OBGYN Flashcards
1
Q
What is adenomyosis?
A
Benign disease characterised by the occurrence of endometrial tissue within the myometrium (muscle layer of the uterus) due to the hyperplasia of the endometrial basal layer.
2
Q
Risk factors for adenomyosis?
A
Later reproductive years (peak incidence is 35-50 yo)
Multiparous
Endometriosis
Uterine fibroids
3
Q
Presentation of adenomyosis
A
1/3rd asymptomatic
Dysmenorrhoea
Menorrhagia
Dyspareunia
Abnormal uterine bleeding
Chronic pelvic pain, aggravated during menses
Infertility/pregnancy related complications
Globular, uniformly enlarged uterus that is soft but tender on palpation
4
Q
Ix for adenomyosis
A
Transvaginal US
MRI is transvaginal US not suitable
Histology after hysterectomy confirms diagnosis
On imaging = myometrial wall thickening and myometrial cysts
5
Q
Mx for adenomyosis
A
No contraception wanted:
- Tranexamic acid (antifibrinolytic to reduce bleeding but not pain)
- Mefenamic acid (NSAID to reduce pain and bleeding)
Contraception wanted:
- 1st line: Mirena coil
- COCP
- Cyclic oral progesterones
More definitive options:
- GnRH analogues (cause less FSH/LH secretion) to induce menopause like state
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
6
Q
What are the pregnancy related associations with adenomyosis?
A
1 Infertility 2 Miscarriage 3 Preterm birth 4 Small for gestational age 5 Preterm premature rupture of membranes 6 Malpresentation 7 Need for c section 8 Postpartum haemorrhage
7
Q
What is androgen insensitivity syndrome?
A
Condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.
Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics.
8
Q
What is the inheritance pattern for androgen insensitivity syndrome?
A
X linked recessive
Mutation in the androgen receptor gene on X chromosome.
9
Q
What is the genetic sex of a person with androgen insensitivity syndrome and what is their genetic phenotype?
A
Genetically male with XY sex chromosomes.
46XY
The absent response to testosterone and conversion of additional androgens to oestrogen = female phenotype externally (normal female external genitalia and great tissue)
10
Q
What internal reproductive organs does a person have who has androgen insensitivity syndrome?
A
- Testes in abdomen or inguinal canal
- Absent uterus, upper vagina, cervix, Fallopian tubes, ovaries
Testes produce anti-Mullerian hormone which prevents them from developing female internal reproductive organs
11
Q
What is partial androgen insensitivity syndrome and give some examples of how it could present?
A
The cells have a partial response to androgens.
Example presentations:
- Ambiguous signs and symptoms
- Micropenis / clitoromegaly
- Bifid scrotum
- Hypospadias
- Diminished male characteristics
- Failure of one or both testes to descend into the scrotum
12
Q
Presentation of androgen insensitivity syndrome
A
- Female external genitalia and physique
- Blind ended vaginal pouch
- Lack of pubic and facial hair
- Taller than female average
- Infertility
- Increased risk of testicular cancer unless testes are removed
- Inguinal hernia in infancy containing testes
- Primary amenorrhoea at puberty
13
Q
When is the diagnosis of partial androgen insensitivity and androgen insensitivity syndrome made?
A
- Partial androgen insensitivity is diagnosed at birth due to ambiguous genitalia
- Complete androgen insensitivity usually diagnosed at puberty as girls don’t get periods.
14
Q
Ix for androgen insensitivity syndrome
A
Hormone tests:
- Raised LH
- Normal/raised FSH
- Normal/raised testosterone levels (for a male)
- Raised oestrogen (for a male)
Genetic testing - buccal smear for 46XY genotype
Pelvic US
15
Q
Mx of androgen insensitivity syndrome
A
Options are:
- Bilateral orchidectomy (removal of testes to reduce cancer risk)
- Oestrogen therapy
- Vaginal dilators or vaginal surgery to create adequate vagina length
Psychological support
16
Q
What is Asherman’s syndrome
A
Adhesions (sometimes called synechiae) form within the uterus following damage to the uterus
17
Q
Risk factors for Asherman’s syndrome
A
Following pregnancy
Dilation and curettage procedure (e.g., for tx of retained products of conception)
Uterine surgery
Pelvic infections
18
Q
Presentation of Asherman’s syndrome
A
Following recent dilation and curettage, uterine surgery or endometritis:
- Secondary amenorrhoea
- Significantly lighter periods
- Dysmenorrhoea
- Infertility
19
Q
Ix for Asherman’s syndrome
A
- Hysteroscopy - gold standard. Can dissect and treat the adhesions
- Hysterosalpingography - inject contrast into the uterus and do x-ray = HONEYCOMB APPEARANCE of uterus
- Sonohysterography - uterus filled with fluid and pelvic US performed
- MRI scan
20
Q
Treatment for Asherman’s syndrome
A
Hysteroscopic dissection of adhesions
Recurrence of adhesions after dissection is common.
21
Q
What is atrophic vaginitis?
A
Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.
Also called:
- Genitourinary syndrome of menopause
22
Q
what is the pathology of atrophic vaginitis?
A
Oestrogen makes the epithelial lining of the vagina and urinary tract thicker, more elastic and produce secretions.
After menopause, low oestrogen levels result in thinner, less elastic and dry mucosa.
Tissue prone to inflammation
Changes in vagina pH and microbial flora = localised infections
23
Q
Symptoms of atrophic vaginitis
A
- Itching
- Dryness
- Dyspareunia
- Bleeding due to localised inflammation
- Recurrent UTIs
- Stress incontinence
- Pelvic organ prolapse
24
Q
Signs of atrophic vaginitis on examination
A
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
25
Mx for atrophic vaginitis
1. Vaginal lubricants
2. Topical oestrogen - estriol cream, estriol pessaries, estradiol tablets, estradiol ring
3. HRT if menopausal
26
CIs for topical oestrogens
- Breast cancer
- Angina
- VTE
27
Diagnosis of atrophic vaginitis
Clinical on examination
Can do a pH test but this is non-specific
28
What is bacterial vaginosis?
An overgrowth of anaerobic bacteria in the vagina caused by a loss of lactobacilli (friendly bacteria that produce lactic acid to keep the pH of the vagina low, preventing other bacteria from overgrowing).
