OBGYN Flashcards
(241 cards)
1
Q
PCOS diagnostic criteria?
A
2/3 of the following present:
- Infrequent or no ovulation (oligomenorrhoea)
- Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone
- Polycystic ovaries on USS (>12) or increased ovarian volume
2
Q
Primary vs secondary PPH
A
Primary within 24hours of delivery (4Ts)
Secondary 24hrs-6 weeks (retained placenta or endometriosis)
3
Q
Combined test
A
11 - 13+6
BHCG, PAPP-A, NT
4
Q
Quadruple test
A
15-20
AFP, unconjugated oestriol, BHCG, Inhibin A
5
Q
Criteria for lactational amenorrhea
A
amenorrhoeic, <6 months post-partum, and breastfeeding exclusively
6
Q
Diagnosistic TRIAD of Hyperemesis Gravidarum
A
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
7
Q
Admission criteria for Hyperemesis Gravidarum
A
- Continued nausea and vomiting and unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (>5% of PPBW), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity
8
Q
Scoring system for ‘nausea and vomiting of pregnancy’ (NVP)
A
Pregnancy-Unique Quantification of Emesis (PUQE)
9
Q
Amsel’s criteria for diagnosis of bacterial vaginosis
A
3/4 should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
10
Q
BV treatment
A
Oral metronidazole
11
Q
Gonorrhoea treatment
A
IM ceftriaxone
12
Q
Contraceptives - time until effective (if not first day period)
A
- instant: IUD
- 2 days: POP
- 7 days: COC, injection, implant, IUS
13
Q
At which week should you refer to an obstetrician for lack of fetal movements?
A
24 weeks
14
Q
Past 28 weeks, when should you refer to an obstetrician for further assessment.
A
less than 10 movements within 2 hours
15
Q
MAD POPS
RF for reduced foetal movement
A
- Medications ie alcohol, benzos, opiates
- Amniotic fluid volume ie. oligo and polyhydramnios
- Distraction
- Posture
- Obesity
- Position of foetus
- Size of foetus
16
Q
Investigation for reduced foetal movement
A
Handheld Doppler or ultrasonography
17
Q
Investigation for reduced foetal movement
A
>28 weeks = HHD
- No HB → USS
- HB present → CTG for 20mins
24-28 weeks OR <24 weeks and movement felt previously = HHD
18
Q
CHAT
High risk groups for hypertensive disorders in pregnancy
A
- chronic kidney disease
- hypertensive disease during previous pregnancies
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
19
Q
What should woman who are high risk for Htn in pregnancy be taking
A
Aspirin 75mg od from 12 weeks until the birth of the baby
20
Q
Htn in pregnancy values
A
- systolic > 140 mmHg or diastolic > 90 mmHg
- or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
21
Q
Pre-eclampsia
A
PIH in association with proteinuria (> 0.3g / 24 hours)
22
Q
Mx for pyrexia >38 degrees during labour
A
- Benzylpenicillin as GBS prophylaxis
- Vancomycin if known severe penicillin allergy
- Erythromycin in PPROM
23
Q
4Ps
RF for GBS infection
A
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection
- Pyrexia e.g. secondary to chorioamnionitis
24
Q
Preveous GBS detected or preveous baby with GBS disease
A
- Council re 50% increased risk
- Offer IPA OR
- testing in late pregnancy (if + offer IAP)
25
Indications to offer IPA
* GBS detected in a previous pregnancy
* Previous baby with GBS disease
* Preterm labour regardless of their GBS status
* Pyrexia during labour (\>38ºC)
26
What bacteria causes GBS
Streptococcus agalacticae (gram + cocci in chains)
27
Lochia
Vaginal discharge containing blood, mucous and uterine tissue which may continue for 6 weeks after childbirth
**Ultrasound** indicated if lochia persists \>**6 weeks**
28
Lochia
Vaginal discharge containing blood, mucous and uterine tissue which may continue for 6 weeks after childbirth
**Ultrasound** indicated if lochia persists \>**6 weeks**
29
In what trimester do Intrahepatic cholestasis of pregnancy and fatty liver of pregnancy occur
3rd
30
Features of Intrahepatic cholestasis of pregnancy
* pruritus, often in palms and soles
* no rash
* raised bilirubin
31
Mx of Intrahepatic cholestasis of pregnancy
* **ursodeoxycholic acid** for symptomatic relief
* **weekly** liver function tests
* Induction at **37** weeks
32
Intrahepatic cholestasis of pregnancy complication
Stillbirth
33
Acute fatty liver of pregnancy features
* abdominal pain
* nausea & vomiting
* headache
* jaundice
* hypoglycaemia
* severe disease may result in pre-eclampsia
34
Investigation for Acute fatty liver of pregnancy
Elevated ALT e.g. 500 u/l
35
Management of acute fatty liver of pregnancy
* support care
* once stabilised delivery is the definitive management
36
Screening for anaemia in pregnancy
* The booking visit (8-10 weeks) AND
* 28 weeks
37
Cut-offs for oral iron therapy in pregnancy
* First trimester\< 110 g/L
* Second/third trimester\< 105 g/L
* Postpartum\< 100 g/L
38
Management of anaemia in pregnancy
* oral ferrous sulfate or ferrous fumarate
* Continue Tx for 3 months after iron deficiency is corrected to allow iron stores to be replenished
39
Pathophysiology of acute fatty liver of pregnancy
* Due to long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus (AD)
* Fetus and placenta are unable to break down fatty acids.
