OBGYN Flashcards
Ectopic pregnancy typical hx.
6-8 weeks amenorrhoea
Lower abdominal pain (unilateral)
Vaginal bleeding - dark brown
Peritoneal bleeding may cause shoulder tip pain on defecation/urination
Placental abruption fx.
Shock out of keeping with visible blood loss
Pain, constant
tender, tense uterus
Normal lie
foetal heart absent
coagulation problems
Beware pre-eclampsia, DIC, anuria
Antenatal care - nausea and vomiting
‘P6’ point acupuncture and ginger are recommended by NICE
Antihistamines - PROMETHAZINE
Conditions NOT screened for in pregnancy
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B streptococcus
Toxoplasmosis
Antepartum haemorrhage definition
Bleeding from the genital tract after 24 weeks of pregnancy prior to delivery of foetus
How to distinguish placenta praevia from abruption. Shock? Pain? Coagulation problems?
Abruption = shock out of keeping with visible blood loss
Praevia = shock in proportion
No pain in praevia, pain in abruption
Uterus is tense and tender in abruption, not in praevia
Coagulation problems are RARE in praevia, common in abruption
Mastitis tx.
Treat if systemically unwell, if nipple fissure present or if symptoms do not improve after 24 hours of effective milk removal or if future indicated infection
FLUCLOXACILLIN FOR 10-14 DAYS
Antibiotics contraindicated in BREAST FEEDING
Ciprofloxacin, tetracycline, chloramphenicol
Endocrine drugs contraindicated in BREAST FEEDING
Carbimazole
Psychiatrc drugs contraindicated in BREAST FEEDING
Lithium, BZPs
Anticoagulants SAFE in BREAST FEEDING
HEPARIN AND WARFARIN
When is hyperemesis gravidarum most common
between 8 and 12 weeks - may persist up to 20 weeks
Referral criteria for nausea and vomiting assoc. w/ pregnancy
Continued N&V and is unable to keep down liquids
Continued N&V with ketonuria and or weight loss (greater than 5% of body weight)
Confirmed or suspected co-morbidity e.g unable to tolerate oral antibiotics)
Hyperemesis gradvidarum
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
Hyperemesis scoring system:
PUQE score
Hyperemesis first-line medications
ORAL cyclizine or ORAL PROMETHAZINE
Phenothiazines: prochlorperazine, chlorpromazine
Second line: Oral ONDANSETRON
Meoclopramide or domperidone - not to be used for > 5 days due to risk of EPSEs
IV if acute vomiting but oral if possible
Definition of pre-eclampsia
New-onset blood pressure > 140/90 at later than 20 weeks of pregnancy plus ONE of
proteinuria
other organ involvement - e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Potential consequences of pre-eclampsia
Eclampsia
Prematurity
IUGR
Liver failure
haemorrhage
cardiac failure
Features of severe pre-eclampsia
BP >160/110
Proteinuria +++
Visual disturbance
headache
Papilloedema
Hyperreflexia
Platelet count decreased
Mx. to reduce risk of hypertension in pregnancy
ASPIRIN 75-150 mg
if one major risk factor or two mild/moderate risk factors present
Pre-eclampsia management: when to refer to secondary care
Every woman should be referred to secondary care for assessment
Pts. w/ BP > 160/110 are likely to be admitted and observed
Pre-eclampsia treatment
Labetalol
Nifedipine if asthmatic
4T causes of postpartum haemorrhage
Tone
Tissue
Thrombin
Trauma
Mx. of PPH (Outline)
ABCDE - Seniors involved immediately
Mechanical ->
Medical ->
Surgical ->
Mx. of PPH (Mechanical)
Uterine massage to simulate contractions
Mx. of PPH (medical)
IV oxytocin (slow IV)
IV ergometrine (if no hx. of hypertension)
IM carboprost
Sublingual misoprostol
Mx. of PPH (Surgical)
IF medical/mechanical measures fail
1) intrauterine balloon tamponade
2) B-lynch suture -> ligation of arteries
3) Hysterectomy
When does secondary PPH occur and what is the usual cause
24 hours -> 6 weeks post partum
Retained placental tissue or endometritis
Post menopausal bleeding: most common cause
Other causes:
Vaginal atrophy
HRT (spotting)
Endometrial cancer (MUST BE RULED OUT)
Vaginal cancer
Endometrial hyperplasia (precursor for carcinoma)
cervical and ovarian cancer
Ix. for post-menopausal bleeding:
All women >55 years with PMB MUST BE seen within 2 weeks for TRANSVAGINAL USS to rule out endometrial cancer
Vaginal atrophy tx.
