OBGYN Flashcards
VTE prophylaxis in OBGYN pre-op patients?
low molecular weight heparin
- once daily
- no routine monitoring
- lower risk of heparin induced thrombocytopenia compared to unfractionated heparin.
What vaccines are offered to pregnant women in UK?
Influenza Vaccine
Pertussis Vaccine (whooping cough) - given between 16-32 weeks, combined with polio/diphtheria/tetanus.
- Abdominal pain
- Vaginal bleeding
- Reduced fetal movement
- woody hard uterus
Diagnosis and initial step?
PLACENTAL ABRUPTION
- Initial step: CTG
If normal > US
If fetal distress > C section
What is the best medication for hypertension in pregnancy?
1st: Labetalol (NOT IN ASTHMA)
2nd: Nifedipine
3rd: Methyldopa (risk of postnatal depression)
All 3 are safe in pregnancy/breastfeeding but first choice is Labetalol.
- Lower abdominal pain/suprapubic tenderness
- Fever
- vaginal discharge
- Rigidity
- Cervical excitation/cervical motion tenderness- deep dyspareunia
Diagnosis and initial step?
PELVIC ABSCESS/TUBO-OVARIAN ABSCESS
complication of PID
In ER > TVS, if painful then abdominal and pelvic US
- multilocular complex adnexal mass with debris, septations and irregular thick walls.
If pregnancy test positive > Ectopic
Endocervical swab can also be done but takes days to get results.
PID
- cause: chlamydia trachomatis (common) and Neisseria gonorrhea
MX OF PID
outpatient
- IM ceftriaxone 500mg/1000mg + oral doxycycline 100mg BID + oral metronidazole 400mg BID for 14 days.
- Ofloxacin + metronidazole orally for 14 days
inpatient
- IV ceftriaxone 500mg + IV doxycycline + oral doxy and metro for 14 days
- IV ofloxacin + IV metronidazole for 14 days
complication of PID: Fitz-Hugh-Curtis syndrome»_space;> RUQ pain + aggravated on breathing/coughing + referred to right shoulder.
CERVICITIS
- Chlamydia > doxycycline 100mg BID for 7 days.
Azithromycin 1g for day 1 then 500mg for 2 days. - Neisseria gonorrhea > IM ceftriaxone 1000mg
if susceptible to ciprofloxacin, then 500mg oral single dose.
- needs long term contraception
- does not wish to have more children
- fibroids distorting uterine cavity
- does not remember to take pills
What is the best contraception?
NEXPLANON
68mg Etonogestrel
should be changed after 3 years.
Hypertension in pregnancy
- chronic
- gestational
- pre-eclampsia
- severe pre-eclampsia
- eclampsia
- HELLP
- chronic: >140/90, <20 weeks
- gestational: >140/90, >20 weeks
- pre-eclampsia: >140/90, >20 weeks, proteinuria, headaches, swollen hands and feet, dipstick 2 +
24 hr urine protein >/= 0.3g
Protein: Creatinine (PCR) >/= 30mg/mmol
Albumin: Creatinine >/= 8mg/mmol - severe pre-eclampsia: >160/110, headaches, visual scotoma, epigastric pain, hyperreflexia, high creatinine, high LFT, low platelets
- eclampsia: pre-eclampsia + seizures
- HELLP: Hemolysis, elevated liver enzymes, low platelets.
MX
- booking blood pressure is important to compare.
- dipstick 1 + and everything else normal > assess within 7 days
- dipstick 2 + and everything else is normal > refer to obstetric unit for same day
- severe pre-eclampsia > IV magnesium sulphate
- definitive management is delivery of baby
- women at risk of pre- eclampsia should take 75-150mg aspirin daily from 12 weeks’ gestation till delivery.
Types of Miscarriage
- Threatened
- Misses/Delayed
- Inevitable
- Incomplete
- Complete
Miscarriage = spontaneous loss in <24 weeks
- Threatened: vag bleed +HR present + os closed
- Misses/Delayed: loss of fetus<20 weeks without symptoms + may or may not bleed + os closed
- Inevitable: os open + vag bleed
- Incomplete: not all products have been expelled
- Complete: everything has been expelled
<20 weeks pregnant
- nausea
- vomiting
- fluid/food intolerance
- lethargy
- urine ketones
- tachycardia
- weight loss
- dehydration
Diagnosis and management?
HYPEREMESIS GRAVIDARUM
MX
1st: IV fluids (0.9% Nacl + KCl/Hartmans/Ringers)
2nd: antiemetics
- chlorpromazine, Pro chlorperazine cyclizine, promethazine
- metoclopramide, ondansetron
3rd: steroids (hydrocortisone)
4th: Parenteral nutrition
others: LMWH (Dalteparin), Thiamine (reduce risk of Wernicke’s encephalopathy)
What is the best contraception for perimenopausal symptoms?
