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OBG Flashcards

1
Q

ECTOPIC PREGNANCY

A

R/L illiac fossa pain
with pain radiating to shoulder due to peritoneal bleeding
amenorrhoea > 6 weeks
O/E : adnexal mass , cervical tenderness and tender abdomen

T/t : 1) Haemodynamically stable : laparoscopic salpingectomy or salpingostomy
2) Haemodynamically unstable (<90/60mmHg) : immediate laparotomy

RARELY METHOTREXATE

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2
Q

Investigation in Ectopic

A

Inv: Beta HCG raised very much
USG ABDOMEN : EMPTY UTERUS ALTHOUGH POSITIVE PREGNANCY TEST WITH FREE FLUID IN POUCH OF DOUGLAS

REPEAT BETA HCG IN 48 HOURS IF USG FINDINGS ARE NOT

CONFIRMATIVE OF ECTOPIC PREGNANCY OR BETA HCG < 1500

NB : REQUIRES TO DO REPEAT BETA HCG IN 48 HOURS IF BETA HCG NOT >1500 , AND IF USG NOT CONCLUSIVE OF ECTOPIC PREGNANCY

Free fluid in Pouch of douglas - RUPTURED ECTOPIC

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3
Q

ECTOPIC PREGNANCY AND IUD

A
  • Absolute Risk OF Ectopic Pregnancy : absolute meaning in term of getting pregnant at all
    Without IUD&raquo_space;> WITH IUD
  • Relative risk Of Ectopic Pregnancy : relative meaning in relation to
    With IUD&raquo_space;»Without IUD
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4
Q

RISK FACTOR FOR ECTOPIC PREGNACY

A

Highest in PID then IUD ….

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5
Q

MISCARRIAGES

A

COMPLETE : Massive bleeding PV + Passage of clots
TVS : Empty uterus no retained products of conception

INCOMPLETE: Bleeding PV + h/o passage of pdts of conception
TVS: Products of conception seen on the uterus but no viable fetus

INEVITABLE : Bleeding heavily + Open cervix
TVS: Fetus present +/- heart beat and miscaarriage is inevitable

MISSED : Pain / bleeding or both
TVS: Fetus without heart beat

THREATENED: Bleeding PV + fetal heart seen on usg

REPEAT URINE HCG AFTER 3 WEEKS TO CHECK FOR Retained products of placenta

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6
Q

Pelvic inflammatory disease

A

Young sexually active female
C.F : Fever+ Adnexal tenderness + Cervical Excitation, dyspareunia, vaginal purulent discharge.
Complications : Infertility, pelvic paina and ectopic pregnancy

Inv: Screening for Chlamydia and Gonorrhoea

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7
Q

Treatment of PID

A

Inpatient management of PID :
IV Ofloxacin + IV Metronidazole x 14 days
IV Ceftriaxone 2g AND Tab Doxy 100 mg BD + Tab Metronidazole 400 mg BD x 14 days

Outpatient management
IV Ceftriaxone 1g stat + Tab doxy 100 mg + Tab Metronidazole 400 mg BD x 14 days
OR
Tab Ofloxacin + Tab Metronidazole x 14 days

Management of PID in Pregnancy
Ceftriaxone or Cefuroxime safe in Pregnancy
Azithromycin safe in pregnancy
Doxy contraindicated in Pregnancy

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8
Q

CERVICITIS

A

Neisseria andChlamydia
C/F : IntermenstrualBleeding and Post Coital Bleeding
Investigations:
1) Vulvovaginal swab - NAAT to find neisseria and chlamydia- first line

AFTER NAAT POSITIVE

2) Endocervical swab and high vaginal swab sent in transport medium for gonorrhoea culture

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9
Q

Treatment of cervicitis

A

1) If chlamydia cervicitis - Doxycyline and azithromycin
2) if Neisseria cervicitis - ciprofloxacin or ceftriaxone

