NOT required?
21 days
How is Depo given and how often?
When is it 1st line?
IM injection - once every 3 months/12 weeks
1st - SCA and Menorrhagia
What do you give young, non sexually active women that complain fo menorrhagia?
Tranexamic acid
What do you give young, non sexually active women that complains of menorrhagia + dysmenorrhea ?
Mefenamic acid
What do you give young, non sexually active women that complain of irregular menses +/- menorrhagia/ dysmenorrhea ?
COCP
Complaints of menorrhagia in female with SCD, what do you give?
Depo - provera
Medication for dysmenorrhea
Mefenamic acid
Medication for metrorrhagia?
COCP
Medication for menorrhagia only?
Tranexamic
What is the 1st line contraceptive method in a sexually active woman with dysmenorrhoea / or fibroids ( do not distort uterine cavity)?
Mirena
If contraindicated =
COCP/POP/implants (if no contraindications)
Uterine cavity distorted - implants = Nexplanon
Emergency contraception for a woman that presented within 3 days of the unprotected sex?
Levonelle pill
Emergency contraception for a woman that presented within 120 hours/5 days of the unprotected sex?
IUD copper
Or
EllaOne pill
What contraception reduces the risk of cervical ca?
Condoms
= reduce risk of HPV infections - therefore reduces risk of ca
How often should nexplanon be replaced?
Every 3 years
= progesterone only subdermal implants
Lower abdominal pain +recent amenorrhoea + vaginal spotting and cervical excitation
Empty uterus on vaginal US
Dx?
Ectopic pregnancy
Management of ectopic pregnancy
- stable
B-HCG
If >1400 - laparoscopy
<1400 - wait and observe - repeat vaginal US later
Management of ectopic pregnancy
- unstable (SBP<90)
Laparotomy - salpingectomy / salpingostomy
Pregnant women + hx of CS comes with profuse vaginal bleeding and severe abdominal pain
She is hypotensive and tachycardic
Dx?
Uterine rupture
Painless vaginal bleeding in late weeks of pregnancy
What do you suspect?
What do you do to rule it out
Placenta Previa
Do TVUS
Painful vaginal bleeding in late weeks of pregnancy + constant abdominal pain
Tender hard abdomen on examination
What do you suspect?
Investigation?
Placenta abruption
Do CTG
3rd trimester
Tachycardia + fever + history of PROM
offensive vaginal discharge
What do you suspect?
Chorioamnionitis
Lower abdominal pain + deep dyspareunia, menstrual irregularities and cervical excitation
Diagnosis?
PID
A women > 51 years old comes with dyspareunia + dysuria
She also complaints of hot flushes and night sweats
Dx?
How to you treat it ?
Suspect post menopausal syndrome
HRT
2ry amenorrhoea after chemo
What do you suspect?
Premature ovarian failure
Painless vaginal bleeding + high placenta
Dx?
Suspect cervical ectropion
Female >51 yo with postmenopausal vaginal bleeding
What do you suspect ?
What investigations are to be done?
Endometrial ca
TVUS - initially to check thickness If thick (>4 mm)- hysteroscopy + endometrial biopsy
What are the commonest cause of postmenopausal bleeding ?
Atrophic vaginitis
Vulvovaginal atrophy
Always TVUS to r/o endometrial ca
Woman of child bearing age + chronic pelvic pain + dysmenorrhea, deep dyspareunia and dyschezia
What do you suspect?
Treatment?
Endometriosis
-NSAIDS + paracetamol
- COCP trial
Laparoscopy - definitive treatment
High fever + lower abdominal pain No vaginal discharge Sexually active, does not use barriers What investigation should done? Dx?
Pelvic US
Turbo-ovarian abscess
Sudden unilateral iliac fossa pain + nausea + vomiting
+/- tender mobile mass
Dx?
Tx?
Ovarian torsion
Refer her to gybe or urgently take to theatre
African women with bloating and heavy regular periods
Enlarged uterus
What do you suspect?
Investigation
Fibroids
TVUS
Investigation for PCOS
Pelvic US
Chronic pelvic pain + worse on standing and during pms
+/- deep dyspareunia
Dx?
Pelvic congestion syndrome
It’s non-organic
Laparoscopy would be unremarkable
1ry amenorrhoea + cyclic pain
Mass in the lower abdomen
Dx?
Hematometra
- Accumulation of blood within uterus
When should VZIG be given ?
- immunocompromised w/ exposure
- pregnant w/ exposure and no VZ antibodies*
- newborns w/ peripartum exposure
*if exposed >2 days before rash appears + immune = reassure
When should oral acyclovir be given in VZV
Pregnant women with chickenpox
Immunocompromised with chickenpox
Pregnant woman , 2nd trimester + non immune + in contact with chickenpox child 7 days ago
Best management ?
VZIG
When is VZIG effective?
If given within 10 days after exposure
Pregnant woman in contact with chickenpox, develops rash
What do you give?
Oral acyclovir w/in 24 hrs
What is the infective period of chickenpox?
2 days before appearance of rash
What are the causes of 1ry postpartum hemorrhage? (4)
4 Ts
Tone - uterine atony = most common *
Trauma - lacerations, incisions, uterine rupture
Thrombin - coagulopathy
Tissues - retained products of conception
Management of uterine atony?
Uterine massage
Oxytocin - uterotonic
How soon after delivery can mirena/IUS be used?