Cyclical HRT
What is the best contraception for a young girl (around 15 yrs) who is not sexually active and has symptoms of dysmenorrhea, menorrhagia and irregular periods?
COCP
- Irregular PAINLESS 1st trimester bleed
- hyperemesis
- uterus large for date
- passage of products of contraception
- “snowstorm appearance” on US
- “Large theca lutein cysts”
Diagnosis and management?
MOLAR PREGNANCY
- partial: hcg MAY be normal (above 25 IU/l is positive)
- complete: snowstorm appearance, theca lutein cysts, hcg levels very high.
MX
- Suction curettage and histology for diagnosis
- 2 weekly serum hcg levels until normal
- advised not to conceive until normal
- contraception for 6 months
- after chemo contraception for 1 year
- ONE SIDED abdominal pain
- vaginal spotting
- LMP 6-8 weeks ago
- TVS inconclusive
- hcg positive
Diagnosis?
ECTOPIC PREGNANCY
- common between 6 to 8 weeks
- fallopian tubes stretch causing cervical motion tenderness
If stable > hcg levels
- hcg should be more than 1500 to diagnose ectopic pregnancy.
If unstable> LAPAROTOMY
- Palpable uterine mass
- decreased fertility
- prolonged heavy periods
Diagnosis and management?
UTERINE FIBROIDS
Types
- sub mucosal: beneath endometrium, bulge into cavity, decreases fertility
- intramural: within muscular wall, MOST COMMON
- sub serosal: external, project outside of uterus
MX
if asymptomatic > follow up annually
if menorrhagia >
LNG-IUS (if cavity intact)
Tranexamic acid/NSAIDS/COCP
Norethisterone, long-acting progestogen injection
if severe menorrhagia > ulipristal acetate
SX
most successful > hysterectomy (pre op GnRh)
preserver fertility > myomectomy (bestone but has risk of uterine rupture during pregnancy), artery embolization.
others > ablation (<3 cm only, does not preserve fertility)
What contraception is used in patient with hx of sickle cell disease?
Depot medroxyprogesterone acetate
What contraception is used if patient is not sexually active and complaints of menorrhagia?
1st: IUS - Mirena
2nd: Tranexamic acid
What contraception can be used if patient complaints of dysmenorrhea only?
Mefenamic acid + COCP
What contraception can be used if patient complaints of dysmenorrhea and menorrhagia?
Tranexamic acid + NSAIDS
What contraception should be used to stop heavy bleeds RAPIDLY?
Norethisterone 5mg TID for 10 days
What contraception should be used if patient complaints of menorrhagia + dysmenorrhea + fibroid not distorting cavity?
IUS - Mirena
What contraception is used within 72 hrs of unprotected sex?
Levonelle pill
What contraception is used within 120 hrs of unprotected sex?
IUCD or EllaOne pill
- increased urine frequency
- dysuria
- urgency
- lower abdominal pain (suprapubic/costovertebral)
- fever, chills, rigor
- nausea and vomiting
- urine smell or color changes
- urine dipstick shows nitrates and leukocytes positive
- pregnancy test positive
- hcg levels high
Diagnosis and management?
UTI
most common organism: Ecoli
urine test: >10*5 bacteria cfu/ml
RISK FACTORS
- female
- pregnancy
- new partner
- sexually active
- familial/genetic
- immunocompromised
- anatomic abnormality
- catheterization
INVESTIGATION
rapid > urine dipstick (not in pregnant or catheterized)
midstream urine for culture
US
MX
- if pregnant >
if susceptible then cefalexin for 7 days
AVOID trimethoprim in 1st trimester (risk of neural tube defects)
AVOID nitrofurantoin at term(risk of neonatal hemolysis)
If only trimethoprim is option give along with 5mg folic acid
- if non pregnant > trimethoprim/nitrofurantoin for 3 days
- if man >
trimethoprim/nitrofurantoin for 7 days
What is the ABSOLUTE risk of ectopic pregnancy while using IUS contraception?
None of the contraception increase the absolute risk of ectopic pregnancy.
IUS is about 5% risk.
Missed pill rules
21/7 regime for COCP
- if one pill missed > have that pill ASAP even if 2 pills a day and continue as normal, no additional contraception.
- if two or more pills missed > take pill ASAP even if 2 a day
week 1 pill + UPSI: emergency contraception
week 2 pill: no UPSI for 7 days
week 3 pills: finish pack, omit pill free interval and start next one.