Not an STI but increases to risk of developing an STI.
29
Examples of anaerobic bacteria associated with bacterial vaginosis
Gardnerella vaginalisis (most common )
Mycoplasma hominis
Prevotella species
30
Risk factors for bacterial vaginosis
- Multiple sex partners
- Excessive vaginal cleaning e.g. soaps, douching
- Recent abx
- Smoking
- Copper coil
31
Presentation of bacterial vaginosis
Fishy smelling watery grey/white vaginal discharge
1/2 of women are asymptomatic
32
Ix for bacterial vaginosis
Speculum examination - to look for discharge
High vaginal swab - to rule out other causes
Vaginal pH - >4.5
CLUE CELLS on microscopy (epithelial cells from the cervix with bacteria stuck inside them - usually gardnerella vaginalis)
33
Mx for bacterial vaginosis
Asymptomatic = no tx
Symptomatic =
- Metronidazole oral/vaginal gel 5-7 days (targets anaerobic bacteria)
No alcohol while taking metronidazole (disulfaram like reaction = nausea, vomiting, shock, angioedema)
Advice about reducing risk of future episodes
34
Complications of bacterial vaginosis
Increased risk of catching STI
35
Pregnancy related complications of bacterial vaginosis
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
Use metronidazole in pregnancy to treat BV
36
What criteria is used for the diagnosis of bacterial vaginosis?
```
Amsel's criteria
(need 3 /4)
1. Clue cells on microscopy
2. Vaginal ph >4.5
3. +ve Whiff test - fishy smell on addition of potassium hydroxide
4. Thin white homogenous discharge
```
37
What is cervical cancer and what type of cancer is it usually?
A human papilloma virus related malignancy of the cervical mucosa.
Usually is SQUAMOUS CELL CARCINOMA
2nd most common type = adenocarcinoma
38
Risk factors for cervical cancer
```
Sex
Human papilloma virus types 16, 18 and 31
Sexual intercourse at an early age
Multiple sex partners
High risk male partners
Immunosuppression (HIV/AIDS)
Smoking
COCP use
Non engagement with cervical screening
High parity
Low socioeconomic income
```
39
What is HPV?
Human Papilloma virus
Most common cause of cervical cancer
Also associated with anal, vulval, vagina, penis, mouth and throat cancers.
Is a STI
Types 16 and 18 are responsible for 70% of cervical cancers
40
Symptoms and signs of cervical cancer
Asymptomatic
Early symptoms:
- Offensive and watery vaginal discharge
- Intermenstrual bleeding
- Post coital bleeding
- Contact bleeding
- Post menopausal bleeding
Advanced cases:
- Pelvic and back pain
- Symptoms of uraemia
- Dyspareunia
- Leg oedema
- Obstructive uropathy and hydronephrosis
41
Appearance of the cervix in advanced cervical cancer
Ulceration
Inflammation
Bleeding
Visible tumour
42
What are premalignant lesions in the cervix called?
cervical intraepithelial neoplasia (CIN)
CIN = the abnormal growth of cells in the transformation zone of the cervix. Is a grading system for the level of dysplasia (premalignant change) diagnosed at colposcopy.
43
How is CIN detected?
Biopsy
44
What are the 3 types of CIN and how likely is each type to progress?
CIN 1 = mild dysplasia (few progress to CIN2, likely to return to normal without tx)
CIN 2 = moderate dysplasia (20-25% progress to CIN3)
CIN 3 = severe dysplasia or carcinoma in situ (cancer precursor, 30-70% develop cervical cancer over 10 years)
45
What is the screening programme for cervical cancer in the UK?
Smear test to collect cells from the cervix with a small brush, then transported to lab via liquid based cytology for detection of dyskaryosib (precancerous changes).
Every 3 years for women 25-49 yo
Every 5 yrs for women 50-64 yo
46
What is done with a smear sample?
Initially tested for high risk HPV.
-ve for high risk HPV = normal smear, and women returned to normal screening programme
+ve for high risk HPV = do cytology (cytology looks for dyskaryosis)
Cytology results:
- Normal = repeat in 12 months
- Abnormal = colposcopy
- Inadequate = repeat in 3 months
- 2 inadequate samples = colposcopy
47
Biopsy methods used to detect CIN
Smear test - cytology (only done after found to be high risk HPV +ve)
Colposcopy: large loop excision of the transformation zone (LLETZ)
Cone biopsy
48
What happens during colposcopy?
A speculum is inserted and a colposcope used to magnify the cervix.
Acetic acid and iodine solutions are used to stain and differentiate abnormal areas.
Do punch biopsy or large loop excision of transformation zone to get a sample for histology
49
Why is acetic acid used in colposcopy?
Causes abnormal cells to appear white (acetowhite).
Occurs in cells with increased nuclear material = cervical intraepithelial neoplasia and cervical cancer cells
50
Why is iodine staining used in colposcopy? and what is this test called?
Schiller's iodine test
Iodine solution used to stain cells, healthy cells go a brown colour.
Abnormal areas don't stain
51
What happens during a large loop excision of the transformation zone and what should you tell the patient for afterwards?
Performed during colposcopy, using local anaesthetic. Diathermy is used to remove abnormal epithelial tissue.
- Bleeding/abnormal discharge for several weeks
- Intercourse and tampons avoided after procedure (risk of infection)
- Risk of preterm labour depending on depth of tissue removed
52
What is a cone biopsy and what are the main risks?
Used for treatment of CIN and very early stage cervical cancer.
Under GA
Remove a cone shaped piece of cervix with scalpel
Main risks:
- Pain
- Bleeding
- Infection
- Scar formation = stenosis of cervix
- Increased risk of miscarriage/premature labour
53
Staging of cervical cancer
Stage O – carcinoma in situ: intraepithelial carcinoma
Stage I – confined to the cervix
Stage II – extends beyond the cervix onto either the vagina or parametrium but not to the lower 1/3rd of the vagina & not to the pelvic wall
Stage III – extension either to the lower 1/3rd of the vagina or pelvic wall.
Hydronephrosis or non-functioning kidney with no apparent cause warrants allocation to stage IIIb.