Within 48 hours of delivery or
After 4 weeks - for fear of uterine perforation 2-28 days after birth
What causes shoulder tip pain in ectopic pregnancy?
Peritoneal bleeding + peritonism
Initial investigation in ectopic?
Urine pregnancy
If +ve = TVUS
- if empty uterus =b HCG
Management of ruptured uterus
Urgent laparotomy
Risk factors of uterine rupture (3)
Previous CS or uterine surgery **
Excessive oxytocin - uterotonics
Unrecognised obstructed labour
First investigation to be done in suspected placental abruption?
What is the management?
CTG
If distressed - urgent CS
If normal - vaginal US to r/o previa
Post menopause sx
Management :
- if uterus
- no uterus
Uterus - HRT or transdermal estradiol & progesterone patches
No uterus or IUS in place - oestrogen only HRT
*progesterone given w/ estrogen to protect uterus against endometrial ca
Post menopausal smoker - how is HRT given?
Transdermal
Oral has higher risk for VTE
What are the 2 types of HRT?
1- sequential /cyclical
= 1st 12 months of menopause/perimenopause
- oestrogen daily / progesterone cyclically
2- continuous combined HRT
= last menstrual > 12 months
- oestrogen + progesterone taken daily
What is chorioamnionitis?
Inflammation of foetal amnion and chorion membranes - typically due to ascending bacterial vaginal infection when there is ROM
Major RF for chorioamnionitis
PROM
Due to ascending bacterial infection
Features of chorioamnionitis
Hx PROM
Maternal tachy followed by fever
+ foetal tachy
Suprapubic tenderness/ and pain and contractions
Aminiotic fluid - purulent/offensive/foul smelling yellow or brown
*sometimes no fever because tachy occurs before
Fundal height landmark for 12 weeks
Public symphysis
Fundal height landmark for 20 weeks
Umbilicus
Fundal height @ 20-36 weeks =
GA in weeks +/-2 = ____ cm
Fundal height landmark @ 36-40 weeks
Xiphoid process of sternum
Cause of large for date uterus (4)
Hyatidiform mole
Concealed accidental hemorrhage
Tumours as fibroids/ ovarian cysts
Foetal malformations (hydrocephalus)
Cause of small for date uterus
Foetal death
IUGR
Pregnancy during amenorrhoea
Malpresentation - transverse lie
Any female <25 that uses Mirena + develops abdominal pain and irregular menses
Suspect -
PID
What is a major RF for PID
-IUS - mirena
=allleviate symptoms of endometriosis adenomyosis and fibroids
*IU system = mirena IUDevice = copper T
Features of trichomoniasis
trichomonas vaginalis frothy yellowish- greenish smelly vaginal discharge \+ vaginal itching On examination - strawberry cervix Vaginal pH >4.5
Treatment of trichomoniasis
Oral metronidazole
Features of bacterial vaginosis
Grey-white fishy, thin discharge VERY offensive Itching uncommon \+ve whiff test - potassium hydroxide Vaginal pH >4.5
Whiff test for diagnosis of ?
Bacterial vaginosis
Gardnerella vaginalis
Treatment of bacterial vaginosis
Metronidazole + clindamycin
What is the normal vaginal pH
3.8 - 4.5
Thick white cottage cheese discharge
Odourless
Vaginal pH 4-4.5
Diagnosis?
Vulvovaginal candidiasis
- Candida albicans
Treatment of vaginal candidiasis
Local clotrimazole
Most common abnormal vaginal discharge in chilbearing age
Bacterial vaginosis
What is Amsel’s criteria?
Diagnostic criteria for BV - 3/4 = diagnosis
- homogenous grey white discharge
- positive whiff test ( fishy smell when you add koh)
- clue cells on microscopy
- vaginal pH > 4.5
Prolonged amenorrhoea in a woman <40
Suspect-
Diagnostic investigation
Treatment
Premature ovarian failure
Ix - FSH
FSH > 25 IU/L on 2 occasions 4 weeks apart - diagnostic
T - HRT until 51 years old
What is early menopause?
Investigation
Amenorrhoea in 40-45 years old
I - US
Presentation of premature ovarian failure
Amenorrhoea / oliguria - commonest presentation
Postmenopausal features
Infertility
Cause of POF
Most common - idiopathic
Can occur after chemo !
Presentation of atrophic vaginitis
Atrophic vaginitis = vulvovaginal atrophy = genitourinary syndrome (GSM)
Urinary = dysuria, frequency, incontinence, etc
+/-
Dyspareunia, vaginal itching/dryness
Cause of atrophic vaginitis
Treatment
Oestrogen deficiency after menopause
Treatment = topical oestrogen (intravaginal or cream)
- if + other menopausal symptoms = HRT or transdermal oestradiol + progesterone patch
Screening test for colorectal ca
Age it is done + frequency
Fecal immunochemical test (FIT)
60-74, every 2 years
Breast cancer screening test
Age it is done + frequency
Mammogram
50-70, every 3 years
If high risk - 40-70 years, annually .