POP
taken same time daily
- traditional POP >3 hrs late: take pill ASAP (if more than one, missed take only one) and no USPI for 48 hrs.
if USPI during missed pill and within 48 hrs of restarting POP > emergency contraception - Desogestrel (cerazette) >12 hrs late: same as above.
- Postmenopausal bleed
- Tamoxifen for breast cancer
Risk of developing?
ENDOMETRIAL CANCER
RISK FACTORS
- Tamoxifen
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed estrogen (add progestogen to reduce this risk)
- DM
- PCOS
INVESTIGATION
1st: TVS (>4mm thickness abnormal)
2nd: hysteroscopy with endometrial biopsy for diagnosis.
- post emergency LSCS bleed
- fever
- fouls smelling discharge
- tender bulky uterus
- placenta and membranes completely removed at time of delivery
- US shows uterus empty
Diagnosis?
ENDOMETRITIS
RISK FACTORS
- emergency LSCS
- curettage
- PROM
- prolonged labor
- multiple pelvic exams
- internal fetal monitoring (scalp electrodes/intrauterine)
MX
co-amoxiclav (Uk guidelines)
gentamycin + clindamycin (WHO guidelines)
gentamycin + cefotaxime + metronidazole (RCOG guidelines)
- Rh negative mother
- father status unknown
- no IM injection in previous pregnancy
- baby develops jaundice
Diagnosis?
Rh incompatibility
- Rh negative mother delivers Rh positive baby
- anti D IgG antibodies formed in mother, causes hemolysis in future pregnancies.
PREVENTION
- Test for anti D antibodies in Rh negative mothers
- if not previously sensitized > single dose of anti D immunoglobulin at 28 weeks/ two doses 28 and 34 weeks
if previously sensitized > no need of anti D
EMERGENCY ANTI D (within 72 hrs)
- delivery of Rh-positive baby (live/stillborn)
- miscarriage> 12 weeks
- termination/evacuation
- blunt abdominal trauma
- ectopic pregnancy
- ECV
- antepartum hemorrhage
- chorionic villus sampling/amniocentesis/fetal blood sampling
MX
- if unborn (hydrops fetalis, heart failure) > intrauterine blood transfusion
- if born (anemia, jaundice, hepatosplenomegaly) > Phototherapy, blood transfusion, exchange transfusion.
Pregnant woman with seizures, headache, visual disturbance and abdominal pain.
Diagnosis?
ECLAMPSIA
MX
- MgSO4 4mg in 100ml 0.9% NS IV over 5-15 mins loading dose
- 1mg/hr for next 24 hrs following last seizure
- recurrent: 2-4mg again over 5-10 mins
CTG shows baseline 150bpm, variability of less than 5 for 30 mins, no accelerations or decelerations. What is the next step?
1 non reassuring factor: change position, IV fluids, reduce oxytocin if ongoing, start tocolytics.
Normal bpm: 110-160
Non-Reassuring bpm: 100-109 or 161-180
Normal variability: 5-25
Non-Reassuring variability: <5 for 30-50 mins/ >25 for 15-25 mins
Normal decelerations: none
Reassuring decelerations: late in 50% for less than 30 mins with no bleeding
If 2 non reassuring factors/1 abnormal factor > expedite birth and conservative mx
- elderly woman with CA- 125 positive (>35)
- abdominal bloating
- loss of appetite
- early satiety
- normal abdominal and pelvic exam
Diagnosis?
What is the next step?
Should we refer to gynecology immediately?
OVARIAN CANCER
RISK FACTORS
- age
- BRCA1 and BRCA2
- family hx
- nulliparity
- smoking
- obesity
PROTECTIVE FACTORS
- COCP
- Pregnancy
MX
If CA 125 raise > Urgent US
If US abnormal > urgent referral to gynecology
BUT IF PATIENT HAS PELVIC/ABDOMINAL MASS OR ASCITES»_space;» REFER TO GYNECOLOGY IMMEDIATELY (skip CA125 and US)
- pregnant woman with post coital bleed
- fetal US and heartbeat normal
- placenta anterior and high
- os closed
- abdomen soft non tender
Diagnosis?
CERVICAL ECTROPION
- columnar epithelium replaces squamous epithelium.
- red ring around os.
- post coital bleed
- excess non purulent discharge
- enlarges due to excess estrogen.
RISK FACTOR
- pregnancy
- COCP
MX
- cervical smear to ensure it is normal
- treated if bothersome
- silver nitrate cautery, diathermy, cryotherapy.
- young woman
- stopped COCP
- amenorrhea
- US normal
- low FSH, LH, Estrogen
- TFT normal
Diagnosis?
