OBGYN Flashcards
What are the risk factors of pelvic organ prolapse?
Multiparity (biggest RF)
Obesity Age CTD (Ehlers Danlos) Race: White > Black / asian Increased abdominal pressure (constipation, straining, obesity, other)
What is the first line conservative and medical treatment for pelvic organ prolapse?
Pelvic Floor Exercises
Pessary
What is a complication of using pessary for pelvic organ prolapse?
Ulcers from irritation
Odour from secretions
What is the surgical management of pelvic organ prolapse?
Obliterative - Unable to have sex, the vagina is stitched up, ensure the patient is happy with this choice!
Reconstructive - Restore normal pelvic anatomy, a variety of approaches. Sutures, meshes, biomaterial. Vaginal, abdominal.
What are the 4 characterstics of hyperemesis gravidum?
- N&V (persistent and prolonged)
- Dehydration + Derranged U&E
- Ketones +++
- > 10% drop in BW
What are the risk factors of hyperemesis?
Anything that causes an increase in B-hCG
- Previous hyperemesis
- Twins or multiple pregnancies
- Molar pregnancy
- TSH
What is your immediate management for a patient with hyperemesis?
- Fluids IV - Crystalloid
- Antiemetic - Cyclizine*
- Vitamine - Thiamine & Folic Acid
- DVT prophylaxis
*Metclopramide and domperidone not used due to oliguric extrapyramidal side effects
What is a major complication of hyperemesis?
Wernickes Encephalopathy (due to depletion of Thiamine from excessive emesis)
What medication may be prescribed to resolve refractory hyperemesis?
Prednisolone
What may you find in a complete miscarriage?
Expulsion of all contents OS closed PV bleeding Abdo pain Uterus not felt with bleeding settled
What may you find in an incomplete miscarriage?
Incomplete expulsion
OS open
Crampy abdominal pain
Products visible
What is the risk of retained products in an incomplete miscarriage?
Cervical shock, remove products to prevent this
What may you find in an inevitable miscarriage?
OS open
Products not expelled
Still bleeding
Crampy lower abdominal pain
What may you find in a threatened miscarriage?
OS closed
Viable pregnancy
What may you find in a missed miscarriage?
Asymptomatic
Gestational sac with NO fetal pole
25 weeks or 7 weeks
What is a recurrent miscarriage?
3 or more CONSECUTIVE miscarriages
What are the causes of recurrent miscarriages occurring in the 1st, 2nd and 3rd trimester?
1st - X abnormalities
2nd - APL syndrome, ANA
3rd - APL syndrome, Endocrine abnormalities, Age (maternal and paternal)
Most common reason / cause is antiphospholipid syndrome (APL)
What blood test should you perform in a patient with recurrent miscarriage?
Test for SLE, APL, X abnormalities (if 3rd loss), USS
If all test are normal»_space;> unexplained miscarriage (TLC for the mother)
What is the Kleihauer-Betke test?
Blood test to measure amount of fetal hB transferred to mothers blood stream.
Results used to determine dose of Anti-D Ig
What are the options for managing an incomplete miscarriage and what are the success rates for each?
- Conservative (50-60% success) if NOT bleeding. Watch and wait for 14 days, call back unless bleeding within those days, and then do a pregnancy test.
- Medical (80% success).
Misoprostol (uterine contractions) + Mifepristone (terminate fetal heartbeat).
If bleeding stops > send home.
If bleeding continues > Surgical - Surgical (90% success)
Suction / Manual Evacuation
What risks are there in the surgical management of an incomplete miscarriage?
Bleeding
Uterine perforation
Cervical trauma
What may a negative sliding scale on USS be indicative of?
Ectopic pregnancy
Implanted strongly to structure therefore pressure applied will not result in movement of the gestation.
What is the clinical presentation of an ectopic pregnancy?
Amenorrhoea + sexually active Colicky abdo pain Dark or Fresh PV bleeding* Fainting/dizziness** Previous surgery (e.g. appendectomy) PID Conception after infertility
- Ddx of PV bleeding, miscarriage, PID, cervicitis
- *fallopian tube distention and stimulation of ANS
What are the risk factors for ectopic pregnancy?