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10
Q

AMENNORHOEA

A

Cause
1. Hypothalamic amennorhoea : Low Gnrh , followed by Low LH and FSH
2. PCOS
3. Hyperprolactinemia
4. Premature ovarian failure : raised FH
5. Post Pill amennorhoea - after 6 months from stopping pill
Inv :Low LH, FSH, Oestrogen (negative feed back ) and raised prolactin
7.Anatomical
8.Pregnancy

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11
Q

ANEMIA IN PREGNANCY

A

<110g/L - First Trimester (upto 12 weeks )
<105g/L- Second (13w-27w ) and third Trimester (28w - 41w)
<100g/L-Post Partum

If anemia confirmed, Tab ferrous sulphate

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12
Q

Terminologies of menstruation

A
  1. Dysmenorraghia : Pain before or during menstruation
  2. Menorraghia : Heavy menstrual bleeding
  3. Amennorhea : Absent menstrual bleeding
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13
Q

DYSMENORRHOEA (Pain during menstruation)

A

Primary : no cause
Secondary : underlying pathology ( Endometriosis, Adenomyosis, PID )

Primary t/t:
* Mefenamic acid - first line
* Combined OCPS - Second line
* Mirena IUS - Third line

Secondary T/t : Treat underlying cause

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14
Q

APLA Syndrome

A

M/C for recurrent miscarriages Any women with one or more first trimester or second trimester miscarriages should be screened for Antiphospholipid antibodies before next pregnancy
T/T any pregnant women diagnosed with APLA should be given asprin 75 mg + Heparin

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15
Q

CTG

A

Normal : HR (110-160bpm ) ; Variability : 5-25 bpm ; Deceleration: none or early

Non reassuring: HR (100-109 OR 161-180 ); Variability : <5 ( 30 - 50 mins ) and >25 ( 15-25 mins) ;Deceleration : Late deceleration for less than 30mins.

Abnormal: HR( <100 or >180 bpm ) ; Variability : <5 (>50mins) or >25 (>25 mins) ; Deceleration: late deceleration for more than 30 mins OR acute bradycarida or single prolonged deceleration for more than 3 mins .

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16
Q

Management according to CTG

A
  • Normal - Continue same tx
  • Suspicious : 1 non reassuring feature
    T/t: Conservative management :
    1. Position to lateral decubitus
    2. iv fluids
    3. oxytocin or tocolytics

*Pathological : 2 non reassuring or 1 abnormal
T/t : Conservative first line
then expedite birth

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17
Q

Preeclampsia

A

GHTN ( New onset hypertension >140/90mmHg after 20 weeks of gestation ) + PROTEINURIA after 20 weeks of gestation
Proteinuria meaning
* 24 hour urine protein> 0.3g/24 hours ( least relied on theses days )
* PCR >30mg/mmol
* ACR>8mg/mmol
other investigations used PLGF

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18
Q

CFs and T/t of Preeclampsia

A

Headache, visual disturbance epigastric pain and oedema on face all of which are usually seen in severe preeclampsia

  • Hypertension >140/90mmHg
  • Hyperreflexia
    T/t : Oral labetalol- first line except in astham where nifedipine is used

ACEI AND ARBS BOTH ARE CONTRAINDICATED IN PREGNANCY

Hydralazine used in BP>160/110mmHg
Aspirin 75 - 110 mg daily from 12 w until delivery

REFERRAL TO SPECIALITY on the same day in any of the following
1. Htn >140/90 mmHg
2. Severe and persistent headache with accompanied visual disturbances
3. Proteinuria 2+ or more

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19
Q

ECLAMPSIA

A

Tonic clonic seizures seen in association with pre eclampsia .
T/t: Loading dose : IV MgSO4 4g in 0.9 % NS over 5- 15 mins
Maintenance dose : IV MgSO4 1g/h in 0.9 %NS over 24 hours
Recurrent Seizures : IV MgSO4 2-4 g over 5- 15 mins

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20
Q

MgSO4 vs Antihypertensives

A
  • MgSO4 : if features of seizures
    + (brisk reflex , clonus or fits )
  • Antihypertensives :In severe hypertension and severe preclampsia
  • Most intially given usually in absence of fits like symptoms
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21
Q