Topical oestrogens
Endometrial hyperplasia tx.
Dillatiation and curettage
Fibroids Ix.
Trans-vaginal US
Features of fibroids
If symptomatic
Menorrhagia
Sub-fertility
Bulk symptoms: Lower abdominal pain, bloating
Mx. of menorrhagia 2ry to fibroids
IUS (if uterus not distorted)
NSAIDs - MEFENAMIC acid
Tranexamic acid
oral progestogen
medical tx. to shrink fibroids
GnRH analogues (short term)
Surgical tx. for fibroids
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
GnRH side effects
Menopause symptoms - flushing, vaginal dryness)
Reason why these are considered a short term measure
Rare feature of Fibroids
Polycythaemia due to autonomous production of EPO
Eclampsia: Tx. to prevent and/or treat seizures
Magnesium sulphate
tx. to continue for 24 hours after last seizure
What else should be monitored during eclampsia?
urine output
reflexes
respiratory rate
oxygen saturations
Treatment for magnesium sulphate induced respiratory depression
Calcium gluconate
Anaemia in pregnancy when should women receive IRON
1TM: 110 g/l
3TM: 105 g/l
Post partum: 100 g/l
Oral FERROUS SULPHATE should be continued for 3 months post-correction
When should aspirin be continued to for pre-eclampsia prophylaxis
till 12 weeks before the scheduled birth of the baby
Endometriosis Px.
Chronic pelvic pain
Secondary dysmenorrhoea - usually days preceding normal period
Subfertility
Deep dyspareunia
Endometriosis Ix.
Laparoscopy is gold standard
Endometriosis Tx.
NSAIDs and paracetamol are first line
COCP if these fail to control symptoms
Endometriosis if conventional mx. fails
GnRH analogues
Surgery
Causes of gynae pelvic pain
Ectopic pregnancy
Ovarian cyst/torsion/rupture
Endometriosis
PID
Primary dysmenorrhoea: definition and management
No underlying pelvic pathology - appears 1-2 years of menarche
Mx. NSAIDs - Mefenamic acid and/or ibuprofen
2) COCP
Secondary dysmenorrhoea definition and Mx.
Develops many years after the menarche due to underlying pathology
Refer all patients to gynaecology for investigation
Causes of secondary dysmenorrhoea
Endometriosis
Adenomyosis - (EM tissue in the MUSCLE of uterus)
PID
IUDs (IUS may actually help dysmenorrhoea)
Fibroids
examination findings in ectopic pregnancy
Abdominal tenderness
Cervical excitation
adnexal mass
In the case of pregnancy of unknown location, which bHCG level points towards diagnosis of ectopic pregnancy
> 1500
Ix. of choice in suspected ectopic pregnancy:
TransVAGINAL US
Ectopic pregnancy
Expectant management:
Medical management:
Surgical management:
Expectant management: Monitor bHCG
Medical management: Methotrexate
Surgical management: Salpingectomy or salpingotomy if contralateral tube damage or other risk factor for infertility
EM cancer definitive management
Localised disease = TAHBSO
Pts. with high risk disease may have follow up radiotherapy
Progestogen therapy for elderly pts. too frail for surgery
EM hyperplasia Mx.