Cervical ca screening test
Age it is done + frequency
Pap smear , cervical smear - cytology, HPV
25-49, every 3 years
50-64, every 5 years
Cervical ectropion management
***Reassure if there is NO bleeding or pain after sex
If symptoms are bothersome - do cervical smear
= if normal - cryotherapy, diathermy, cautery with silver nitrate
It is not a risk factor for cervical ca
What is a cervical ectropion
Stratified squamous ectocervix is replaced by
I
Columnar epithelium
= happens in high oestrogen states = pregnancy COCP puberty
Asymptomatic , but can have painless vaginal bleed or non purulent watery discharge post-coital
Symptomatic ectropion
Next step?
Refer to colposcopy
Pre-eclampsia
- def
- RF
- Tx
HTN + proteinuria > 0.3g/24 hr
Usually after >20th week gestation
RF - 1st pregnancy , pregnant teens, women >40
Tx - no cure! Except for delivery !
Mild - conservative treatment to allow baby to mature under close monitor
Medications given in pre-eclampsia
MgSo4 to prevent seizures
Corticosteroids to allow for baby maturation
Labetalol to lower BP
Foetal complication of pre-eclampsia
Risk of pre-term delivery
Oligohydramnios
Sub -optimal foetal growth
Maternal complication of pre-eclampsia
Liver + kidney failure
Clotting disorders
HELLP syndrome
What is HELLP syndrome
Complication of preeclampsia
Hemolysis - low HB
Elevated Liver enzymes
Low Platelets
Features - epigastric/RUQ pain +- NV =/- dark urine (hemolysis) =/- HTN
Treatment of HELLP
Deliver baby
MgSo4 if seizures develop
Features of AFLP (acute fatty liver of pregnancy)
ELLP - raised liver enzymes + low platelets
Low glucose
+- raised ammonia
Features of Disseminated intravascular coagulation (DIC) on labs
High PT PTT & bleeding time
Low platelets & fibrinogen
DIC triggers
Sepsis, surgery, major trauma, cancer , complications of pregnancy
Post menopausal bleeding
Initial test
Diagnostic/ most definitive step
Most likely dx
Initial - TVUS
Def - hysteroscopy with endometrial biopsy
Dx - atrophic vaginitis but most worrisome is endometrial ca
Risk factors for endometrial ca (7)
Obesity Nulliparity Unopposed oestrogen (oestrogen, no progesterone) PCOS Tamoxifen Early menarche Late menopause DM
What can reduce risk of endometrial ca
Progesterone
What is antiphospholipid syndrome associated with
What can be done?
Recurrent miscarriages
- to avoid = give aspirin + LMWH
Who should you screen for antiphospholipid syndrome
Females w/ recurrent abortions ( 3 or more miscarriages) in 1st trimester (<13 weeks HA)
+
1 o more abortions in 2nd trimester
What does screening for antiphospholipid syndrome include
Lupus anticoagulants
Anti-cardio lip in antibodies
Anti-B2 glycoproteins -1 antibodies
Clinical features of endometriosis
Chronic pelvic pain
Dysmenorrhoea
Deep dyspareunia
Can have sub fertility, urinary symptoms and dyschezia
Gold standard investigation / most definitive investigation
Laparoscopy
Management of endometriosis
1st line - NSAID /paracetamol
If it doesn’t help - hormonal treatment
= COCP trial or progesterone 3-6 months before laparoscopy
If fertility is an issue - lap first
Causative organisms of PID
Chlamydia trachomatis - most common
Neisseria gonorrhoea
Features of PID
Pelvic/ Lower abdominal pain Fever Deep dyspareunia Cervical excitation Vaginal/cervical discharge Dysuria + menstrual irregularities
Investigation for PID
Chlamydia + gonorrhoea screening
Common risk factors for PID
<25 years old IUS Multiple partners Previous STIs Uterine instrumentation
Complications of PID
Infertility - 10-20 % risk
Turbo-ovarian abscess = if left untreated or not treated properly
Ectopic pregnancy
Chronic pelvic pain
Lower abdominal pain + tenderness + high fever
No discharge
Suspect?
What investigation to be done?
Turbo -ovarian abscess
Pelvic ultrasound
Management of PID
Outpatient
- oral ofloxacin + oral metronidazole
Inpatient
-IM ceftriaxone + oral doxycycline + oral metronidazole “CDM”
Treatment of cervicitis
Chlamydia
N.gonorrhoea
Chlamydia - doxy (1st line) 100 mg bid 7 days
2- or azithromycin 1g PO + 500 mg PO OD for 2 days
Neisseria gonorrohea
- ceftriaxone 1gm IM single dose
Or
Cipro 500mg PO single dose
Difference between cervicitis & PID
Cervicitis - has vaginal discharge , no ascending infection so no pelvic pain
PID involves adnexa and genital structures - pelvic pain, deep dyspareunia, cervical excitation
What are the 5 Ds of endometriosis
Dysmenorrhoea Dyspareunia Dyschezia Dysuria Dull chronic pelvic pain
When does intermenstrual spotting settle in women on depo
What should you do if it becomes bothersome
After a year of use
Depo is given once every 3 months
———
COCP 3 months or mefenamic acid for 5 days
Treatment of stress incontinence
Caused by weak tone -
- Pelvic floor excercise s ( 8 contractions, 3x day for at least 3 mo)
- if ^ fails - retro public mid urethral tape = free tension vag tape
- Duloxetine
Treatment of urge continence
Cause = detrusor over activity
Bladder retraining - gradually increase time between voiding for 6 weeks
Meds - antimuscarinin = oxybutynin
What does tamoxifen increase the risk of
What is it used for
Endometrial cancer
Used for - breast ca tx, prevents bone loss (osteoporosis)
What is the most alarming symptom in patients on tamoxifen
Vaginal bleeding
What can be given with tamoxifen to reduce risk of bone mets
Bisphosphonates
What is threatened abortion
Vaginal bleeding + closed os
Visible foetal heart threatened
What is an inevitable abortion
Open Os + ongoing bleeding
No way to save it
Delayed/ missed abortion is ?