Stage IV – Extension beyond the true pelvis or involvement of mucosa of bladder or rectum
54
Mx of cervical cancer
CIN / early stage I = LLETZ pr cone biopsy
Stage I- II = radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage II-IV = chemotherapy and radiotherapy
Stage IV b = palliative care, chemo/radiotherapy
Pelvic exenteration = removal of all pelvic organs in very advanced disease
Bevacizumab - monoclonal antibody used to target VEGF
55
Prevention of cervical cancer
HPV vaccine
- Given to boys and girls before they become sexually active to prevent them from contracting HPV
- Current vaccine = Gardasil
- Vaccine protects against strains 6, 11, 16 and 18
6& 11 = genital warts
16 & 18 = cervical cancer
56
Complications of cervical cancer
```
Uraemia (due to ureteral obstruction)
Severe bleeding
Sepsis
PE
Infiltration of the ureter = urinary obstruction, hydronephrosis, kidney failure
Fistula formation
```
57
What is cervical show and the mucus plug?
When the mucus plug comes free and is discharged towards the end of pregnancy. Can happen several days before labour starts or at the start of labour when the cervix dilates.
Mucus plug = mucus accumulates in the cervix during pregnancy to form a plug hat seals the entrance to the uterus and protects it from infection.
Bloody show = discharge is tinged pink or brown/streaks of blood
58
What causes chlamydia?
Chlamydia trachomatis
Gram negative bacteria
59
symptoms of chlamydia in women
```
Asymptomatic
Dysuria
Abnormal vaginal discharge
Intermenstrual / post coital bleeding
Deep dyspareunia
Lower abdominal pain
Cervical excitation
```
60
symptoms of chlamydia in men
```
Urethritis (dysuria, urethral discharge)
Epididymo-orchitis - testicular pain
Epididymal tenderness
Mucopurulent
Reactive arthritis
```
61
Diagnosis of chlamydia in women
Nucleic acid amplification test (NAAT), from one of the following samples (in order of preference):
1. endocervical swab
2. vulvo-vaginal swab (self taken lower vaginal swab)
3. First catch urine sample
62
Diagnosis of chlamydia in men
Nucleic acid amplification test (NAAT), from one of the following samples (in order of preference):
1. First catch urine smaple
2. Urethral swab
63
Apart from genital swabs/first catch urine, what other samples should you consider taking for chlamydia?
Rectal and pharyngeal NAAT swabs for chlamydia in the rectum or throat.
Do gonorrhoea testing (endocarvical charcoal swab)
64
Mx of chlamydia
Doxycycline 100mg BD 7 days
65
Mx of chlamydia in pregnancy
Doxycycline is CI in pregnancy and breastfeeding.
Give:
Azithromycin 1g stat then 500mg OD 2 days
or
Erythromycin 500mg QDS 7 days
66
When should you test for a cure of chlamydia?
Rectal chlamydia
Pregnancy
When symptoms persist
67
Patient information when diagnosed with chlamydia
Abstain from sex for 7 days
Treatment of all partners to reduce re-infection
Refer to GUM for contact tracing and notification of sexual partners (trace back 4 weeks for symptomatic men and 6 months for women/asymptomatic men)
Provide advice about preventing future infections
Consider safeguarding
68
Complications of chlamydia
```
PID
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
```
69
Pregnancy related complications of chlamydia
```
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis & pneumonia)
```
70
What is lymphogranuloma venereum
Condition affecting the typhoid tissue around the site of infection with chlamydia.
Most commonly seen in MSM.
Primary stage = painless ulcer on penis/vagina/rectum
Second stage = lymphadenitis in inguinal/femoral lymph nodes
Tertiary stage = proctitis (inflammation of rectum) = anal pain, change in bowel habit. tenesmus and discharge
Give doxycycline 100mg BD for 21 days
71
What screening is available for chlamydia?
National screening programme for people aged 15-24
| Opportunistic screening of sexually active
72
What is cord prolapse?
the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina, after the rupture of the fetal membranes.
Significant danger of the presenting part compressing the cord = fetal hypoxia
73
Risk factors for cord prolapse
```
Abnormal lie after 37 weeks gestation
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Cephalopelvic disproportion
```
74
Diagnosis of cord prolapse
50% occur at artificial rupture of membranes
Fetal distress on CTG
Vaginal examination
Speculum exam to confirm diagnosis
75
Mx cord prolapse
Emergency C-section
Do not push the cord back in/touch the cord = vasospasm
Keep the cord warm and wet
If baby is compressing the cord - push the presenting part upwards while the women lies in left lateral position with a pillow under the hip or in knee chest position (all 4s) - using gravity to draw the foetus away from the pelvis
Retrofitting of the bladder via a catheter (500mls saline)
Terbutaline (tocolytic medication) - minimise contractions
76
What is gestational diabetes?
Diabetes triggered by pregnancy as pregnancy causes a reduced insulin sensitivity (placenta secretes substances that have an anti-insulin property).
77
Risk factors for gestational diabetes
```
Previous gestational diabetes
Previous macrosomic baby >4.5kg
BMI >30
Ethnic origin
Family hx of diabetes
Maternal age >40
PCOS
```
78
Symptoms of gestational diabetes
Elevated BMI
Fetal macrosomia
Polyuria
Polydipsia
79
Ix for gestational diabetes
Oral glucose tolerance test
- Screening test
- Performed after overnight fast of at least 8 hours
- Drink 75g glucose drink at the start of the test, BM measured before drink and 2 hours later
- If previous GDM - test ASAP & again at 24-28 weeks
- Risk factors/symptoms - test at 24-28 weeks
Normal result =
- fasting <5.6
- at 2 hours <7.8
(think 5 - 6 - 7 - 8)
80
Mx of gestational diabetes
1. Women must monitor their BMs
2. 4 weekly USS to monitor fetal growth and amniotic fluid vol (28-36 weeks)
3. Fasting glucose <7 = trial diet and exercise 1-2 wks, metformin then insulin
4. Fasting glucose >7 = insulin +/- metformin
5. Fasting glucose >6 + macrosomia = insulin +/- metformin
Use short acting insulin in GDM
Can't tolerate metformin or refuse insulin = glibenclamide (a sulfonylurea)
81
What should women with pre-existing diabetes do before conception?