Cause is usually tubular abnormalities. Things that affect this include…
Previous ectopic Endometriosis Smoking Salpingitis; surgery Progesterone IUD Sexual partners
How may the levels of B-hCG affect your management of ectopic pregnancy?
<500 - Conservative
500-1500 - Medical
>5000 - Surgical
How may the presence of a fetal heart beat affect the management of an ectopic pregnancy
> > > Always SURGICAL!
What is the difference between a salpingostomy and a salpingectomy?
Salpingostomy - Creating of a new opening into fallopian tube
Salpingectomy - removal of fallopian tube
hint: salpingOstomy, Opening
salpingEctomy, ecsize
What is the management of an ectopic pregnancy?
- Give Anti-D
- IVI for shock
- BHCG (dipstix + blood)
- TV USS + CTG for fetal heart beat
- Immediate laparotomy
- Methotrexate*
- Follow up twice a wk until BHCG <20
*MUST arrange a follow up if given methotrexate! Cannot conceive for 3 months, provide adequate contraception.
What is a molar pregnancy?
aka hyaditiform moles
What is the typical appearance on USS?
Complete: No genetic material in ovum, sperm from father, 46XY or 46XX
Incomplete: Two sperms, empty ovum
*snowstorm appearance on USS
What are the key diagnostic features of a molar pregnancy?
1st trimester of pregnancy Vaginal bleeding (frogspawn) Amenorrhoea / Missed period Extremes of reproductive age (<20yrs, >35yrs) Severe Hyperemesis
What is the management of molar pregnancies?
Surgical - Suction
Regular BHCG monitoring for 6months to 1 year
Avoid pregnancy for 1 year
What is the prognosis for a patient who has had a molar pregnancy?
Increased risk of recurrent molar pregnancy
Risk of choriocarcinoma, fortnightly B-hCG rest required to see if normalised, otherwise requires referring to molar pregnancy specialist
At what BMI should you do an OGTT in antenatal care?
> 30
What is the mnemonic for interpreting CTG’s?
DR C BRAVADO
Define Risk
Contractions
Baseline RAte
Variability
Acceleration
Deceleration
Overall plan
What are the features of pre-eclampsia?
PRE-eclampsia
Proteinuria (>0.3g/24h)
Rising blood pressure (>140/90)
Edema of the legs
What are the fetal and maternal complications of gestational diabetes?
Fetal: Macrosomia, Respiratory Destress Syndrome, Neonatal Hypoglycaemia, Congeintal Abnormalities (CHD)
Maternal: C-Section, pre-eclampsia, type 2 diabetes
What are the risk factors for pre-eclampsia?
Nulliparity FHx Obesity Diabetes HTN Extreme's of ages (<20 or >30)
At how many weeks pregnancy does pre-eclampsia usually develop?
~20 weeks
What are the clinical features of pre-eclampsia?
Headache
Nausea
Visual distrubances
Epigastric pain
What complications may arise from untreated UTI in pregnancy? What are the symptoms?
Pyelonephritis
(Fever, rigors, nausea, vomiting, loin pain)
Premature labour
What signs may be present, and should you comment about, during an obstetric examination?
hint: SSSUM
Symmetry - symmetrical / assymetrical abdominal distention
Scars - low transverse scar from C-sect, laparoscopic
Skin changes - Linea nigra (dark line from xiphisternum to pubis), Striae gravidum (purple stretch marks denoting current parity), Striae albicans (silvery stria denoting previous parity)
Umbilicus - flattened, eversion (polyhydramnios / multiple)
Movements - Fetal movements (occuring after 24 weeks)
What rate is a normal fetal heart beat?
110 - 160
What are some causes / associations of polyhydramnios?
Type 2 Maternal Diabetes
Macrosomia
Multiple pregnancies
Impaired swallowing by fetus
What are some consequences of polyhydramnios?
Pre-term labour
Placental abruption
Malpresentations (breech)
What are some causes of oligohydramnios?