Foetus is dead - silently before 20 weeks
OS is closed
There may not be vaginal bleeding
Incomplete abortion is
On US there are still products of conception
What is a complete abortion?
On US, the uterus is empty
Difference between miscarriage and still-birth
<24 weeks - miscarriage
> 24 weeks - abortion
When is the foetal heart usually seen?
6 weeks
What is post-pill amenorrhoea
When should you be concerned - and what is to be done?
Amenorrhoea after cessation of COCP - normally for 3-6 months
If it persists >6 months — check FSH (esp if younger than 40)
If FSH > 25 IU/L - suspect POF
Abnormal labs in premature ovarian failure
FSH, LH - increased
Estradiol - <50 (decreased)
Prolactin - normal
Anemia in pregnancy : 1st trim 2nd trim 3rd trim Postpartum
1 -<11g/dl
2 & 3 - <10.5 g/dl
Postpartum < 10
1= 1-13 weeks (first 3 months) 2= 14-26 weeks (4,5,6) 3= 27-40 weeks (7,8,9)
Treatment of postpartum anemia
Ferrous sulphate - even if patient is asympromatic
Medication to control HTN in preeclampsia
Labetalol
If contraindicated *asthma - give nifedipine
Management of eclampsia
Regimen + doses
If recurrent
Control/prevent seizure - MgSo4
If another fit occurs- give another IV bolus dose
Regimen =
- 4g in 100ml .9% NS by infusion pump over 5-10 minutes
- 1g/hr maintenance for 24 hrs after last seizure
Recurrent - give further 2g MgSo4 bolus of increase infusion or 1.5-2 /hr
Symptoms of MgSo4 overdose
Loss of deep tendon reflex
Nausea
Vomiting
Confusion
Deep tendon reflexes
biceps C5/6 brachioradialis - C6 triceps - C7 patella - L4 achilles - S1
Treatment of MgSo4 overdose
Stop MgSo4
Urgent serum MgSo4
If ongoing seizure - give diazepam
Antidote = ** calcium gluconate**
Deliver baby if seizure has been managed and patient is stable
What is turtles sign
Where can it be seen
Management
Retraction of the foetal head immediately after it emerges
Shoulder dystocia
= call for help - episiotomy- rotation manoeuvres
Management +Manoeuvres in shoulder dystocia
- Call for help! + discourage pushing
SD- usually due to imp action of anterior foetal shoulder on maternal pubic symphysis - Mc Roberts - flexion + abduction of maternal hips / thighs towards abdomen
- Suprapubic pressure
Episiotomy - for better access of internal manoeuvres
= deliver posterior arm or internal rotation
Risk factors for shoulder dystocia (5)
Macrosomia = >4,5kg Maternal BMI >30 Maternal DM Hx of prev SD Prolonged labour
Dx of hyperemesis gravidarum
Severe/prolonged NV in pregnancy
8-12 weeks gestation (up to 20 weeks)
Treatment of hyperemesis gravidarum
What should you look for
F>A>S>T - fluids , antiemetics, steroids,thiamine
IVfluids - 1st step - NS.9% if k+ low add 20-40 kcl
Antiemetic - 1.zines , 2. Metoclopramide, ondansetron , 3. Steroids
Thiamine to prevent wernickes
Look for - ketonuria, tachycardia, weight loss, sunken eyes, loss of skin turn or and a prolonged capillary refill
What are the possible complications?
Wernicke’s encephalopathy
- thiamine added in later management
Mallory Weiss tear due to severe vomiting
What recommended vaccines should pregnant women receive
When should they be given?
Influenza + pertussis (DPT + influenza given)
B/w 20-32 weeks
What vaccines should HIV patients avoid
BCG, yellow fever vaccine
If CD4 < 200 avoid MMR as well
What are the stages of labour
Stage 1 = onset of true labour - full dilation of cervix
2 phases
- latent = 0-3cm dilation usually takes 6 hrs
- active = 3-10 cm dilation - normally 1cm/hr
Stage 2 - full dilation to delivery
Stage 3 - after delivery to delivery of placenta
Normal head delivers in what position
Occipital-anterior
If labour stuck in latent phase i.e 3cm with no further dilation/ poor progress
What should be done?
Amniotomy - if water hasn’t broken IV oxytocin (syntocinon)
Bilateral cystic mass on pelvic US + 1st trimester bleeding
Uterus = large for date + hyperemesis
Suspect?