* Fatty acids enter maternal circulation, and accumulate in liver → inflammation and liver failure.
40
The combined test
* Between 11 - 13+6 weeks
* NT + serum B-HCG + PAPP-A
41
Combined test findings for Down's, Edwards and Pataus
* Down's syndrome = ↑ HCG, ↓ PAPP-A, thickened NT
* Edward (18) and Patau (13) give similar results but hCG tends to lower
42
The quadruple test
* 15 - 20 weeks
* AFP, unconjugated oestriol, B-HCG and inhibin A
43
Quadruple test findings for Down's, Edwards and Pataus
44
What is meant by ‘lower chance’ and ‘higher chance’ on combined and quadruple test results
* 'lower chance': 1 in 150 chance or more e.g. 1 in 300
* 'higher chance': 1 in 150 chance or less e.g. 1 in 100
45
‘Higher chance results’ next steps
Offered NIPT or a diagnostic test (e.g. amniocentesis or CVS)
46
NIPT
* analyses cell free fetal DNA, cffDNA → Derived from placental cells and identical to fetal DNA
* High sensitivity and specificity (esp for trisomy 21)
47
CVS vs amniocentesis
* CVS → USSguided biopsy of the placental tissue. Used when testing is done earlier in pregnancy (before 15 weeks), 2% risk miscarriage
* Amniocentesis → USS-guided aspiration of amniotic fluid. Used later in pregnancy, 1% risk miscarriage
48
# ABRUPTION
RF for placental abruption
* Abruption previously
* BP (i.e. Htn or pre-eclampsia);
* Ruptured membranes (premature or prolonged)
* Uterine injury
* Polyhydramnios;
* Twins
* Infection
* Older age (\>35)
* Narcotic use (i.e. cocaine, smoking)
49
Clinical features of placental abruption
* Sudden onset, continue severe abdo pain
* Vaginal bleeding
* Shock
* CTG indicating fetal distress
* “*woody*” abdomen on palpation →large haemorrhage
50
Concealed vs revealed abruption
Concealed: cervical OS closed, most bleeding remains within uterine cavity
Revealed: blood loss is observed via vagina
51
# 7: ECB CF CC
Initial steps to manage major haemorrhage
* Escalate to senior obstetrician, midwife, anaesthetist
* 2x grey cannula
* Bloods - FBC, UE, LFT, coagulation studies
* Crossmatch 4 units of blood
* Fluid and blood resus as required
* CTG monitoring of foetus
* Close monitoring of mother
52
Definitive Mx of abruption
Fetus alive and \< 36 weeks
* fetal distress: immediate caesarean
* no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and \> 36 weeks
* fetal distress: immediate caesarean
* no fetal distress: deliver vaginally
Fetus dead
* induce vaginal delivery
53
How to determine what dose of Anti-D prophylaxis is required
Kleihaur test to quantify amount of Fatal blood mixed with maternal blood → determine dose of Anti-D
54
Maternal complications of abruption
* shock
* DIC
* renal failure
* PPH
55
foetal complications of abruption
* IUGR
* hypoxia
* death
56
RF for GD
* BMI of \> 30 kg/m²
* previous macrosomic baby weighing 4.5 kg or above
* previous gestational diabetes
* first-degree relative with diabetes
* family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
57
Screening for GD
OGTT
* Previous GD → perform OGTT asap after **Booking** AND at **24-28** weeks if first test is normal
* Any of the other risk factors → OGTT at 24-28 weeks
58
Diagnosis of GD
* fasting glucose is \>= 5.6 mmol/L
* 2-hour glucose is \>= 7.8 mmol/L
59
Mx of GD
\<7mmol/l
1. Trial of diet and exercise for 1-2 weeks
2. Metformin
3. Short acting insulin
\>7mmol/l → Insulin
\>6 mmol/l + complications ie. macrosomia or hydramnios → Insulin
60
Management of pre-existing diabetes
* weight loss if BMI \> 27 kg/m^2
* Stop oral hypoglycaemics, apart from metformin, and commence insulin
* folic acid 5 mg/day from pre-conception to 12 weeks gestation
* detailed anomaly scan at 20 weeks incl four-chamber view of heart and outflow tracts
* tight glycaemic control reduces complication rates
* treat retinopathy as can worsen during pregnancy
61
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
62
Alternative to metformin or insulin for GD
Glibenclamide (a sulfonylurea)
63
Retinopathy screening for pre-existing diabetes in pregnancy
Should be performed **shortly after booking** AND at **28** weeks
64
# CHAT
High RF for pre-eclampsia
* CKD
* Hypertensive disease in previous pregnancy or pre-existing Htn
* Autoimmune disorders (SLE, APS)
* Type 1 or type 2 Diabetes
65
Moderate RF for pre-eclampsia
BMI \> 35
Age \> 40
Multiple pregnancy