HELLP SYNDROME

A

Hemolysis
Elevated Liver enzymes
Low Platelet

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22
Q

CFS of HELLP

A
  • Epigastric or RUQ Pain
  • Nausea and vomitng
  • Tea coloured urine
  • Raised BP
    T/t: Immediate delivery
    supportive tt
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23
Q

POST PILL AMENNORHOEA

A

Non resumal of menses even after it has been 6 months from stopping the OCP

Investigations include

Low LH AND FSH
RAISED PROLACTIN

T/t : Reassurance
IF pregancy desiration : Clomiphene can be given

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24
Q

Cervical cancer risk factors

A
  • Most common cause of Cervical cancer is HPV
  • Multiple sexual partners due to hpv
  • Smoking
  • immunosuppresive states like HIV Or Post organ transplant
  • Combined OCP very rare
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25
Oestrogen actions
* Endometrial Proliferation * Reduced Bone resorption * Breast tissue overgrowth * Reduces risk of emboli
26
Combined Oral Contraceptives
Has both oestrogenic and antiestrogenic actions due to action of oestrogen and progestin in the pill
27
CERVICAL ECTROPION
MOA: replacement of stratified squamous epithelium with columnar epithelium R/F: Pregnancy and OCP C/F : Intermenstrual bleeding , Postcoital bleeding Management : No symptoms or no bleeding on touch- REASSURE Symptomatic/ affecting QALY and bleeds on touch : Colposcopy and further diathermy or cryotherapy
28
HRT
Types : Systemic and Topical **Systemic** : Tablets, Transdermal patches and skin creams, all of which are used in hot flushes , sweating etc **Topical** : Vaginal creams, Vaginal rings and Vaginal tablets all of which are used in local symptoms like vaginal dryness , recureent UTI , Vaginal atrophy
29
Further Classifications of HRT ( CONTENTS)
Oestrogen only and Combined HRT : Oestrogen only : In hysterecrtomy and IUS patients Combined HRT : With intact uterus to avoid risk of endometrial Ca bcoz there is progestins in this pill.
30
Further classification of HRT
**Sequential** : menopausal symptoms present and are given in early menopausal ( last period < 12 months ) and after starting of this , graudually shifted to continous HRT after 12 months. **Continous HRT** : ideal for women in late menopausal stage ( last period > 12 months ago. RISK OF HTN , CAD , MI , smoker and HRT : Patch >>>>oral | ****
31
RED FLAGS IN VAGINAL BLEEDING
Sequential HRT : Bleeding normal Continous HRT : Spotting seen upto 4- 6months RED FLAGS : Vaginal bleeding beyond 6 months HMB and bleeding after a period of amenorrhoea Mangement : IMMEDIATE TVS
32
Female infertility
CAUSES : OVULATION AND TUBES, OVARIES DISORDERS Investigations : **Mid luteal Progesterone - first line** ( 7 Days prior to cycle end ) followed by LH And FSH and HSG for tubal disorders. Advices : Low BMI , 1 year of regular unprotected sex, lower alcohol and smoking and take folic acid
33
LH, FSH, OESTROGEN AND PROLACTIN LEVELS IN DIFFERENT CONDITIONS
PCOD : **High LH** ; FSH , oestrogen and prolactin normal HIGH TESTOSTERONE Premature ovarian Failure : **low oestrogen** therefore **HIGH LH AND FSH** Turners sydrome : **Low oestrogen** and therefore **HIGH LH AND FSH** Sheehans syndrome : Pituitary necrosis , causing **LOW LH , FSH AND THEREFORE LOW OESTROGEN** POST PILL AMENORRHOEA : HIGH ESTROGEN , LOW LH AND FSH AND HIGH PROLACTIN
34
PCOD