Hyatidiform mole
Bilateral cystic masses = theca lutein cysts
Types of gestational trophoblastic disease
1. Hyatidiform mole = 2 types - -complete - b HCG will be extremely high can lead to hyperemesis - partial 2. Gestation trophoblastic neoplasia = choriocarcinoa, invasive mole - this type is malignant and needs chemo
Management of molar pregnancy
Surgical evacuation - products of conceptions examined to confirm dx
Check HCG every 2 weeks
- no pregnancy allowed until HCH normal ** strict contraception/barrier
What does the snowstorm appearance of molar pregnancy represent
Hydropic villi and intrauterine hemorrhage
What is an advanced complication of sapling it is (PID)
Turbo-ovarian abscess
- lower abdominal pain + tenderness + high fever + no discharge
Vitamin that reduces risk of having a baby with teratogenic effects (neutral tube defect)
Folic acid
Dosage of folic acid in pregnancy
400 ug/ 0.4mg , once a days for 12 weeks of pregnancy
When should 5mg of folic acid be given in pregnancy?
for 12 weeks: DM BMI >30 On antiepileptics Family History of NTD Previous pregnancy w/ NTD
For whole pregnancy :
Thalassemia or thalassemia trait
Sickle cell disease
Initial next step in uterine or tubal perforation
US abdomen and pelvis
Can’t wait for a CT
Third trimester bleeding (painless) after intercourse
Everything else is normal
Dx?
Placenta previa
What is Rhesus isoimmunisation
Rh -ve mother carrying Rh +ve child
Leak of foetal RBCs - anti-D IgG antibodies in mother
= isoimmunisation
So the mother is sensitised
Next pregnancy - the antibodies can cross placenta and cause
- hemolysis (anemia)
- hydrous fetalis (oedema)
Rhesus -ve mother is pregnant
Last pregnancy had Rh +ve baby
What would need to be done?
US to assess Middle cerebral artery
= this is to estimate foetal Hb (severity of anemia)
If abnormal - fetacl cord sample to quantify Hb
Baby born to Rhesus -ve mother develops severe jaundice soon after birth
She did not receive any IM injections in her previous pregnancy
What is the cause of the jaundice?
Rhesus incompatibility
Hemolysis - jaundice
How soon should anti D immunoglobulin be given ?
ASAP - always within 72 hrs of giving birth
Birth = sensitising event
Causes of jaundice in 1st 24 hrs
Rh incompatibility
ABO incompatibility
Hereditary spherocytosis
G6PD deficiency
When should anti D be give in non sensitised Rh -ve mothers?
28 & 34 weeks
Anti D should be given ASAP in what situations? (7)
Always within 72 hours
Delivery of RH +ve infant = live/stillborn
Any termination of pregnancy
Miscarriage if gestation >12 weeks
Ectopic
Antipartum hemorrhage
Amniocentesis / CVS/ foetal blood sampling
Abdominal trauma
What tests should be done for babies born to Rh -ve mothers
Cord blood @ delivery
Full blood count
Direct Coombs test
= direct antiglobulin- demonstrates antibodies on RBCs of baby
Complications of babies born to Rh -ve mothers (4)
Treatment?
Hydrous fetalis
Jaundice, anemia , hepatosplenomegaly
Heart failure
Kernicterus
Tx - transfusion, UV phototherapy
Gold standard dx of endometriosis
Treatment
Laparoscopy
NSAID/ paracetamol / COCP trial, IUS
Surgical - laparoscopic excision
- endometriosis - chronic, cyclical pelvic pain + dyspareunia
Risk of pregnancy in laparoscopic tubal sterilisation
1:200 = 0.5%
Contraceptive with lowest failure rate
1.Etonogestrel contraceptive implant ** 0.05%**
= implanon,nexplanon
- Mirena - levonorgestrel IUS - 0.2$
What is a pearl index?
No of contraceptive failures/ 100 women
= no. Of total accidental pregnancies
__________________________________
Total months of exposure
Failure rate of tubal ligation
5%
Absolute risk of pregnancy with Mirena
None
- absolute risk does not increase with any contraceptive method
Mirena increases relative risk of ectopic
= 1:20
Cervical screening ages + frequency
25-49 - every 3 years
50 -64 - every 5 years
Pap smear / cervical smear
Borderline or mild dyskaryosis on cervical smear
Management
Test original sample for HPV
If + = patient referred for colposcopy
If -ve = goes back to routine recall
Inflammatory changes without dyskaryosis seen on Pap smear
Next step?
Repeat smear in 6 months
Moderate dyskaryosis on Pap smear
Management
=CIN II
Refer for urgent colposcopy within 2 weeks
Severe dyskaryosis on Pap smear
Next step
= CIN III
Urgent colposcopy w/in 2 weeks
Suspected invasive cancer on Pap smear
Colposcopy w/in 2 weeks
Inadequate sample of Pap smear
Next step
Repeat smear
- if persistent ( 3 inadequate samples)
= assess by colposcopy
Women who have been treated for CIN I/II/II - when should they come back for ‘test of cure’?
After 6 months of treatment
Cervical smear is Normal
Swabs negative for chlamydia and neisseria
US normal
Cervix appears normal
But patient has abnormal intermenstrual bleeding > 6-8 weeks
Next step?
Refer for colposcopy
When is termination of pregnancy legal?
Before 24th week of gestation
(23 weeks +6 days)
Unless it is life saving or evidence of extreme foetal abnormality
Or risk of serious physical/mental injury to the woman
Legal aspects of abortion
What must be done?