First pregnancy or \>10 years since last pregnancy
FxH of pre-eclampsia
66
How to rule out pre-eclampsia
Placental growth factor (PlGF) between 20-35 weeks to rule of pre-eclampsia
In pre-eclampsia PlGF is LOW
67
Scoring system to determine whether woman with pre-eclampsia should be admitted
fullPIERS and PREP-S
68
Medical Mx of pre-eclampsia
1. Labetolol
2. Nifedipine (modified-release)
3. Methyldopa (stop within two days of birth)
Severe pre-eclampsia OR eclampsia → hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
During labour → IV magnesium sulphate (cont for 24 hours afterwards)
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
69
The Bishop scoring system
* Assess the need for induction
* Position, consistency, effacement and dilatation and foetal station
* Score \< 5 means induction will likely be necessary
* Score ≥ 8 indicates labour will likely occur spontaneously
70
Indications for Induction of labour
* Prolonged pregnancy
* PPROM, where labour does not start
* Diabetic mother \> 38 weeks
* Pre-eclampsia
* Rhesus incompatibility
71
Induction methods
* vaginal prostaglandin E2 (PGE2)
* membrane sweep
* maternal oxytocin infusion
* amniotomy
* cervical ripening balloon
72
Main complication of induction of labour
Management
Uterine hyperstimulation
Mx
* Remove vaginal prostaglandin and stop oxytocin.
* Start tocolysis with terbutaline
73
Causes of Increased AFP
* NTD
* Abdominal wall defects
* Multiple pregnancy
74
Causes of Decreased AFP
* Down's syndrome
* Trisomy 18
* Maternal diabetes mellitus
75
3 types of placenta accreta
* accreta: chorionic villi attach to myometrium
* increta: chorionic villi invade the myometrium
* percreta: chorionic villi invade through the perimetrium
76
Screening for postpartum depression
Edinburgh Postnatal Depression Scale
77
Causes of folic acid deficiency
* phenytoin
* methotrexate
* pregnancy
* alcohol excess
78
Prevention of NTD during pregnancy
* All women should take 400mcg of folic acid until 12th week of pregnancy
* High risk woman should take **5mg** of folic acid from **before conception** until the 12th week of pregnancy
79
High risk for NTD
* Either partner has a NTD
* Previous pregnancy with NTD
* FxH of NTD
* Antiepileptic drugs
* Coeliac disease, diabetes, or thalassaemia trait
* BMI of 30 kg/m2 or more
80
PPH primary vs secondary
PPH is blood loss of \> 500 ml after a vaginal delivery
* Primary within 24 hours
* Secondary PPH occurs between 24 hours - 6 weeks
81
Risk factors for primary PPH
* previous PPH
* prolonged labour
* pre-eclampsia
* Emergency C-section
* placenta praevia, placenta accreta
82
Management of PPH
83
RA drugs safe in pregnancy
sulfasalazine and hydroxychloroquine
84
When to stop Methotrexate
Both partners should stop 6 months before trying to conceive
85
Clinical features of Placenta praevia
* shock in proportion to visible loss
* no pain
* uterus not tender
* lie and presentation may be abnormal
86
Diagnosis of placenta praevia
20-week anomaly scan to diagnose placenta praevia
Repeat TVS at:
* 32 weeks gestation
* 36 weeks gestation (if present at 32-week scan,
87
RCOG definitions of placenta praevia
* Low-lying placenta → placenta is within 20mm of internal cervical os
* Placenta praevia → placenta is over the internal cervical os
88
Classical grading of placenta praevia
* I - placenta reaches lower segment but not the internal os
* II - placenta reaches internal os but doesn't cover it
* III - placenta covers the internal os before dilation but not when dilated
* IV ('major') - placenta completely covers the internal os
89
Management of placenta praevia
* Elective c-section for grades III/IV at 37-38 weeks
* If grade I then trial of vaginal delivery may be offered
If a woman with known placenta praevia goes into labour prior to elective c-section → emergency c-section
90
Mx of placenta praevia with bleeding
* admit
* ABC approach to stabilise the woman
* if not able to stabilise → emergency caesarean section
* if in labour or term reached → emergency caesarean section
91
2 absolute indications for a C-section
* absolute cephalopelvic disproportion
* placenta praevia grades 3/4
92
Planned VBAC
Appropriate method of delivery for women at \>= 37 weeks with a single previous Caesarean delivery
93
2 CI to VBAC
* Previous uterine rupture
* Classical caesarean scar
94
Anti-D routine IM injections