- Inability of fetus to contribute to fluid, i.e. urinate (renal dysgenesis, polycystic kidneys, Potter’s syndrome)
or
- Rupture of amniotic membranes
What is a consequence of oligohydramnios?
Poor development of fetal lung tissue
What syndromes are assessed on nuchal scanning?
Pataus syndrome
Edwards syndrome
Downs syndrome
Nuchal scan measures the “fat PED” of the neck
At what weeks is the nuchal scan performed?
10-14 weeks
What invasive procedures are available for assessing whether a baby has a syndrome and at what week are they performed?
What risks do these tests carry and what is the probability of it happening?
Chorionic Villus Sampling (11-14 wks) - Needle into tummy
Amniocentesis (16 wks) - obtain babies cell from surrounding fluid
1/100 chance of miscarriage
What are the causes of PPH (4T’s)?
Tone - Abnormal uterine contraction
Tissue - Retained products of conception
Trauma - of genital tract
Thrombin - abnormal coagulation
What are the risk factors and protective factors of ovarian cancer?
Risk factors
- Early menarche
- Late menopause
- Nulliparity
- Fhx of ovarian/breast cancer
Protective factors
- Multiparity
- Lactation
- COCP use
What are the symptoms of ovarian cancer?
Abdominal pain and distension
Abnormal vaginal bleeding
Changes in bowel habits
Ovarian / pelvic mass
Evidence of pleural effusion, bowel obstruction or breast symptoms due to metastesis
What are the risk factors for cervical cancer?
HPV STIs e.g. chalmydia Multiple sexual partners Smoking Sex at a young age
What are the symptoms of cervical cancer?
Post-coital bleeding
Offensive vaginal discharge
Intermenstrual + Post-Menopausal bleeding may also be seen.
Late features include altered bowel habits, painless rectal bleeding, haematuria and chronic urinary frequency
What are some differentials for late pregnancy bleeding?
Divide by structures affected
- Cervical: Cervicitis, Polyp, Cancer
- Vaginal: Lacerations (more sensitive in pregnancy)
- Uterine: Rupture
- Placental: Abruption, previa, vasa previa
- Other: Hemorrhoids (notices only after BOed?)
What are the symptoms and RF of placental abruption
Painful between contractions!
Bleeding! (may be concealed)
Fetal distress
Firm tender uterus
Hypertension! Blunt trauma Cocaine use Multiparity Smoking
Placental Abruption is the No1 cause of late pregnancy bleeding and painful bleeding!
What CTG changes present in placental abruption?
Bradycardia
+
Late Decelerations (always seen in placental problems due to lack of blood flow to the fetus)
What are the complications of placental abruptions?
DIC! (prolonged PT and PTT, Thrombocytopaenia, schistocytes and helmet cells on film)
Preterm delivery
Maternal and/or fetal shock (resulting in renal failure)
Death
What is uterine rupture and what is the most common risk factors?
Complete separation of the wall of uterus
Classical (Vertical) C-Section
therefore uterine scarring as a result is a huge risk factor
What are the symptoms of uterine rupture?
How do you manage uterine rupture?
TEARING uterine pain
Popping sensation (significant pressure within uterus relieved on rupture which feels like pop)
Most reliable symptom is Fetal Distress (late decelerations)
Mx: Emergency C-Section
How may vasa-previa present?
artificial rupture of membrane > painLESS fresh pink blood > emergency c section
Vasa vessels covering cervical os. These vessels supply fetus. On artificial rupture, without knowing if vasa-previa, can result in massive bleeding.
What is the initial symptom of placenta-previa?
PainLESS uterine bleeding
Name three obstetric causes of late pregnancy painLESS bleeding?
Placenta Previa
Vasa Previa
Abnormal placentation
Name two obstetric causes of late pregnancy PAINFUL bleeding?
Placental Abruption
Uterine Rupture
What is endometriosis? How does it differ to adenomyosis?
What are the characteristic symptoms and signs of endometriosis?
Endometrial glands and stroma OUTSIDE NORMAL LOCATION.