2 registered medical practitioners must sign legal document
1 is needed in case of emergency
Only a registered medical practitioner can perform an abortion - must be done in NHS hospital or licensed premise
Methods of abortion
<9 weeks
<13 weeks
>15 weeks
- Mifepristone = anti-progestogen (RU486)
- given + 48 hrs later prostaglandin given to stimulate contractions - Surgical dilation and suction
- Surgical dilation and evacuation or later medical abortion (mini labour)
Ages of consent that are valid for termination
Pregnant females 12-15
- if they understand all aspects of procedure + physical/mental likely to suffer if they don’t receive termination
(Pregnancy should be <24 weeks)
> 16
Amenorrhoea and all labs are normal
(LH FSH estradiol prolactin)
Cause?
Absent uterus
Amennorhoea +
Raised LH & FSH (ratio >2:1)
Normal/raised estradiol
Cause?
PCOS
Raised FSH on 2 separate occasions + amenoorhoea
Low LH and estradiol
Dx?
Premature ovarian failure
Amenorrhoea +
Raised FSH LH ; Low estradiol
Possible causes?
Turners syndrome
= ovarian failure days genesis - no working ovaries - low oestrogen
Absent ovaries
Primary amenorrhoea + LH FSH and oestrogen are normal
What should you suspect ?
Absent uterus ( congenitally like in mullerian agenesis)
Most important RF in ovarian ca
Family history
Most important RF in bladder ca
Smoking
Most important RF in colorectal ca
Age > family history
Ovarian ca RF (3)
Family history - BRCA1 BRCA2 genes (autosomal dom) Increased ovulation ( early menarche, late menopause, nulliparity) Age
Anything that increases ovulation increases the RF and vice verse
Pregnancy and COCP are protective
Physiological jaundice vs prolonged
Day 2-14 , commonly seen in breast fed babies
Prolonged = > 14 days
Tests done in prolonged jaundice
Conjugated + unconjugated bilirubin - most imp
=Raised conjugated = could indicate biliary atresia - urgent intervention
Direct anti globulin test - Coombs
Thyroid fn
FBC + blood film , U&Es , LFT
Causes of prolonged jaundice (6)
Biliary atresia Hypothyroidism Galactosemia UTI Breast milk jaundice Congenital infections - CMV, toxoplasmosis
What should you suspect in a case of heavy and irregular vagina bleeding over the age of > 40?
What do you do ?
Endometrial hyperplasia
- TVUS, if endometrium is thick — hysteroscopy + biopsy
Endometrial hyperplasia w/o atypia
What is the 1st line of treatment
Mirena
-progesterone decreases the thickness caused by excess estrogen
Dx of POF
Tx
FSH measured x2, 4 weeks apart
If both are raised - POF
Hx of amenorrhea + hot flushes / night sweats in woman <40
Tx - HRT until age 51
Types of fibroids - what are their approaches
Which is most common?
Submucosal / Subserosal / Intramural* (Commonest) Hysteroscopic myomectomy (SM)/ laparoscopic (SS)
SM - into uterine cavity SS - outside uterus IM - within muscle layer
Features of fibroid (6)
Fibroid = benign smooth muscle tumour -Afro carribean Menorrhagia Bloating Asymptomatic/ lower abd pain /cramping Urinary sx (frequency) Subfertility
Dx of fibroid
Management
TVUS - dx
Management -
Mirena IUS - shrinks fibroid, manages bleeding
= for women that don’t want to get pregnant currently + fibroid is small , uterine cavity not distorted
^ if CI - uterine ablation (but affects fertility )
To save fertility - myomectomy
Who should NOT be given the following :
COCP Mirena and Depo-provera
Hx of pulmonary embolism
Migraine with aura
Hysteroscopic vs abdominal myomectomy
Hysteroscopic - for submucosal (project into uterus)
Abdominal - subserosal (project outside uterus)
Most successful option for treatment of fibroid
Hysterectomy
Treatment options fibroid
Hysterectomy
Uterine artery embolisation - saves fertility but myomectomy preferred
Endometrial ablation - if fibroids < 3 cm , does not save fertility
= considered if 1 st line treatment CI
GnRH agonist - used before surgery to shrink fibroid and decrease post op bleeding
Test used to assess ovulation in female w/ 28 day regular cycle
Day 21 progesterone
= mid lateral progesterone level
Progesterone> 30 nmol/l = ovulation
(1 week before expected start of cycle)
** cycle = 28 = 28-7 = day 21
Cycle 32 - 31-7 = day24
Cycle 35 - 35-7 = day 28
Safest antihypertensive in pregnancy
Labetalol
Retained products of conception can lead to
Endometriosis (. Uterine infection )
Features of endometritis (3)
Fever* may not always be present
Foul smelling vaginal discharge + bleed
24hrs - 12 weeks after delivery
RFs of endometritis (3)
Emergency CS
Prolonged labour
After surgical termination of pregnancy
Investigation + Treatment of endometritis
I - HVS
T- co-amoxiclav
Iceberg tip sign + flat-fluid level on US
Unilocular
Dermoid cyst
Echo genie tubercle projecting into cyst lumen on US
Dx?