Good glucose control
| 5mg folic acid from preconception until 12 weeks gestation
82
What medications should women with pre-existing diabetes be taking?
stop oral hypoglycaemic agents apart from metformin
| Start insulin if needed
83
Management for pregnant women with pre-existing diabetes
- Metformin + insulin
- Weight loss if BMI >27
- Detailed anomaly scan at 20 weeks
- Retinopathy screening
- Planned delivery at 37-38 + 6 weeks
- Sliding scale insulin regime during labour (dextrose & insulin infusion titrated to blood sugar levels)
84
Postnatal care required for women with gestational diabetes
Diabetes improves immediately after birth
GDM = stop meds immediately after birth
Follow up of fasting glucose 6 weeks after birth
85
Postnatal care required for women with pre-existing diabetes
Lower insulin and be aware of hypoglycaemia in postnatal period - insulin sensitivity will increase after birth and with breastfeeding
86
What are babies at risk of if their mother is diabetic?
```
Neonatal hypoglycaemia - requires close monitoring with regular Bus and frequent feeds. aim for BM >2, need IV dextrose/NG feeding if below.
Polycythemia (^Hb)
Jaundice
Congenital heart disease
Cardiomyopathy
Macrosomia
```
87
What is abnormal uterine bleeding
Irregularities in the menstrual cycle: frequency, duration, regularity of cycle length and volume of menses.
Irregular menstrual periods indicate anovulation or irregular ovulation.
88
Causes of abnormal uterine bleeding
PALM - COEIN
[Palm = structural causes, Coein = non-structural causes)
```
P = polyps
A = adenomyosis
L = leiomyomas
M = malignancy / hyperplasia
```
```
C = coagulopathy
O = ovulatory dysfunction
E = endometrial
I = iatrogenic
N = not yet classified
```
Extremes of reproductive age
PCOS
Physiological stress
Medication e.g. progesterone only contraception
Hormone imbalances - thyroid, Cushings, high prolactin
89
Causes of primary amenorrhoea
Hypogonadotrophic hypogonadism (abnormal functioning of the hypothalamus/pituitary gland)
Hypergonadotrophic hypogonadism (abnormal gonads)
Imperforate hymen
90
Causes of secondary amenorrhoea
```
Pregnancy
Menopause
Physiological stress
PCOS
Medications e.g., contraceptives
Premature ovarian insufficiency
Thyroid hormone abnormalities
Excessive prolactin from a prolactinoma
Cushing's syndrome
```
91
Causes of Intermenstrual bleeding
```
Hormonal contraception
Cervical ectropion, polyps or cancer
STI
Endometrial polyps or cancer
Vaginal pathology
Pregnancy
Ovulation
Medications - SSRIs and anticoagulants
```
92
causes of dysmenorrhoea
```
Primary dysmenorrhoea
Endometrosis
Adenomyosis
Fibroids
PID
Copper coil
Cervical or ovarian cancer
```
93
causes of menorrhagia
```
Dysfunctional uterine bleeding
Extremes of reproductive age
Fibroids
Endometriosis/adenomyosis
PID
Copper coil
Anticoagulant medications
Bleeding disorders e.g. VWD
Diabetes
Hypothyroidism
Connectve tissue disorders
Endometrial hyperplasia or cancer
PCOS
```
94
causes of post coital bleeding
```
Cervical cancer, ectropion, infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
```
95
Causes of pelvic pain
```
Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
PID (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)
```
96
Causes of vaginal discharge
```
Bacterial vaginosis - clear fishy smelling
Candidiasis (thrush) - creamy white and thick
Chlamydia - yellow strong smelling
Gonorrhoea - white or green discharge
Trichomonas vaginalis - thin increased volume
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
```
97
causes of pruritus vulvae
```
Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress
```
98
what is an ectopic pregnancy?
A pregnancy that is implanted outside the uterus. The most common site is a Fallopian tube.
Can implant in the entrance to the Fallopian tube = corneal region, ovary, cervix or abdomen
99
Risk factors for ectopic pregnancy
```
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
```
100
Presentation of ectopic pregnancy
```
Presents around 6-8 weeks gestation.
Missed period
Constant lower abdominal pain in R or L iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness
```
Ask about:
- Unprotected sex
- Dizziness/syncope (blood loss)
- Shoulder tip pain (peritonitis)
101
Ix for ectopic pregnancy
bHCG
Transvaginal USS - see gestational sac with yolk sac or fetal pole in Fallopian tube, empty uterus, fluid in the uterus (pseudogestional sac)
102
What is a pregnancy of unknown location?
Positive pregnancy test with no evidence of pregnancy on the USS.
Can't exclude an ectopic
103
How do you manage a pregnancy of unknown origin?
Serial bHCG
- Check after 48 hours
- In an intrauterine pregnancy the bHCG will double every 48 hrs. Repeat USS in 1-2 weeks to confirm intrauterine.
- In an ectopic pregnancy/miscarriage the bHCG will not double every 48 hours. Close monitoring.
- Fall in bHCG of >50% over 48 hours = miscarriage. Do a urine pregnancy test 2 weeks later to ensure complete miscarriage
104
Management of ectopic pregnancy
Pelvic pain/tenderness + positive pregnancy test = refer to early pregnancy assessment unit
All ectopic pregnancies need to be terminated.
3 options:
1. expectant management (natural termination)
2. Medical management (methotrexate)
3. Surgical management (salpingectomy or salpingostomy)
105
Criteria for expectant management of ectopic pregnancy
- Follow up needs to be possible
- Unruptured ectopic
- Adnexal mass <35mm
- No visible heartbeat
- No significant pain
- HCG <1500
106
Criteria for medical management of ectopic pregnancy
- Follow up needs to be possible
- Unruptured ectopic
- Adnexal mass <35mm
- No visible heartbeat
- No significant pain
- HCG <5000
+confirmed absence of intrauterine pregnancy on US
107
Side effects of medical management of ectopic pregnancy
Use of methotrexate:
- IM injection into buttock
- Halts the process of pregnancy + spontaneous termination
Cannot get pregnant for 3 months after treatment = harmful effects can last
Common SEs:
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis (inflammation of the mouth)
108
Criteria for surgical management of ectopic pregnancy
- Pain
- Adnexal mass >35 mm
- Visible heartbeat
- HCG >5000
109
Surgical options for management of ectopic pregnancy
Laparoscopic salpingectomy
- GA
- Removal of affected Fallopian tube
Laparoscopic salpingotomy
- Done for women at increased risk of infertility due to damage to the other tube
- Cut open the Fallopian tube, ectopic pregnancy removed, tube closed
- Increased risk of failure to remove ectopic pregnancy
Give anti-rhesus d prophylaxis to rhesus negative women having surgical management
110
What is endometrial cancer?