Rhesus negative mothers
* 28 weeks
* Birth (if babies blood group found to be positive)
95
Anti-D additional indications ie. sensitising events
* antepartum haemorrhage
* amniocentesis
* abdominal trauma
96
Within what timeframe of a sensitising event is Anti-D given
72 hours
97
What is the Kleinhauer test
* Performed after any sensitising event \>20 weeks
* Checks how much foetal blood has passed into maternal circulation
* Determines dose of Anti-D
98
Anticoagulants in pregnancy
* NOACs are CI in pregnancy
* Women already on NOACs should be switched to LMWH
99
Management of chickenpox exposure in pregnancy
If doubt about mothers exposure hx → check for varicella antibodies
If not immune:
* \<= 20 weeks → VZIG asap
* \> 20 weeks → either VZIG or antivirals (aciclovir or valaciclovir) 7 to 14 days after exposure
100
SSRIs of choice in breastfeeding women
Sertraline or paroxetine
101
PPROM complications (foetal and maternal)
* fetal: prematurity, infection, pulmonary hypoplasia
* maternal: chorioamnionitis
102
Investigation for PPROM
* Sterile speculum examination → look for pooling of amniotic fluid in posterior vaginal vault
* Ultrasound may be useful to show oligohydramnios
103
What investigation is CI in PPROM
Digital examination due to the risk of infection
104
Management of PPROM
* admit
* Regular obs to ensure chorioamnionitis is not developing
* oral **erythromycin** should be given for **10 days**
* corticosteroids to reduce risk of RDS
* consider delivery at 34 weeks
105
RF for shoulder dystocia
* fetal macrosomia
* high maternal BMI
* DM
* prolonged labour
106
Mx shoulder dystocia
McRoberts' manoeuvre
(flexion and abduction of hips, mother's thighs towards abdomen)
107
Maternal and foetal complications of shoulder dystocia
Maternal
* PPH
* perineal tears
Fetal
* brachial plexus injury
* neonatal death
108
Stages of postpartum thyroiditis
1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function
109
Antibody in postpartum thyroiditis
Thyroid peroxidase antibodies are found in 90% of patients
110
Management of postpartum thyroiditis
Thyrotoxic phase → propranolol for symptom control
Hypothyroid phase → thyroxine
111
Booking visit
8 - 12 weeks (ideally \< 10 weeks)
* Booking bloods/urine
* urine culture to detect asymptomatic bacteriuria
112
Early scan to confirm dates, exclude multiple pregnancy
10 - 13+6 weeks
113
Down's syndrome screening including NT
11 - 13+6 weeks
114
Information on the anomaly and the blood results. If Hb \< 11 g/dl consider iron
Routine care: BP and urine dipstick
16 weeks
115
Anomaly scan
18 - 20+6 weeks
116
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
25 weeks (only if primip)
117
Second screen for anaemia and atypical red cell alloantibodies. If Hb \< 10.5 g/dl consider iron
28 weeks
118
First dose of anti-D prophylaxis to rhesus negative women
28 weeks
119
Second dose of anti-D prophylaxis to rhesus negative women\*
34 weeks
120
Check presentation - offer external cephalic version if indicated
36 weeks
121
Most common breech
A frank breech → hips flexed, knees fully extended.
122
Breech associated with greatest mortality and morbidity
Footling breech, → one or both feet come first with the bottom at a higher position
123
RF for breech
* uterine malformations ie. fibroids
* placenta praevia
* polyhydramnios or oligohydramnios
* fetal abnormality
* prematurity
124
Breech position increases risk of what complication
cord prolapse
125
Mx of breech
* ECV from 36 weeks in nulliparous women
* ECV from 37 weeks in multiparous women
If still breech → planned caesarean section or vaginal delivery
126
# 'MAMA R' can't have ECV
Absolute CIs to ECV
* Multiple pregnancy
* Antepartum haemorrhage within last 7 days
* Major uterine anomaly
* Abnormal CTG
* Ruptured membranes
127
Antenatal complications of twins
* polyhydramnios
* pregnancy induced hypertension
* anaemia
* antepartum haemorrhage
128
Fetal complications of twins
* prematurity
* light-for date babies
* malformation
129
Labour complications of twins
* PPH increased
* malpresentation
* cord prolapse, entanglement
130
Mx twins during pregnancy
* Rest
* USS for diagnosis + monthly checks
* additional iron + folate
* more antenatal care (e.g. weekly \> 30 weeks)
* precautions at labour (eg. 2 obstetricians)
131
TTTS affects what type of twins?