ROTTERDAM CRITERIA : 1. Anovulation: infertility ,anovulation .. 2. Hyperandrogenism : acne, hirsutism 3. USG : Polycystic ovaries Investigation : Increased LH: FSH Ratio where LH>>>FSH Raised testosterone, T/t: Weight loss - first line COCPS , POPS Clomiphene citrate last laproscopic drilling
35
Premature ovarian insufficiency
Presence of menopausal symptoms like hot flushes etc seen in women of early 40 or late thiries like 39 years . Low estrogen--- raised FSH > 25 IU , normal LH CFs: Irregular menses , can fall pregnant T/t : Hormonal replacement therapy until age 51
36
Menorrhagia ( HMB )
First line investigation : FBC , then others depending Managment : * LNG IUS - first line * Tranexa or OCP * . Norethisterone
37
Special cases of Menorrahagia
* Only dysmenorrhoea in young girl - Mefenamic acid * Dysmenorrhoea, Menorrhagia, irregular menstrual cycles in young Girl - OCP * Dysmenorrhoea, Menorrhagia, Irregular menstraul cycles in sexually active girl - LNG IUS
38
Post menopausal bleeding
M/C Atrophic vaginitis Endometrial cancer ALWAYS DO Transvaginal scan first to r/o endometrial cancer
39
Endometrial cancer
C/F : Post menopausal bleeding Inv: **Transvaginal scan first line** ( when ET > 4mm ) , then do **hysteroscopy and biopsy** for confirmation NB: **Tamoxifen** ( SERM ) has estrogenic action on Uterus and causes endometrial proliferation therefore it is a high risk factor for endometrial cancer
40
FIBROID
* Menorrhagia * Abdominal pain * Constipation/Urinary symtoms Investigation : TVS T/t: if uterus not distorted: LNG IUS , Tranexa, NSAIDs If uterus distored : OCP, NSAIDS, Tranexa if family not complete : Abdominal Myomectomy
41
Endometriosis
5 Ds : * Disorders of menstruation ( menorrhagia ) * Dymenorrhoea * Dyspareunia * Dyschezia * Dull aching abdominal pain Others: Mass in POD, Investigations: Inital --TVS Gold standard--Laparoscopic ablation- Chocolate cyst in ovaries and Powder like Burned lesions in POD T/t: Nsaids and COCP - For 3 months if not controlled , Larparoscopic ablation and mirena NB: if endometriosis is suspected start on COCPs initially, followed by Laparosocpy
42
Ovarian Cancer
Female above 50 years C/F: Abdominal pain , bloating , loss of appetite Screening : First abdominal and pelvic examination if abdominal or pelvic mass Refer to gynecology immediately No mass : Do CA 125 immediately CA 125 : >>> 35 IU/ml Urgent USG Abdomen + Pelvis If findings conclusive refer OBGYN
43
LOST LOOP THREADS
LOST LOOP Initial investigation : Urine Pregnancy test followed by vaginal examination / speculum examination Tranvaginal scan if not found Abdominal XRAY If not found -- probably expelled out
44
MISSED PILL COCP
First ask how many pills missed 1 pill missed : take the missed ASAP and continue the schedule with no further actions 2 or more pills missed : Take the missed ASAP and continue the schedule AND **NO SEX UNTIL SHE HAS TAKEN PILLS for 7 DAYS STARIGHT** Then ask which week the pills have been missed First week : Consider emergency contraception if UPSI OCCURED in pill free interval or in the week 1 Second week : No emergency contraception Third week : No emergency contraception but need to conitnue OCP even after day 21 ie no PILL FREE PERIOD
45
MISSED PILL MANAGEMENT ( POP )