Adenomyosis is where the glands are in the myometrium
- Cyclical pelvic pain* (not always but very indicative)
- Uterosacral nodularity
*Most common presenting complaint is chronic pelvic pain
Also a differential for subfertility / infertility
Chiefly affects reproductive-aged women
What are some risk factors for endometriosis?
Family history: Increased incident if 1st degree relatives also affected
Anatomical: anything causing Outflow Obstruction
Environmental: TCDD, caffeine, alcohol
*protective factors: smoking, exercise
What is the treatment for primary dysmenorrhoea?
NSAIDs
COCP
What are the symptoms of endometriosis?
Pain Symptoms
- Secondary Dysmenorrhoea (not responsive to NSAIDS or COCP)
- Dysparenuia (endometrial implants on uterosacral ligament which is moved during sexual intercourse)
- Dysuria (implants in the urethra)
- Defecatory pain (implants in the rectum)
Infertility / Subfertility (implants in the tubes / ovaries)
Intestinal obstruction (will appear like malignancy on CT, need to do laparoscopy to diagnose properly)
Urethral obstruction (increased frequency, urgency, retention, leading to renal failure, consult urologist)
What may you see, in endometriosis, on physical exam?
Visual inspection?
Speculum?
Bimanual?
Visual: Normal
Speculum: Usually normal, maybe blue/red lesions that easily burn
Bimanual:
UTEROSACRAL NODULARITY & TENDERNESS
FIXED RETROVERTED UTERUS (should be anteroverted)
Cystic adnexal mass
What is the management of endometriosis?
Conservative: Watch and wait
Medical: NSAIDs and COCP»_space;> GnRH Agonist (gonadorelin)
Surgical: ablation, resection, hysterectomy (make sure they dont want children, these patients are young and often want children!)
What are some differentials of endometriosis?
Gynecological
- PID (fever)
- Haemorrhagic ovarian cyst (no uterosacral nodularity)
- Ovarian torsion (acute pain, not chronic)
- Primary dysmenorrhea (younger, no other findings)
- Ectopic (dx with B-hCG)
Non-Gyne
- Chronic UTI (extensive hx)
- Interstitial cystitis (UA)
- Renal calculi (hx of kidney stones)
- GI: IBD, IBS, Diverticulitis (not common in young ppl)
- MSK:
What is a normal and abnormal frequency for voiding?
Every 4h is considered normal
Voiding more than 6x per day, or more frequent than every 2h is abnormal.
What is nocturia?
Interruption of sleep >1x per night to void
What questions may you ask in the urinary history of someone coming in complaining of incontinence?
OFNAUSPA
Onset Frequency Nocturnal Amount Urge (Sudden? Make it in time?) Stress (Staining, coughing, walking?) Pads (How many, types?) Access (to lavatories)
What is the conservative, medical and surgical treatment for stress incontinence?
Conservative
- Pelvic floor exercises
Medical
- Pseudoephedrine / Duloxetine
Surgical
- Colposuspension (elevation of bladder neck)
What are the different causes of urge incontinence that you should question about during a history?
BPH / Prostatic Carcinoma
- Elderly male
- Sx, from start to end, of hesitancy, intermittency, weak stream, terminal dribbling and feelings of incomplete voiding
- Metastatic sx include bone pain, weight loss, jaundice
Autonomic Neuropathy
- MS, PD, DM
- Other neurological symptoms present
UTI
- Fever, flank/groin/back pain, dysuria, haematuria, confusion, N&V
Stool impaction
- Constipation
Also consider Post Menopausal Atrophic Changes of the Bladder which is seen in post-menopausal women who have not / never undergone HRT
What clinical examination would you perform in a patient presenting with incontinence?
Performed with comfortably full bladder to demonstrate incontinence with cough
Signs of estrogen deficiency on inspection of genitalia
Uterovaginal descent on straining
Pelvic exam - pelvic mass which may be causing symptoms from pressure effects
Neurological disease, assess S2, S3, S4 dermatomes
What is the conservative, medical and surgical management of urge incontinence?