Monochorionic twins (share placenta)
132
How does TTTS affect the foetuses
Placental BV abnormalities mean 'donor' foetus receives less placental BF than 'recipient' foetus
* Recipient → fluid-overloaded
* Donor → anaemic
* Differences in urine production → one may have oligohydramnios and other may have polyhydramnios
133
Investigation for TTTS
* Usually occurs in early or mid-pregnancy
* USS at 16 and 24 weeks focus on detecting TTTS
* \>24 weeks purpose of USS is to detect IUGR
134
# FORCEPS
Requirements for instrumental delivery
* Fully dilated cervix
* OA position (OP possible with Keillands forceps and ventouse)
* Ruptured Membranes
* Cephalic presentation
* Engaged presenting part
* Pain relief
* Sphincter (bladder) empty
135
Indications for instrumental delivery
* Prolonged active second stage
* Maternal exhaustion
* Foetal distress
* Breech presentation
136
Puerperal pyrexia
temperature of \> 38ºC in the first 14 days following delivery
137
Causes of Puerperal pyrexia
* Endometritis: most common cause
* UTI
* Wound infections (perineal tears, c-section)
* Mastitis
* VTE
138
Mx of puerperal pyrexia
If endometritis is suspected → refer to hospital for IV Abx
Clindamycin and gentamicin until afebrile for \>24 hours
139
Types of endometrial hyperplasia
* simple
* complex
* simple atypical
* complex atypical
140
Mx of endometrial hyperplasia
Simple EH without atypia:
* High dose progestogens + repeat sampling in 3-4 months
* ie. levonorgestrel IUS
Atypia: Hysterectomy
141
Features of fibroids
* Asymptomatic
* Menorrhagia (→ Iron-deficiency anaemia)
* Bulk-related symptoms
* Sub-fertility
141
Features of fibroids
* Asymptomatic
* Menorrhagia (→ Iron-deficiency anaemia)
* Bulk-related symptoms
* Sub-fertility
142
Bulk related symptoms of fibroids
* lower abdo pain: cramping pains, often during menstruation
* bloating
* urinary symptoms eg. frequency
143
Rare feature of fibroids
Polycythaemia secondary to autonomous production of erythropoietin
144
Rare feature of fibroids
Polycythaemia secondary to autonomous production of erythropoietin
145
Diagnosis of fibroids
TVS
146
Mx asymptomatic fibroids
No treatment is needed other than periodic review to monitor size and growth
147
Mx of menorrhagia secondary to fibroids
* levonorgestrel IUS
* NSAIDs e.g. mefenamic acid
* Tranexamic acid
* COCP
* progestogen (oral or injectable
148
Medical Tx to shrink/remove fibroids
Medical
* GnRH agonists may reduce size of fibroid
Surgical
* myomectomy
* hysteroscopic endometrial ablation
* hysterectomy
* uterine artery embolization
149
Why are GnRH agonists used short term?
Side-effects → menopausal symptoms
* Hot flushes
* Vaginal dryness
* Loss of BMD
150
Complications of fibroids
* Subfertility
* Iron-deficiency anaemia
* Red degeneration → haemorrhage into tumour, commonly occurs during pregnancy
151
Mx miscarriage
1. Expectant - wait 7-14 days
2. Medical - vaginal misoprostol
3. Surgical - vacuum aspiration (suction curettage) or surgical management in theatre
152
Types of urogenital prolapse
* cystocele, cystourethrocele
* rectocele
* uterine prolapse
* less common: urethrocele, enterocele (herniation of POD, incl SI into vagina)
153
RF for urogenital prolapse
* increasing age
* multiparity, vaginal deliveries
* obesity
* spina bifida
154
Mx of urogenital prolapse
* if asymptomatic and mild → no tx
* conservative: weight loss, pelvic floor exercises
* ring pessary
* surgery
155
Surgical options for urogenital prolapse
Cystocele/cystourethrocele → anterior colporrhaphy, colposuspension
Uterine prolapse → hysterectomy, sacrohysteropexy
Rectocele → posterior colporrhaphy
156
Clinical features of endometriosis
* chronic pelvic pain
* secondary dysmenorrhoea
* deep dyspareunia
* subfertility
157
non-gynaecological features of endometriosis
* Urinary symptoms e.g. dysuria, urgency, haematuria.
* Dyschezia (painful bowel movements)
158
non-gynaecological features of endometriosis
* Urinary symptoms e.g. dysuria, urgency, haematuria.