Ovarian teratoma
Observations after removal of hyatidiform mole
BHCG every 2 weeks until normal
No pregnancy should happen until this happens
Features of PCOS (6)
LH:FSH >/= 2:1 - both raised Increased insulin - acanthosis Increased androgen - and , hirsute Sam Amenorrhoea/ oligomenorrhoea Infertility / subfertility Obesity
Management of PCOS
General - weight loss
Menstrual irregularity - COCP , mirena , weight loss
Infertility - weight loss, clomifne citrate (1st line)**+ metformin
Other - laparoscopic drilling
** if main complaint heavy bleeding = mirena or COCP
Initial step of management in PCOS
Always weight loss
Gestational HTN vs pre-eclampsia
Preeclampsia - HTN after week 20 + any of the following
Significant proteinuria >.3g/24hr
Protein creatinine ratio > 30 mg/mmol
Albumin creatinine ratio > 8mg/ mmol
AFP marker for
Liver (HCC)
Teratoma of testicles/ ovaries
LDH is a marker for
Testicular seminoma
CA199 marker for
Pancreatic ca
CA 15-3 marker for
Breast ca
CA 125 marker for
Ovarian ca
CEA marker for
Colorectal ca
Dyspareunia + dysuria_ frequency in a woman > 51
Also complains of vaginal itching
Tx?
Atrophic vaginitis - topical estrogen cream
Tender white plaque on vulva
Itchy, especially at night
Treatment ?
Lichen sclerosis
Topica steroids + F/U
Treatment of vaginal thrush
Topical clotrimazole
Yellow - greenish offensive discharge + itching
Strawberry cervix
Ph > 4.5
Treatment
Trichomoniasis vaginalis
- metronidazole
Offensive discharge - no itching
Fishy smell
Ph >4.5
Treatment
BV - metronidazole
Chronic pelvic pain , worsened by standing and premenstrually
Post coital ache
Dx?
Pelvic congestion syndrome
Investigation are unremarkable
Treatment of PMS
COCP
Recurrent miscarriage in 1st trimester
Suspect -
What do you give to prevent further miscarriage
Antiphospholipid syndrome
Give LMWH + aspirin
PID treatment
Outpatient - OM
Oral ofloxacin + oral metronidazole
To
IM ceftriaxone + oral doxy + oral metronidazole
In - CDM
Ceftriaxone + doxy + metronidazole
Failed at home treatment of PID
What do you do?
Admit
Give IV ceftriaxone + oral doxycycline
Features of molar pregnancy (4)
Large for date uterus + +ve pregnancy
Hyperemesis
Vaginal bleeding 1st trim
Passage of vehicle through vagina
Pain management in pregnant women
Paracetamol
Involve consultant if she needs more
Most common STI in the UK
Chlamydia
Treatment o chlamydia cervicitis
Doxycycline 100mg BID 7 days
Most appropriate investigation of cervicitis
What can happen if it is left untreated
Endocervical swab
Vulvovaginal swab
Untreated - sapping it is
Missing IUD threads - can’t be seen on speculum
What do you do next?
TVUS
If you still can locate it do an abdominal XR
ABx that are safe and not safe in pregnancy
Macrolides - erythromycin = safe
Trimethoprim - anti folic acid - CI in 1st trimester
= risk of teratogenicity , if used give 5mg folic acid
Nitroufuratoin - CI near term (1 week before + 1 week after delivery)
=risk of neonatal hemolysis
Avoid cipro - risk of arthropathy
ABx for UTI that are safe in pregnancy
Amoxicillin
Cefalexin
Macrolides
P450 enzyme inducers
CRAP GPs
- decrease warfarin effec - decrease INR
Can’t be used w/ COCP unless additional contraceptive method used -IUS IUD
Carbamazepine, rifampin, chronic alcohol, phenytoin, griseofulvin, phenobarbital , sulfonylureas
P45 enzyme inhibitors
Increase effect of warfarin, can be used with COCP
SICK FACES
Sodium valproate, isoniazid, cimetidine, ketoconazole, fluconazole, acute alcohol, chloramphenicol, erythromycin (macrolides), sulfonamides, cipro, omeprazole, metronidazole
Treatment of TB in pregnancy
RIPE
But avoid streptomycin - harmful to foetus
Tx of chlamydial cervicitis in pregnancy
Erythromycin
Instead if doxy or azithromycin
Cyclical pain + 1ry amenorrhoea
Hematometra
- blood accumulates within uterus
- imperforate hymen , transverse vaginal septum
Secondary PPH
12hrs - 12 weeks after delivery
Due to retained placental tissue or endometritis
Most common cause of 1ry PPH
Uterine atony - 90% of cases
Treat of MgSo4 overdoes
Stop MgSo4
- get serum level checked
Give diazepam - if ongoing seizure
Calcium gluconate- antidote
Gold standard of endometriosis dx?
Laparoscopy
Preferred laxative in pregnancy
Lactulose - osmotic laxative
Ispaghula 1 st line, Lactulose 2nd
Constipation management in general
- Lifestyle - water, diet , excercise
1st line - senna
Pregnancy - ILS
I ispaghula , Lactulose, senna
2+ proteinuria in pregnant woman > 20 weeks
Normotensive
What do you do?
Urgent referral to 2ry care - same day w/in 24 hrs
1+ proteinuria in pregnant woman > 20 weeks
Normotensive
What do you do?
Reassess in GP clinic after 1 weeks
Gestational HTN
Management
New HTN after 20th week w/o significant proteinuria
Mild - 140/99 - 149/99 - observe , no meds
If > 149/99 - oral labetalol 1st line
= nifedipine if CI
If ^ CI = methyldopa
Routine bloods at antenatal booking
HIV
Hepatitis B
Syphilis screen
FBC, blood group
Vaccines recommended in pregnant women
Influenza + pertussis
Inflammatory changes w/o dyskaryosis
What do you do
Repeat smear in 6 months
Borderline or mild dyskaryosis
Next step
Retest original sample form HPV
If +ve - colposcopy
Moderate/sever dyskaryosis
Suspected invasive ca
Urgent colposcopy within 2 weeks
Inadequate cervical smear sample
Repeat smear
If 3 samples in adequate - colposcopy
Loading dose of MgSo4 in eclampsia fit
Regimen?