Cancer of the endometrium that lines the uterus
80% adenocarcinomas
Oestrogen dependent cancer e.g., oestrogen stimulates the growth of endometrial cancer cells
111
What do you need to rule out for any woman presenting with postmenopausal bleeding?
Endometrial cancer
112
Risk factors for endometrial cancer
```
Age 55-65
Postmenopausal
Unopposed oestrogen:
- Early menarche and delayed menopause
- Infertile, hx of repeated abortions
- Nulliparity
- Obesity
- PCOS
- Oestrogen therapy without progesterones
- Tamoxifen
HTN
DM
Lynch syndrome - hereditary non-polyposis colorectal carcinoma (HNPCC)
Endometrial hyperplasia
Family hx
```
113
Protective factors
COCP
Mirena coil
Increased pregnancies
Cigarette smoking
114
What is a precancerous condition that can lead to endometrial cancer?
Endometrial hyperplasia
Most cases return to normal, 5% progress to endometrial cancer.
Mx: Mirena coil or continuous oral progestogens
115
Presentation of endometrial cancer
```
Postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
```
116
Referral criteria for endometrial cancer
2 week wait for:
- Post menopausal bleeding
Transvaginal USS for women 55yo+ if:
- Unexplained vaginal discharge
- Visible Haematuria + raised platelets, anaemia or elevated glucose levels
117
Ix for endometrial cancer
1. Transvaginal USS for endometrial thickness (normal <4mm post menopause)
2. Pipelle biopsy (sensitive for endometrial ca)
3. Hysteroscopy with endometrial biopsy
118
Staging of endometrial cancer
Stage 1 = confined to uterus
Stage 2 = invades cervix
Stage 3 = invades ovaries, Fallopian tubes, vagina or lymph nodes
Stage 4 = invades bladder, rectum or beyond the pelvis
119
Mx for endometrial cancer
Stage 1 and 2 = total abdominal hysterectomy with bilateral sapling-oophorectomy
Can have radiotherapy, chemotherapy, progesterone hormonal treatment to stop growth of cancer
120
What is endometriosis?
Ectopic endometrial tissue is found outside of the uterus.
Endometrioma = a lump of endometrial tissue outside of the uterus
121
what is a chocolate cyst?
Endometriomas in the ovaries
122
Theories about the aetiology of endometriosis
1. Retrograde menstruation through the Fallopian tubes into the pelvis and peritoneum where endometrial tissue seeds itself
2. Uterine embryonic cells remain outside of the uterus
3. Spread of endometrial cells via the lymphatic system
4. Cells outside of the uterus go through metaplasia and become endometrial cells
123
Risk factors for endometriosis
Reproductive age group
Positive family history
Nulliparity
Mullerian anomalies
124
Symptoms of endometriosis
- Dysmenorrhoea
- Pre or post menstrual bleeding
- Chronic or cyclic pelvic pain – worsens with onset of menses
- Deep Dyspareunia
- Sub-fertility
- Uterosacral ligament nodularity
- Pelvic mass
- Fixed, retroverted uterus
- Depression
- Dysuria, flank pain and haematuria
- Dyschezia (painful bowel movements), haematochezia (fresh blood in stool)
- Infertility
125
Ix for endometriosis
Pelvis USS - unremarkable or large endometriomas and chocolate cysts
Laparoscopic surgery - gold standard investigation. Biopsy lesions during laparoscopy and remove deposits of endometriosis to improve symptoms
126
Examination findings in endometriosis
Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
Fixed cervix on bimanual examination
Tenderness in vagina, cervix and adnexa
127
Mx of endometriosis
Initial management:
- Establish a diagnosis
- Provide clear explanation
- Analgesia and NSAIDs
Hormonal management:
- COCP
- Progesterone only pill
- Medroxyprogesterone acetate injections e.g., depo-provera
- Nexplanon implant
- Mirena coil
- GnRH agonists (goserelin)3
Surgical management
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions
- Hysterectomy
128
What are endometrial polyps
Focal overgrowth of localised benign endometrial tissue
129
Risk factors for endometrial polyps
```
HTN
Obesity
Tamoxifen / HRT
Hx of cervical polyps
Lynch syndrome (hereditary non-polyposis colorectal cancer)
```
130
Characteristics of endometrial polyps
- Localised within the uterine wall and extend into the uterine cavity
- Can be pedunculated or sessile
- Can be single or multiple
- Can be up to many cm in size
- May contain smooth muscle cells +/- blood vessels
- Express both oestrogen and progesterone receptors (oestrogen stimulates growth)
131
Symptoms of endometrial polyps
Usually asymptomatic
- Irregular menstrual bleeding
- Spotting
- Menorrhagia
- Postmenopausal bleeding
- Infertility
132
Ix for endometrial polyps
Transvaginal US
Hysteroscopy
Endometrial biopsy to rule out other conditions e.g. endometrial hyperplasia or carcinoma
133
Mx for endometrial polyps
Asymptomatic women = observe and follow up
Symptomatic women= Surgical removal
134
What epilepsy drugs are safe in pregnancy?
Levetiracetam
Lamotrigine
Carbamazepine
135
What epilepsy drugs are not safe in pregnancy?
```
Sodium valproate (neural tube defects)
Phenytoin (cleft lip/palate)
```
136
Management of epilepsy in pregnancy
- Folic acid 5mg before conception
- Epilepsy controlled with a single anti-epileptic before conception
- Seizure control can worsen in pregnancy due to stress, lack of sleep, hormonal changes and altered medications
137
HTN medications unsafe in pregnancy
ACEi
ARBs
Thiazide like diuretics
[Can cause congenital abnormalities]
138
HTN medications safe in pregnancy
Labetalol
CCB - nifedipine
A blocker - doxazosin
139
management for women at high risk of pre-eclampsia in pregnancy
Aspirin 75mg OD from 12 weeks until birth
High risk groups:
- HTN during previous pregnancy
- CKD
- SLE / antiphospholipid syndrome
- T1DM / T2DM
140
What happens to BP during normal pregnancy?