* Dyschezia (painful bowel movements)
159
Pelvic exam findings of endometriosis
* Reduced organ mobility
* Tender nodularity in posterior vaginal fornix
* Visible vaginal endometriotic lesions may be seen
160
Investigation for endometriosis
laparoscopy is the gold-standard
161
Mx of endometriosis
1. NSAIDs and/or paracetamol
2. COCP or progestogens
If no response to above → refer to secondary care for GnRH analogues or surgery
162
Primary vs secondary dysmenorrhea
Primary
* No underlying pelvic pathology
* Pain typically starts just before or within a few hours of period starting
Secondary
* Due to underlying pathology
* Pain usually starts 3-4 days before period
163
Mx dysmenorrhea
Primary
1. NSAIDs ie. mefenamic acid and ibuprofen are
2. COCP
Secondary → refer to gynaecology for investigation
164
Primary amenorrhea
Primary amenorrhoea is defined as not starting menstruation:
* By 13 years when there is no other evidence of pubertal development
* By 15 years of age where there are other signs of puberty ie breast bud development
165
Secondary amenorrhea
* No menstruation for **\> 3 months** after previous regular menstrual periods.
* No menstruation for **6-12 months** in women with previously infrequent irregular periods
166
Causes of primary vs secondary amenorrhea
167
Investigations for amenorrhea
* Exclude pregnancy
* FBC, UE, coeliac screen, TFT
* Gonadotrophins
* Prolactin
* Androgen levels
* Oestradiol
168
Gonadotrophin results for amenorrhea
* LOW = hypothalamic cause, RAISED = ovarian problem (POF)
* RAISED if gonadal dysgenesis (e.g. Turner's syndrome)
169
Cervical screening
* 25-49 years: 3-yearly screening
* 50-64 years: 5-yearly screening
170
Cervical screening in pregnancy
Usually delayed until 3 months post-partum
171
Bleeding in the first trimester
Symptoms suggesting ectopic → EPAU
* pain and abdominal tenderness
* pelvic tenderness
* cervical motion tenderness
\>6 weeks → EPAU for TVS
\<6 weeks and no pain → Expectant, repeat pregnancy test in 7 days
172
Cervical cancer RF
* **HPV** **16,18 & 33**
* smoking
* HIV
* early first intercourse, many sexual partners
* high parity
* lower socioeconomic status
* COCP
173
Mechanism of HPV causing cervical cancer
HPV 16 & 18 produces oncogenes E6 and E7
* E6 inhibits the p53 TSG
* E7 inhibits RB suppressor gene
174
RF ovarian cancer
* FxH: BRCA1 or BRCA2
* Many ovulations: early menarche, late menopause, nulliparity
175
Investigation for ovarian cancer
1. Abdo and pelvic exam
2. CA125
3. USS
Refer to gynaecology if an abdo exam demonstrates ascites or pelvic or abdominal mass
176
Basic investigations for infertility
* semen analysis
* Progesterone 7 days prior to expected next period
177
Interpretation of day 21 progesterone in assessing fertility
178
Key counselling points for fertility
* folic acid
* aim for BMI 20-25
* advise regular sexual intercourse every 2 to 3 days
* smoking/drinking advice
179
Initial imaging modality for suspected ovarian cysts/tumours
USS
* simple: unilocular, likely to be benign
* complex: multilocular, likely to be malignant
180
Cysts in pre vs post-menopausal women
Premenopausal
* Conservative approach as malignancy is less common
* If \< 5 cm and 'simple' then likely to be benign.
* Repeat USS for 8-12 weeks, refer if persists
Postmenopausal
* **REFER** for assessment regardless of nature or size
181
182
HRT CIs
* Current or past breast cancer
* Any oestrogen-sensitive cancer
* Undiagnosed vaginal bleeding
* Untreated endometrial hyperplasia
183
What is the only instance where oestrogen can be prescribed for HRT withOUT progesterone?