Simple
Atypical
Simple: High dose progestogen w/ repeat sampling in 3-4 months
Atypial: hysterectomy advised
Gynaecological causes of abdominal pain->
All women should receive
Bimanual vaginal examination
urine pregnancy test
consideration of abdominal/pelvic US
Menorrhagia Ix.
FBC - anaemia? de-compensating
Trans-vaginal US if symptoms suggest structural cause
Menorrhagia Mx.
Does not Require contraception
Does NOT require contraception
Mefenamic acid 500 mg TDS (particularly if dysmenorrhoea)
Tranexamic acid 1g TDS
If no improvement then try other drug whilst awaiting referral
Menorrhagia Mx.
Requires contraception
1) Intrauterine system (mirena)
2) COCP
3) Long acting progestogens
Which medication may be used as a short term option to RAPIDLY control heavy bleeding in periods
Norethisterone 5 mg
HRT oestrogen Increases risk of which cancers
Breast (increased further by addition of progestogen) and endometrial cancer
HRT: Method of delivery to avoid increase in risk of VTE
Transdermal delivery
Menopause: when should contraception be used until
12 months after LAST PERIOD in women > 50 years
24 months after LAST PERIOD in women < 50 years
HRT contraindications
Current or past breast cancer
Any oestrogen-senstive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
non-HRT Mx. of post-menopausal vasomotor symptoms
FLUOEXETINE, CITALOPRAM, VENLAFAXINE
Dysfunctional uterine bleeding meaning
Menorrhagia in the absence of underlying pathology (50% of patients w/ bleeding)
Miscarriage: medical management
Vaginal MISOPROSTOL
addition of mifepristone is NOT recommended
Miscarriage: surgical management
Vacuum aspiration (suction curettage)
surgical mangement under GA
Ovarian cancer Ix.
CA125
US
Diagnosis is difficult and usually involves diagnostic laparotomy
Aside from ovarian cancer, which conditions may also increase CA125
endometriosis
menstruation
benign ovarian cysts
Ovarian torsion Mx.
Laparoscopy is usually diagnostic and therapeutic
PID Ix.
Pregnancy test (exclude ectopic)
High vaginal swab (often negative)
Screen for chlamydia and Gonorrhoea
Complications of PID
Perihepatitis -> Fitz-hugh Curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy
PCOS suggested Ix.
Pelvic US
FSH
LH
Prolactin
TSH
Testosterone
SHBG
Check for impaired glucose tolerance
Causes of post-coital bleeding
Cervical ectropion (50%)
Cervicitis -> 2ry to chlamydia
Cervical cancer
Polyps
Trauma
PMB action
Every woman over the age of 55 with PMB should be investigated within 2 weeks by ultrasound for endometrial cancer
Commonest cause of PMB
Vaginal atrophy -> reduction of oestrogen causes thinning,drying and inflammation of the walls of the vagina
Urinary incontinence initial Ix.
Bladder diaries for 3 days
Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
Urine dipstick and culture
Urodynamic studies
Mx URGE incontinence
Bladder retraining - 6 weeks
1) Oxybutynin, tolterodine, derifenacin
2) Mirabegron (B3 agonist) if there is concern about anticholinergic side effects in FRAIL elderly pts.
Mx. STRESS incontinence
Pelvic floor training -> 3 months
Surgical procedures - retropubic mid-urethral tape
Duloxetine offered to women if they DECLINE surgical procedures
Fibroids - diagnosed with which investigation
Transvaginal US
Vaginal candidiasis diagnosis
Clinical -> high vaginal swab NOT indicated unless diagnostic uncertainty
Vaginal candidiasis mx.
1) ORAL fluconazole 150 mg
2) Clotrimazole 500 mg PESSARY as single dose if oral therapy contraindicated
If pregnancy ONLY topical anti-fungals are to be used
Recurrent vaginal candidiasis Ix.
High vaginal swab for microscopy and culture
Blood glucose test to exclude DIABETES (glycosuria)