BP falls in the 1st trimester
Continues to fall until 20-24 weeks
After this BP increases to pre-pregnancy levels by term
141
What is HTN in pregnancy defined as?
>140/90
OR
increase above booking readings of >30/15
142
3 categories of HTN in pregnancy
1. Pre existing HTN (>140/90 before pregnancy, no proteinuria, no oedema )
2. Pregnancy induced HTN (PIH) (HTN after 20 weeks, no proteinuria, no oedema - resolves after birth)
3. Pre-eclampsia (HTN + proteinuria + oedema)
143
what are fibroids?
Also called uterine leiomyoma
Benign smooth muscle tumours of the uterus
Oestrogen sensitive
144
Types of uterine fibroids
1. Intramural - within the myometrium, change the shape of the uterus as they grow
2. Subserosal - below the outer layer of the uterus, grow outwards filling the abdominal cavity
3. Submucosal - below endometrium
4. Pedunculated - on a stalk
145
Symptoms of fibroids
```
asymptomatic
Menorrhagia
Prolonged menstruation
Abdominal pain
Bloating/feeling full
Urinary/bowel symptoms
Deep dyspareunia
Reduced fertility
Polycythaemia (autonomous production of erythropoietin)
```
146
Ix for fibroids
Hysteroscopy
Pelvic USS
MRI scan
Bimanual pelvic examination - irregularly enlarged firm uterus
147
Mx for fibroids
Asymptomatic = no mx
<3cm & symptomatic:
- Mirena
- NSAIDs + tranexamic acid
- COCP
- Cyclic oral progestogens
- Endometrial ablation
- Resection during hysteroscopy
- Hysterectomy
>3cm & symptomatic
- Same medical management as above
- GnRH agonist before surgery to shrink fibroid (goserelin)
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
148
Risk factors for fibroids
Early menace
Nulliparity
Reproductive years
149
Complications of fibroids
```
Menorrhagia - iron deficiency anaemia
Reduced fertility
Miscarriage/premature labour
Constipation
Urinary outflow obstruction & UTIs
Red degeneration of fibroid
Torsion of fibroid (pedunculated)
Malignant change to leiomyosarcoma
```
150
What is red degeneration of fibroids
Ischaemia, infarction and necrosis of fibroid
Usually in pregnancy
Severe abdo pain + fever + pregnancy + hx of fibroids
mx = supportive, rest, fluids, analgesia
151
What are genital warts caused by?
HPV types 6 and 11
152
Symptoms of genital warts
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
- Warts affecting penis, scrotum, vulva, inside vagina, cervix, perianal skin or inside anus
- Can be weeks, months or years after initial infection
- Painless fleshy growths
153
Tx for genital warts
Topical treatments:
- Podophyllotoxin
- Imiquimod
Physical ablation
- Excision
- Cryotherapy
- Electrosurgery
- Laser surgery
Vaccination
154
What causes gonorrhoea?
Neisseria gonorrhoeae
| Gram negative diplococcus
155
incubation period for gonorrhoea?
2-5 days
156
What is gonorrhoea?
STI where neisseria gonorrhoeae infects mucous membranes with columnar epithelium (endocervix, urethra, rectum, conjunctiva, pharynx). Spreads via contact with mucous secretions from infected areas
157
Symptoms of gonorrhoea
```
Females:
- Altered/increased vaginal discharge (commonly thin, watery, green/yellow)
- Dysuria
- Dyspareunia
- Lower abdominal pain
- Easily induced cervical bleeding
- Pelvic tenderness
Men:
- Mucopurulent / purulent urethral discharge
- Dysuria
```
Can get anal and pharyngeal infection
158
Diagnosis of gonorrhoea
NAAT to detect RNA or DNA of gonorrhoea on endocarvical, vulvovaginal or urethral swabs or first catch urine
MSM = rectal and pharyngeal swabs too
+ do charcoal swab for MC&S before using abx due to high rates of antibiotic resistance
159
Mx for gonorrhoea
IM ceftriaxone single dose if sensitivies not known
Oral ciprofloxacin single dose 500mg if sensitivities known
- Look at local resistances
- Refer to GUM for contact tracing
- Follow up test of cure with NAAT
- Abstain from sex for 7 days of treatment
- Provide advice about future reinfection
160
Complications of gonorrhoea
```
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis - in neonates (ophthalmia neonatorum)
Urethral strictures
Disseminated gonococcal infection - untreated gonorrhoea, bacteria spreads to skin and joints causing skin lesions, polyarthralgia, tenosynovitis and systemic symptoms
Skin lesions
Fitz-Hugh-Curtis syndrome - inflammation of liver capsule
Septic arthritis
Endocarditis
```
161
What is group B strep infection in newborns?
This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.
162
Risk factors for GBS
- Prematurity
- Prolonged rupture of membranes
- Previous sibling GBS infection
- Maternal pyrexia e.g. secondary to chorioamnionitis (mum has fever >38)
163
When to investigate and treat GBS
* universal screening for GBS should not be offered to all women
* a maternal request is not an indication for screening
* women who've had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered maternal intravenous antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
* if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
* maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
* maternal intravenous antibiotic prophylaxis should be offered to women in preterm labour regardless of their GBS status
* women with a pyrexia during labour (>38ºC) should also be given intravenous antibiotics
164
Abx given for GBS
Benzylpenicllin
165
What causes genital herpes?
Herpes simplex virus (HSV-1, HSV-2)
After an initial infection, the virus becomes latent in the associated sensory nerve ganglia. Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.
166
symptoms of herpes
Primary infection –
- Small red blisters around the genitals that are painful
- Vaginal or penile discharge
- Flu like symptoms, fever, muscle aches
- Itchy genitals
The virus lays dormant in the body & can be reactivated causing recurrent outbreaks
167
Ix for herpes
viral PCR Swab of open sore
168
mx for herpes
acyclovir
```
Paracetamol
Topical lidocaine 2% gel (e.g. Instillagel)
Cleaning with warm salt water
Topical vaseline
Additional oral fluids
Wear loose clothing
Avoid intercourse with symptoms
```
169
What is a Hydatidiform mole?
Also known as a molar pregnancy
Can be a complete or partial mole.