POST PILL AMENORRHOEA
- for up to 6 months
- due to suppression of pituitary gland
MX
- waiting for period
- if patient anxious/wants to conceive, we can start medication after 3 months itself.
- Clomiphene citrate
What is the main cause of cervical cancer?
main cause: HPV
others: smoking, multiple sexual partners, immunosuppression, COCP (don’t ever ask to stop COCP as risk is very minute).
First investigation in patient with menorrhagia with no other symptoms?
Full blood count
menorrhagia + recurrent nose bleeds/bruises + family hx of coagulation disorders > Coagulation screen
menorrhagia + palpable uterine mass suspecting fibroids > US
- near term pregnant woman comes with leaking clear fluids
- fever and sweating
- suprapubic tenderness
- small for date uterus
- CTG shows fetal tachycardia
Diagnosis?
CHORIOAMNITIS
due to prolonged rupture of membranes
- continuous leak of urine from vagina
- hx of hysterectomy
Diagnosis?
VESICOVAGINAL FISTULA
CAUSES:
- cancer
- hysterectomy
- pelvic radiotherapy
- difficult vaginal delivery
- heavy vaginal bleeding
- uterine thickness > 12mm
- diagnosis of benign endometrial hyperplasia without atypia
- does not plan on having more children
Management?
LNG- IUS
UKMEC 1 contraception in migraine with aura?
IUCD
white cheesy discharge + vaginal itching
Diagnosis?
VAGINAL THRUSH- candidiasis
- tender white plaques on vulva
- itchy
- worse at night
- hx of diabetes
Diagnosis?
Management?
LICHEN SCLEROSUS
MX
- topical steroids
- follow up in 3 and 6 months (may progress to squamous cell carcinoma)
- woman <40 yrs old didn’t have period for 10 months
- worried about early menopause
What test would you order?
PREMATURE OVARIAN FAILURE
- serum FSH
- diagnosis: 2 levels of > 25 IU/L taken 4 weeks apart
- can have hx of chemo or radiotherapy
MX
- HRT till 51 yrs old
- placental abruption leading to stillborn
- placenta delivered intact
What factor would lead to postpartum hemorrhage?
Disseminated intravascular coagulation.
- chronic cyclical pelvic pain
- dysmenorrhea
- taken NSAIDS
- painful sex
- COCP used but no benefit
- no urinary pr bowel symptoms
Diagnosis?
ENDOMETRIOSIS
TVS can be done but can be normal in some cases.
gold standard: Laparoscopy for diagnosis and treatment
MX
1st: NSAIDS
2md: COCP
3rd: LNG-IUS
postmenopausal woman wants prophylaxis from recurrent UTIs
Management?
1st: Topical vaginal estrogen tablets
2nd: antibiotic prophylaxis
- patient with urge incontinence
- wets herself before she reaches the toilet
Management?
1st: modify fluid intake, reduce caffeine and alcohol, bladder training. (for 6 weeks)
2nd: Antimuscarinic (anticholinergic) drugs to reduce involuntary contractions of detrusor muscle.
- oxybutynin (avoided in frail older women)
- tolterodine
- darifenacin
- mirabegron (costly, so not 1st line)
What is the best contraception for a young girl (around 15 yrs) who is not sexually active and has symptoms of dysmenorrhea only?
Mefenamic acid -NSAIDS
What is the best and most specific modality in determining viability of fetus in 1st trimester?
TVS
- patient with stress incontinence
Management?
1st: pelvic floor exercises (8 contractions TID for 3 months)
2nd: Retropubic mid-urethral tape
3rd: Duloxetine (if not suitable for surgery)
- 2nd or 3rd trimester
- severe itching
- excoriations on trunk
- no rash
Diagnosis?
Investigation?
INTRAHEPATIC CHOLESTASIS OF PREGNANCY- obstetrics cholestasis
Investigation of choice: Liver function test
ALP physiologically raised in pregnancy but ALP and AST both will be raised in IHC.
Most sensitive + specific: serum bile acids ( >/= 19 micromol/L)
Diagnosis: LFT + bile acid
Associated risk: stillbirth
MX
- monitor LFTS and bile acid after one week
- topical emollients (calamine lotion, chlorpheniramine maleate/piriton)
- Ursodeoxycholic acid (does not reduce risk of stillbirth)
- early induction of labor if moderate/severe case
- if prolonged prothrombin time»_space;> vitamin K daily
IUD thread not found.
Management?
1st: speculum examination
2nd: exclude pregnancy.
3rd: TVS/Pelvic US
4th: abdominal Xray (in cases with acute abdomen > suspect uterine perforation»_space; laparoscopic removal)
Depending how question is phrased a COCP may be the answer.