ASK which pill is being used Traditional Pill : if missed > 27 hours ----ACTION PLAN Cerazette ( desogestrel ): if missed > 36 hours ------ACTION PLAN WHAT IS ACTION PLAN ? 1) TAKE THE MISSED PILL ASAP 2) NO SEX FOR THE NEXT 48 HOURS 3) IF UPSI IN THE PERIOD BETWEEN MISSED PILL AND 48 HOURS FROM RESTARTING MISSED PILL --- THEN EMEREGENCY CONTRACEPTION
46
Pelvic Organ Prolapse
Non surgical Management : For mostly POQ1/2 ( ie 2 is when it lies in the introitus ) Pelvic floor muscle training-- first line Insertion of vaginal pessary followed by .. usually in symptomatic persons Surgical management : In those not reluieved by medical managament
47
Female genital mutilation
ILLEGAL IN UK < 18 years : contact police >18 years : initiate safe guarding
48
Gestational sac and Crown rump length
Gestational sac : seen in from 5 weeeks of gestation >25 mm along with no visible fetal pole - Miscarriage Crown rump length: >7mm with no fetal cardiac activity - Miscarriage Repeat all second time after 7 days to confirm diagnosis
49
PLACENTA ABRUPTIO
Premature separation of placenta * Painful vaginal bleeding * Uterine contraction and tenderness * Fetal distress Risk Factors Old age , cocaine use , smoking , Trauma , Multiple Pregnancy, HTN, Pre eclampsia CTG : Fetal distress Management : IVF , Blood Transfusion , C Section
50
UTERINE RUPTURE
Uterine rupture : always give past h/o c section or trauma or any surgeries to uterus Pain and tenderness on previous uterine scars Maternal and fetal distress CTG : Fetal distress Management : immediate laparotomy
51
PLACENTA PREVIA
Painless vaginal bleeding ( typical wakes up in pool of blood ) No signs of fetal distress Abnormal fetal lie
52
ALGORITHM FOR PLACENTA PREVIA
A 30 YEAR OLD PREGANT WOMEN AT 32 WEEKS OF GESTATION COMES WITH PAINLESS VAGINAL BLEEDING FIRST SPECULUM EXAMINATION FOLLOWED BY TRANSVAGINAL EXAMINATION
53
Investigation of Placenta previa
TVS AT 20 weeks usually first sees Low lying placenta---reassure REPEAT SCAN AT 32 Weeks confirms Placenta previa---- REASSURE REPEAT SCAN AT 36 weeks again check placenta position -- if still low lying ------ prepare for C SECTION
54
FOLIC ACID IN PREGNANCY
NB: FOLIC ACID GIVEN TO PREVENT NEURAL TUBE DEFECTS * ALL WOMEN : 400 Ug daily UPTO 12 WEEKS * CERTAIN CASES : 5 Mg daily UPTO 12 WEEKS Certain cases include : BMI >30, DM , EPILEPTIC, ANY H/O NEURAL TUBE DEFECTS * SPECIAL CASES : 5 Mg daily for full pregnancy special cases includes : sickle cell / thallesimia
55
CHORIOAMNIONITIS
Infection of amniotic fluid R/F: Prolonged labor, PROM, Multiple vaginal examinations C/F: Fever, abdominal pain , suprapubic tenderness, speculum - offensive vaginal discharge , foul odour amniotic fluid on examination
56
PPH
Primary PPH : vaginal bleeding of >500 ml within 24 hours post partum Secondary PPH : Vaginal bleeding after 24 hours upto 12 weeks post partum
57
FURTHER CLASSIFICATION
MINOR : <1000ML MAJOR : Moderate : <1500ml Severe: >2000ml
58
CAUSES OF PPH
ATONY TRAUMA TISSUE RETAINED CLOTTING DISORDERS
59
Management of PPH
1) Basic Resus: like blood transfusion etc 2) Correction of Uterine atony : Bimanual palpation uterus Oxytocin IV infusion Ergometrine IV/IM Carboprost IM Balloon tamponade B Lynch sutures B/L ligation of uterine arteries Hysterectomy
60
POST PARTUM BLEEDING @ 4 weeks
If not breastfeeding : can expect bleeding upto 21 days; no intervention required , REASSURE If exclusively breastfeeding , LOCHIA , ( MILD PINK VAGINAL BLEEDING can occur ) , if heavy bleeding occurs , Further investigations include ENDOCERVICAL AND HIGH VAGINAL SWABS : in case of infection risks PELVIC USG : to check for retained products of placenta