Is a type of tumour that grows like a pregnancy inside the uterus.
170
What is a complete mole?
A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
171
What is a partial mole?
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
172
3 types of gestational trophoblastic disease
1. Hydatidiform moles (complete and incomplete)
2. Invasive mole - malignant
3. Choriocarcinoma - malignant, likely to metastasise to lungs
173
Symptoms of hydatidiform mole
Behaves like a pregnancy - periods stop and hormonal changes of pregnancy occur
```
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
```
174
Ix for hydatidiform mole
US pelvis - snowstorm appearance of uterus
| Confirm diagnosis with histology of mole after evacuation
175
Mx of hydatidiform mole
Evacuation of the uterus (histology of the products of conception)
Refer to gestational trophoblastic disease centre
Monitor hCG levels until they return to normal
May require systemic chemotherapy if mets
effective contraception for 12 months to avoid pregnancy
176
What is primary post partum haemorrhage
Loss of >500ml of blood vaginally within 24 hours of delivery
Minor PPH = 500-1000ml
Major PPH = >100ml
177
What are the causes of primary PPH?
```
4 Ts:
Tone = uterine atony
Tissue = retention of placental tissues
Trauma = damage during delivery
Thrombin = coagulopathies/vascular abnormalities
```
178
Risk factors for primary PPH
Risk factors for uterine atony:
- Older mum
- Obese mum
- Asian mum
- Uterine over distention – multiple pregnancy, polyhydramnios, fetal macrosomia
- Long labour (induction)
- Placenta praevia, placental abruption, previous PPH
179
Symptoms of uterine atony
- Profuse vaginal bleeding
| - Soft enlarged (increased fundal height), boggy ascending uterus
180
Ix for primary PPH
Examination:
- General examination for haemodynamic instability
- Abdominal exam
- Speculum exam – look for local trauma causing bleeding
- Examine placenta – look to see the placenta is complete
Bloods:
- FBC
- Cross match blood
- Coagulation profile
- U&Es
- LFTs
181
Mx for primary PPH
1 Call for help
2 ABCDE
3 Definitive management:
- Uterine atony =
o Bimanual compression – inset gloved hand into vagina, form a fist inside the anterior fornix of the vagina, compress the anterior uterine wall, use the other hand to apply pressure on the abdomen behind the uterus
o Medical therapy – to increase uterine myometrial contraction
Syntocinon (synthetic oxytocin)
Ergometrine
Carboprost (prostaglandin analogue)
Misoprostol (prostaglandin analogue)
o Surgical
Intrauterine balloon tamponade
Haemostatic suture around uterus e.g. b-lynch
Bilateral uterine or internal iliac artery ligation
Hysterectomy
- Trauma
o Primary repair of laceration
o If uterine rupture – laparotomy and repair or hysterectomy
```
- Tissue
o IV oxytocin
o Manual removal of placental with regional or general anaesthetic
o Prophylactic Abx
o IV oxytocin infusion after removal
```
- Thrombin
o Correct coagulation abnormalities with blood products (need haematology help)
182
Prevention of primary PPH
Active management of 3rd stage of labour routinely reduces PPH risk by 60%
- IM oxytocin given to women who have delivered vaginally/c-section
183
What is secondary post partum haemorrhage?
= excessive vaginal bleeding in the period from 24 hours after delivery to 12 weeks postpartum
184
Causes of secondary PPH?
```
- Uterine infection (endometritis)
RFs: c-section, PROM, long labour
- Retained placental fragments or tissue
- Abnormal involution of the placental site
- Trophoblastic disease
```
185
Ix for secondary PPH
US for retained products of conception
| Endocervical or high vaginal swabs for infections
186
Mx for secondary PPH
Surgical evacuation of retained products of conception
| Abx for infection
187
Indications for instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
Increased risk of requiring instrumental delivery when epidurals are used
188
Options for instrumental deliveries
Ventouse = suction cup on a cord
Forceps = large metal tongs used either side of the babies head and used to apply traction and pull the head
189
Risks to mother during instrumental delivery
```
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury:
- Obturator = weakness of hip adduction & rotation, numbness of medial thigh
- Femoral = weakness of knee extension, loss of patella reflex and numbness of anterior thigh & medial lower leg
```
190
Risks to baby during instrumental delivery
```
Ventouse = cephalohaematoma
Forceps = facial nerve palsy
```
- Subgaleal haemorrhage
- Intracranial haemorrhage
- Skull fracture
- Spinal cord injury
191
What is lichen sclerosus?
Chronic inflammatory skin condition that presents with patches of shiny white skin, commonly affecting the labia, perineum and perianal skin
Autoimmune condition
192
Lichen sclerosus symptoms
woman aged 45 – 60 years
'porcelain' white patches that may scar on vulva
itch is prominent
skin appears shiny, tight and thin
may result in pain during intercourse or urination
193
Diagnosis of lichen sclerosus
Clinical
| Can biopsy
194
Mx of lichen sclerosus
Topical steroids and emollients
| [clobetasol propionate]
195
Complications of lichen sclerosus
Squamous cell carcinoma of the vulva
Bleeding
Narrowing of vaginal/urethral openings
196
What is the 'lie' of a foetus?
The relationship between the long axis of the foetus and the mother - longitudinal, transverse or oblique
197
what is the 'presentation' of a foetus?
The fetal part that enters the maternal pelvis first
- cephalic vertex (normal)
- breech
- shoulder
- face
- brow
198
What is the 'position' of a foetus?
The position of the fetal head as it exits the birth canal
- occipito-anterior (normal)
- Occipito-posterior
- occipito-transverse
199
Normal presentation of a foetus at birth
facing backwards, head first
| = cephalic vertex presentation
200
Risk factors for malpresentation
- Prematurity
- Multiple pregnancy
- Uterine abnormalities e.g. fibroids, partial septate uterus
- Fetal abnormalities
- Placenta previa
- Primiparity
201
what is the definition of menopause?
No periods for 12 months
Is a permanent end to menstruation
On average - happens at 51 yo
202
What is postmenopause?
the period from 12 months after the final menstrual period onwards
203
What is perimenopause?
the time around menopause, where the woman experiences vasomotor symptoms and irregular periods.