If the woman does NOT have a uterus
(oral or transdermal patch)
184
Mx of vasomotor symptoms of menopause
fluoxetine, citalopram or venlafaxine
185
Mx of vaginal dryness due to menopause
vaginal lubricant or moisturiser
186
Mx of psychological symptoms of menopause
self-help groups, CBT or antidepressants
187
Mx urogenital symptoms of menopause
Urogenital atrophy → vaginal oestrogen
Vaginal dryness → moisturisers and lubricants
188
Non-Hormonal Treatments for Menopausal Symptoms
* Lifestyle changes: diet, exercise, weight loss, smoking cessation, reducing alcohol, caffeine and stress
* Cognitive behavioural therapy (CBT)
* Clonidine
* SSRI (eg. Fluoxetine)
* Venlafaxine (SNRI)
* Gabapentin
189
Clonidine
Agonist of alpha-2 adrenergic receptors and imidazoline receptors
* Lowers BP and reduces HR
* Helpful for vasomotor symptoms and hot flushes, particularly if HRT is CI
190
Indications for HRT
* Premature ovarian insufficiency
* Reducing vasomotor symptoms
* Improving low mood, decreased libido, poor sleep and joint pain
* Reducing risk of osteoporosis in \<60s
191
Risks of HRT
Increased risk of:
* breast cancer (combined)
* endometrial cancer
* VTE
* stroke and CAD in long term use in older women
192
Ways to reduce the risks of HRT
* Reduce risk of endometrial cancer by adding progesterone in women with a uterus
* Reduce VTE by using patches
193
Mx of PMS
Mild
* Advice on sleep, exercise, smoking and alcohol
* Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
Moderate
* new-generation COCP ie. yasmin®
Severe
* SSRI
* Continuously or just during the luteal phase eg. day 15–28)
194
Investigation for ectopic pregnancy
TVS
195
RF for endometrial cancer
* obesity
* nulliparity
* early menarche and late menopause
* unopposed oestrogen
* diabetes mellitus
* tamoxifen
* PCOS
* HNPCC
196
Investigation for suspected endometrial cancer
women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
197
Staging of ovarian cancer
1: Confined to ovary
2: Outside ovary but within pelvis
3: Outside pelvic but within abdomen
4: Distant metastasis
198
Mx of vaginal candidiasis
* First line oral fluconazole 150 mg as a single dose
* clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is CI
* If vulval symptoms, consider adding a topical imidazole
* If pregnant → only LOCAL treatments (e.g. cream or pessaries)
199
Androgen insensitivity syndrome
X-linked recessive
Causes genotypically male children (46XY) to have a female phenotype
200
Most common cause of PMB
vaginal atrophy
201
Features of complete hydatidiform mole
* vaginal bleeding
* uterus size greater than expected for gestational age
* abnormally high serum hCG
* ultrasound: 'snow storm' appearance of mixed echogenicity
202
3 main categories of anovulation
Class 1 → Hypogonadotropic hypogonadal anovulation
* ie. hypothalamic amenorrhoea
Class 2 → normogonadotropic normoestrogenic anovulation
* ie. PCOS
Class 3 → hypergonadotropic hypoestrogenic anovulation
* premature ovarian insufficiency
203
In which class of anovulation are ovulation induction usually unsuccessful?
What is the alternative
Class 3 → ie. premature ovarian insufficiency
* In this class, any attempts at ovulation induction are typically unsuccessful
* Usually require IVF with donor oocytes
204
Forms of ovulation induction
1. Exercise and weight loss (first line in woman with PCOS)
2. Letrozole (first line medical therapy in PCOS)
3. Clomiphene citrate
4. Gonadotropin therapy (for class 1 ovulatory failure)
205
MoA and SE of Letrozole
MoA - aromatase inhibitor
* Reduces negative feedback of oestrogens to pituitary → increases FSH → promotes follicular development
SE: fatigue and dizziness
206
MoA and SE of Clomiphene
MoA - SERMs
* Blocks negative feedback effect of oestrogens at hypothalamus → increase in GnRH pulse frequency → increases FSH and LH → stimulates follicular development
SE: hot flushes, abdominal distention and pain, nausea and vomiting
207
Why is Letrozole first line compared to Clomiphene and Gonadotropin therapy
Rate of **mono-follicular** development is much higher with letrozole compared to clomiphene and gonadotropin therapy
Gonadotropin therapy is also a/w increased risk of ovarian hyperstimulation syndrome
208
Ovarian hyperstimulation syndrome
Ovarian enlargement with multiple cystic spaces + increase in capillary permeability → fluid shift from intravascular to extra-vascular space
Can result in:
* Hypovolaemic shock
* Acute renal failure
* Venous or arterial thromboembolism
209
Management of OHSS
* Fluid and electrolyte replacement
* Anti-coagulation therapy
* Abdominal ascitic paracentesis
* Pregnancy termination to prevent further hormonal imbalances
210
Diagnosing vaginal candidiasis
Clinical unless \>4 episodes in year (chronic)
211
Investigating chronic vaginal candidiasis
1. Check compliance with past tx
2. Confirm diagnosis
* HVS for MCS
* consider blood glucose to excl diabetes
* excl ddx ie lichen sclerosus
3. Consider induction-maintenance regime
* induction: oral fluconazole every 3 days for 3 doses
* maintenance: oral fluconazole weekly for 6 months
212
Tx of PID
* oral ofloxacin + oral metronidazole OR
* IM ceftriaxone + oral doxycycline + oral metronidazole
213
Complications of PID
* Perihepatitis (Fitz-Hugh Curtis Syndrome)
* Infertility
* Chronic pelvic pain