4g MgSo4 in 100 ml 0.9% NS - infusion pump over 5-10 mins
^load
Regimen:
1. Loading dose
2. 1g/hr MgSo4 for 24 hrs after last seizure- maintenance
3. Recurrent seizure - further 2g bolus or increase infusion to 1.5-2g/hr
Young non sexually active women : 1.Menorrhagia only 2.Menorrhagia + dysmenorrhoea 3.Metrorrhagia +/- menorrhagia/dysmenorrhoea Treatment
- Tranexamic acid
- Mefenamic acid
- COCP
Sexually active female w/ menorrhagia/dysmenorrhoea/ fibroids not distorting uterine cavity
1st line treatment
Mirena IUS
If CI/ no long contraception wanted - COCP (if no CI for that)
Uterine cavity distorted - nexplanon (implants)
Sickle cell - Depo
post-partum thyroiditis treatment.
Manage symptoms
Palpitations and tremors = propanolol
Usually resolves on its own in 1st year after delivery
Cervical ectropion bleeds on touch
Next step?
Colposcopy
If last smear >3 years ago -order smear
What are the antiphospholipid antibodies?
Lupus anticoagulants
Anti-cardiolipin antibodies
Anti-B2 glycoproteins 1 antibodies
Folic acid dose in DM pregnancy
5mg for first 12 weeks
Postmenopausal HRT
No uterus or IUS in place - oestrogen only HRT
Otherwise combined HRT
If smoker - give transdermally as oral router higher risk of VTE
Meigs syndrome
Ascites
Pleural effusion
Benign ovarian tumour
Early pregnancy w/ no feta, cardiac activity on TVUS
What next ?
Measure CRL and gestational sac diameter
CRL <7mm or GSD<25mm - repeat TVUS in 1 week
CRL >/=7mm or GSD >/=25mm -2nd opinion , rescan in 7 days
UKMEC categories
1- breast feeding after 6 months, varicose veins
2- smoking, BMI >30
3- migraine with aura = absolute CI
1- no restrictions , safe
4- absolute CI
Contraceptive method in migraine with aura
IU copper device and barrier methods
2. POP, IUS, DMPA
Moderate to high risk of developing preeclampsia (11)
What should be given?
Hx of HTN or pre eclampsia FHx of pre eclampsia Pregnancy >40 yrs BMI > 35 CKD , chronic HTN , SLE , antiphospholipid syndrome Pregnancy interval >10 years Dm Twins, triplet pregnancy
Aspirin 75-150 mg daily from week 12 until delivery
Contraception for woman with history of DVT
IUCD,
Safest contraception
IUCD
Herpes tx in pregnancy
1st Time
1st time -
- 1st + 2nd trim
=oral acyclovir 400 mg TID 5 days
= + from week 36 onwards 400mg TID to reduce neonatal transmission
3rd trim - same as ^ +CS preferred method of delivery
Herpes tx in pregnancy - recurrent
from week 36 onwards 400mg TID
Risk of neonatal herpes is low even if lesions are present
Initial management of single prolonged deceleration
Switch to lateral left decubitus position
IV fluids
Prepare for CS as needed
Tx UTI in pregnancy
Nitrofurantoin unless CI
Cefalexin
Amoxicillin
When should serum CA 125 be checked as 1st step
Any woman 50 or over + 1 of the following : Abdominal distension/ bloating Loss of appetite or early satiety Pelvic or abdominal pain Increased urinary urgency/frequency
*check CA125 and then do US
Lowest failure rate contraception
Etonogestrel contraceptive implant 0.05%
Mirena 0.2%
Both better than tubal ligation
PCOS, Tried COCPs but develop side effects
Suggested contraception
Norethisterone
Missed pill (POP) What do you advise
Take next dose ASAP
Continue taking at usual times
Use condoms if having intercourse for 48 hrs of restart time
Missed pill COCP
What do you advise
1 missed
2 or more missed
1 missed -
Take next dose ASAP - even if 2 pill a day
Continue taking as usual
2 or more missed -
Take next dose ASAP - even if 2 pill a day
Use condoms or abstain from unprotected sex for 7 days
Emergency contraception if in week 1 ONLY
If missed in week 3 - omit pill free interval
Pelvic organ prolapse
- stage 1
- stage 2
Management
1- prolapse above introitus
2- until level of introitus
Try pelvic floor muscle training - 16 weeks = 1st option for. Symptomatic pelvic organ prolapse
Vaginal pessary as additional treatment
Migraine w/ aura in woman on COCPS
Most appropriate action
Advise her to switch to POPs
Initial investigation for :
-Menorrhagia w/ no other complaints; uterus not palpable on examination
- menorrhagia + no other complaints ; uterus is palpable on abdominal exam
1- FBC
2- pelvic US -= look for submucosal fibroids
Normal cervical smear cytology + positive screeen for HPV
What should be done ?
Re-screen for HPV in 12 months
If cytology abnormal - refer for colposcopy