61
PPH investigations
Endocervical or High vaginal swab ; in cases of infection Pelvic USG : To check for retained products of placenta
62
Hyperemesis Gravidarum
63
T/t hyperemesis gravidarum
MILD : OPD with oral/buccal antiemetics Mod- severe : IV fluids ( NaCL 0.9% + KCL ) IV antiemetics IV Steroids ( Rare) Parenteral nutrition (Rare) Termination of Pregnancy ( very rare) OTHERS: Add thiamine - to prevent wernickes encephalopathy Add LMWH - To prevent venous thrombosis
64
MOLAR PREGNANCY
Most common cause of hyperemesis Uterus large for DATE, most characteristic feature Painless vaginal bleeding Investigation : Most initial : Serum B hcg Most appropriate : Trans vaginal USG- snow storm appearance or bunch of grapes appearance T/t: * Suction curettage * 2 weekly screening of serum and urine BhCG till it becomes normal * Chemotherapy i/c/o choriocarcinoma or Raised BhCG After uterine evacuation
65
Additional info on Molar pregnancy
When is it advised to conceive again : 6 months after BhCG levels have become normal or if on chemotherapy - 12 months after completing t/t NB: women to be on contraception while on surveillance period
66
GDM
ALL women screened at 24 - 28 weeks ( OGTT) DIAGNOSIS FBS: >5.6 , 2hour OGTT: >7.8 **High risk groups include** BMI>30 Previous h/o GDM Family h/o diabetes Ethnicity history Previous macrosomy baby wt>4.5 kg
67
Management of GDM
FBS<7 1) Diet and exercise 2) regular glucose monitoring 4 TIMES i) Fasting ii) 1 hour post breakfast iii) 1 hour post lunch iv) 1 hour post dinner 3) R/W after 1-2 weeks and if not in range - OFFER METFORMIN FBS>7 1) Immediate T/T with insulin with/ without metformin 2) DIET AND EXERCISE
68
CHICKEN POX AND PREGNANCY
NO RASH : Exposure to CHCIKEN POX patients between 2 days before rash and 5 days after rash check Varicelle antibody IGg levels if negative -- give oral aciclovir RASH + : Immediate hospital admission for IV aciclovir
69
UTI in Pregnancy
Trimethoprim - Term OK ( avoid in 1st trimester ) Nitrofurantoin - Not in Term ( Used in 1st and 2nd trimester ) In first trimester : Nitrofurantoin ---- First line followed by Amoxicillin or cefelexin Amoxicillin : if culture sensitivity results sensitive Cefelexin : No need to wait for culture sensitivity
70
UTI IN NON PREGNANT WOMEN
Nitrofurantoin / Trimethoprim
71
Vaccination and Pregnancy
P-Pertussis (16 weeks) R-R S V (28 weeks ) C-COVID 19 ( any trimester ) - I-Influenza (any trimester )
72
Tests in Pregnancy
Blood Grouping and RH Anti D Ab Syphillis HIV Hep B FBC Haemoglobinopathies SCANS : Dating scan ( 10 - 13 weeks ) Fetal anomaly scan ( 18 - 20 weeks ) Nutritional supplements : Folic acid 400 Ug upto 12 weeks Vitamin D 10 g full pregnancy
73
UTERINE PERFORATION FOLLOWING HSG
USG ABDOMEN + PELVIS
74
Urinary incontinence
Stress: Pelvic floor exercises if not controlled - mid urethral or vaginal tape Duloxetine Urge : Bladder retraining Antimuscarinics - Oxybutynin,
75
ATROPHIC VAGINITIS
Post menopaiusal bleeding + dyspareunia
76
INDICATIONS FOR CERVICAL CANCER
Colposcopy indications -Abnormal cervical smear -Bleeding cervical polyp -Bleeding cervical ectropion -Suspicion of cervical cancer (postcoital bleeding/vaginal discharge with infection ruled out) CERVICAL SMEAR NEVER IN SYMPTOMATIC
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