Includes the time leading up to the last period and the 12 months after
204
What is premature menopause
menopause before the age of 40
| caused by premature ovarian insufficiency
205
what are the changes in the sex hormones associated with menopause
oestrogen and progesterone low (lack of ovarian follicular function)
LH and FSH high - no negative feedback from oestrogen
206
Perimenopausal symptoms
```
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
```
207
Risks due to lack of oestrogen following the menopause
Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
208
diagnosis of menopause
clinical if >45 yo
FSH blood test if <45 yo with symptoms of menopause
```
- Bloods:
o Reduced oestrogen
o Reduced progesterone
o Reduced inhibin B
o Very increased FSH
o Testosterone and prolactin levels within normal ranges
- Vaginal pH >4.5
- Lipid profile = Increased total cholesterol, reduced HDL
```
209
when to consider treating menopause symptoms
Treatment not warranted for all women as the menopause is a normal ageing process.
Treatment considered in the following cases:
- Symptoms severe enough to infringe significantly on functional capacity
- Premature menopause
- Surgical menopause (e.g. post oophorectomy)
210
Lifestyle modifications and local medical therapy for menopause symptoms
- To help with hot flushes avoid bright lights and other predictable emotional triggers. Temp control e.g. fans
- For atrophic vaginal symptoms = vaginal oestrogen creams, rings or tablets
- Impaired sleep = exercise, acupuncture and relaxation techniques
- Prevention of osteoporosis = smoking cessation, vitamin D, weight bearing exercises, bisphosphonates (alendronic acid)
211
Ci for HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
212
What HRT can be given for menopausal symptoms?
- Is used for the short term treatment of menopausal symptoms
- Types:
o Oestrogen therapy (for women who have had a hysterectomy)
o Oestrogen plus progesterone therapy (for women with a uterus)
- Routes = oral or transdermal
213
SEs of HRT
nausea, breast tenderness, fluid retention and weight gain
214
Risks of HRT
o Cancer
Unopposed oestrogen can result in endometrial hyperplasia = increased risk of endometrial cancer
Oestrogen + progesterone therapy = increased risk of breast cancer
* Ovarian cancer
o Cardiovascular disease – CHD, DVT, PE, stroke
o Gallbladder disease
o Stress urinary incontinence
215
Non-hormonal medication for menopausal symptoms
- Used to treat menopausal women with vasomotor symptoms who don’t want to use hormonal replacement / have contraindications for HRT:
o Selective oestrogen receptor modulators = tamoxifen, ospemifene and raloxifene
o Paroxetine = for hot flushes
o Clonidine +/- gabapentin
216
Contraception for perimenopausal women
Need contraception for 2 years after last menstrual period in women <50 yo / 1 year after last menstrual period in women >50 yo
Use barrier method, Mirena, progesterone only pill, sterilisation or depot injection if <45yo
Can have COCP as long as there are no other CIs
217
Side effects of the progesterone depot injection (depo-provera)
Weight gain
| Reduced bone mineral density (can't have depot >45yo)
218
What is miscarriage (early and late)?
Miscarriage is the spontaneous termination of a pregnancy.
Early miscarriage is before 12 weeks gestation.
Late miscarriage is between 12 and 24 weeks gestation.
219
what is a missed miscarriage?
The foetus is no longer alive but no symptoms have occurred
220
what is a threatened miscarriage?
vaginal bleeding with a closed cervix and a foetus that is alive
221
What is an inevitable miscarriage?
Vaginal bleeding with an open cervix
222
What is an incomplete miscarriage
Retained products of conception remain in the uterus after the miscarriage
223
what is a complete miscarriage?
a full miscarriage has occurred and there are no products on conception left in the uterus
224
What is an anembryonic pregnancy?
a gestational sac is present but contains no embryo
225
Ix for miscarriage
Transvaginal USS
Key features in early pregnancy to assess viability of pregnancy:
- Mean gestational sac diameter
- Fetal pole and crown rump length
- Fetal heartbeat
226
Mx of miscarriage
<6 weeks = expectant management
>6 weeks:
- Expectant
- Medical (misoprostol)
- Surgical
Rhesus negative mums need anti-D prophylaxis if there's been any tx & >12 weeks or there's surgical management at any gestation
227
Risk factors for miscarriage
- Older mum (increase in chromosomal abnormalities)
- Previous miscarriage
- Obesity
- Chromosomal abnormalities (mum or dad)
- Smoking
- Uterine anomalies
- Previous uterine surgery
- Anti-phospholipid syndrome
- Coagulopathy
228
Symptoms of miscarriage
```
VAGINAL BLEEDING
- Pass clots
- Pass products of conception
- Haemodynamic instability w significant blood loss = pallor, tachycardia, tachypnoea, hypotension
- Bleeding often accompanied by pain:
o Cramping pain
o Suprapubic
o Tender on examination
```
Incidental finding on US
229
What is expectant management of a miscarriage? what are the cons, follow up and CI
- Allows the products of conception to pass naturally
- Means women can stay at home, don’t require medications and no anaesthetic/surgical risk
- Cons: unpredictable timing, heavy bleeding, pain, chance of it being unsuccessful & need further interventions
- Need follow up – scan in 2 weeks / pregnancy test in 3 weeks
- CI = infection, high risk of haemorrhage e.g., coagulopathy
230
What is medical management of a miscarriage? What are the side effects of the medication used?
- Vaginal misoprostol (prostaglandin analogue)
- Works by stimulating cervical ripening and myometrial contractions
- Usually give mifepristone 24-48hrs before misoprostol
- Can be at home w access to gynae
- Side effects of medication:
o Vomiting / diarrhoea
o Heavy bleeding + pain
o Chance of requiring emergency surgical intervention
- Pregnancy test 3 weeks later
231
what is surgical management of miscarriage? and what are the risks involved?
12 weeks: Manual vacuum aspiration with local anaesthetic
- Evacuation of retained products of pregnancy under general anaesthetic
- Indication = haemodynamically unstable, infected tissue or gestational trophoblastic disease
- Is a planned procedure
- Risks: general anaesthetic, infections, uterine perforation, haemorrhage, Asherman’s syndrome (scar tissue in uterus), bowel and bladder damage, retained products of conception
232
What is recurrent miscarriage defined as?
3 or more consecutive spontaneous abortions
| occurs in around 1% of women
233
causes of recurrent miscarriage
```
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
```