* Ectopic pregnancy
214
Meigs' syndrome
Benign ovarian tumour (usually **fibroma**) associated with **ascites** and **pleural effusion**
215
Staging system for cervical cancer
FIGO Staging
I → confined to cervix
II → Extension beyond cervix but not to pelvic wall
III → Extension beyond cervix to the pelvic wall
IV → Extension beyond pelvis OR involvement of bladder or rectum
216
Management of cervical cancer
IA
* hysterectomy +/- lymph node clearance
* if wanting to preserve fertility → cone biopsy
IB
* B1 radiotherapy + chemotherapy
* B2 radical hysterectomy with pelvic lymph node dissection
II, III and IV
* Radiation + chemotherapy
* Consider palliative chemo for IVB
217
Need for contraception after the menopause
* 12 months after last period \> 50 years
* 24 months after last period \< 50 years
218
Emergency hormonal contraception
Levonorgestrel (Levonelle)
* within 72 hours UPSI
* H-contraception can be started immediately
Ulipristal (EllaOne)
* selective progesterone receptor modulator
* within 120 hours UPSI
* H-contraception 5 days later
IUD
* Inserted within 5 days UPSI OR
* If \>5 days, may be fitted upto 5 days after likely ovulation date
219
Postpartum contraception
POP
* can start any time postpartum
* past day 21 additional contraception for first 2 days
* small amount enters breast milk but not harmful
COCP
* UKMEC 4 if breastfeeding \< 6 weeks postpartum
* CI in first 21 days due to VTE risk
* past day 21 additional contraception for first 7 days
IUD/ IUS
* Either within 48 hours of childbirth OR after 4 weeks
220
UKMEC categories
1. condition for which there is no restriction for the use of the contraceptive method
2. advantages generally outweigh the disadvantages
3. disadvantages generally outweigh the advantages
4. represents an unacceptable health risk
221
Contraceptive patch regime
wear one patch a week for three weeks and do not wear a patch on week four
222
Breastfeed and emergency contraception
* Breastfeeding should be delayed for one week after taking ulipristal
* No restrictions for levonorgestrel
223
Contraceptive MoAs
224
COCP If 1 pill is missed (at any time in the cycle)
* take last pill even if it means taking two pills in one day and then continue taking pills daily
* no additional contraception needed
225
COCP If 2 or more pills missed
If missed in week 1 (Days 1-7)
* Emergency contraception if UPSI in pill-free interval or week 1
If missed in week 2 (Days 8-14):
* No need for emergency contraception so long as pill has be taken for seven consecutive days
If missed in week 3 (Days 15-21):
* finish pills in current pack and start a new pack the next day (omitting pill free interval)
226
Switching from a traditional POP to COCP
7 days of barrier contraception is needed
227
Mode of delivery for HIV in pregnancy
* vaginal delivery recommended if viral load is \< 50 copies/ml at 36 weeks
* Otherwise C-section
* Zidovudine infusion should be started four hours before C-section
228
Baby born to mother with HIV
Requires neonatal antiretroviral therapy
* Oral Zidovudine to neonate if maternal viral load is \<50 copies/ml.
* Otherwise triple ART for 4-6 weeks
229
Factors which reduce vertical transmission of HIV in pregnancy
* maternal ART
* c-section
* neonatal ART
* bottle feeding
230
Risk malignancy index (RMI)
Pre-surgical prognostic criteria for ovarian cancer
* CA125 levels
* menopausal status
* USS score
231
When should VTE prophylaxis be started in pregnancy
Start LMWH from:
* 28 weeks if there are three risk factors
* First trimester if there are four or more of these risk factors
Risk assessment done at booking and any subsequent admissions
232
Except for RFs, list 4 other senators where VTE prophylaxis is required
* **Previous VTE**
* **High-risk thrombophilias**
* Hospital admission
* Surgical procedures
* Cancer or arthritis
* OHSS
233
Duration of VTE prophylaxis
Continued throughout antenatal period and for 6 weeks postnatally
Temporarily stopped in labour → started immediately after delivery (except with PPH, spinal anaesthesia and epidurals)
234
Alternative if LMWH is CI
* Intermittent pneumatic compression
* Anti-embolic compression stockings
235
What is required to diagnose a miscarriage
* TVS demonstrating a CRL \> 7mm with no cardiac activity
* 2 different sonographers
236
3 manoeuvres for shoulder dystocia
1. McRoberts - hyperflex and abduct hips, apply suprapubic pressure
2. Wood's screw manoeuvre - put hand in vagina and rotate foetus 180 degrees
3. Rubin manoeuvre - press on posterior shoulder to allow anterior shoulder extra room
237
RF for cord prolapse
* prematurity
* multiparity
* polyhydramnios
* twin pregnancy
* cephalopelvic disproportion
* abnormal presentations e.g. Breech, transverse lie
238
Mx cord prolapse
* Push presenting part back into the uterus
* Minimal handling and keep warm and moist if past introitus
* 'all fours' (L lateral is an alternative)
* Tocolytics
* Retrofill the bladder
* C-section is first-line but if cervix is fully dilated and the head is low, consider instrumental
239
Antiphospholipid syndrome in pregnancy
Aspirin + LMWH (disc at 34 weeks)
240
Babies born to mothers who are hep B surface antigen +, or high risk of hepB
Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth Further second dose at 1-2 months and at 6 months