Conservative
- Involve incontinence advisory service
- Fluid intake habits altered
- Bladder training for detrusor instability
Medical
- HRT
- Abx for UTI
- Antimuscarinics (oxybutynin / tolterodine)
Surgical
- None
What are some common side effects of anticholinergics / antimuscarinics?
dry mouth
blurred vision
constipation
What investigations should be performed in a patient presenting with incontinence?
MSU - To exclude UTI
Urodynamic studies - Stress incontinence will be normal, detrusor instability will produce anomalies
How may you examine a patient presenting with symptoms congruent with a prolapse?
Record bodyweight, height, and fitness for surgery if indicated.
Inspect for masses, atrophy of genitalia, obvious prolapses.
Ask to cough, look for stress incontinence/prolapse. Describe prolapse.
Use Sim’s Speculum to assess prolapses.
Use bimanual to exclude masses.
What is the conservative, medical and surgical management of prolapses?
Conservative
- Stop smoking
- Loose weight
- Pelvic floor exercises
- Pessaries
Medical
- Vaginal estrogen cream
- HRT
Surgical
- Repair of prolapse
- Hysterectomy
How may you explain stress vs urge incontinence?
Stress
- Weak support
- Gives in to stress
- Unable to hold urine when pressure increases
Urge
- Bladder sensitive
- Urges to go ever if very little volume
- detrusor instability, sensitivity
How may you counsel a surgically-unfit patient on managing her procidentia?
Ensure to patient that it is not harmful although it is progressive.
Advise estrogen cream to prevent excoriation and dryness of the vagina. Alternatively, HRT can be prescribed.
Pessaries can be inserted. Intially ring pessaries, then move onto shelf pessaries. 6 monthly replacements, risks of ulcers and excoriations, where if occurring will be remedied with estrogen creams for 2-4 weeks.
Risk of urinary incontinence and fecal impaction with pessaries.
What are the causes of post-coital bleeding?
Cervical carcinoma
Cervical polyp
Cervical ectropion
Chlamydia
What factors should you question the woman about for a couple presenting with sub-fertility?
Miscarriages
PCOS
STIs / PID
Cancers
What general questions should you ask about a couples sexual relationship who have come in with sub-fertility?
Regularity
Problems with sex (pain, erectile dysfunction)
How long trying for?
Previous pregnancies together or with other partners?
What factors should you question a man about for a couple presenting with sub-fertility?
Undecended testes Torsion or trauma Mumps as an adult STIs (chlamydia) Cancer
What questions should you ask about in the SH of sub-fertility?
Drinking, smoking, drugs
Employment? Tiredness?
Long time spent away from each other?
What questions should you ask the woman in DH for sub-fertility?
Current medications
Allergies
Have you tried medicines to help with fertility
History of contraception use in the past (take full history)
What are the female causes of subfertility?
Age
Weight
Unhealthy habits
Systemic conditions (SLE)
Iatrogenic - Surgery / Chemotherapy
Ovulatory disorders
- PCOS
- hyperprolactinaemia
- thyroid
- premature menopause
Tubular pathology
- PID
- Endometriosis
Uterine pathology
- fibroids
What are the male causes of subfertility?
V - systemic conditions (SLE) I - Gonorrhoea, Chlamydia, Mumps T - Trauma A - SLE? M - I - chemotherapy, vasectomy N - testicular cancer, prostate cancer C - undecended testes D - E - F - K - downs
What medication can be given to stimulate ovulation?
clomiphene
What method of conception may be offered where there is a problem with the fallopian tubes or sperm quality?
IVF
What are the causes of pelvic pain?
Gyne
- PID
- Ectopic pregnancy
- Ovarian cyst / rupture / torsion / haemorrhage
- Endometriosis
- Ovulation pain
Urological
- Pyelonephritis
- Renal colic
GI
- Appendicitis
- Diverticulitis
- IBS / IBD
Symptoms of PID
BILATERAL pelvic pain PV Discharge Dyspareunia and Dysmenorrhoea Fever Bleeding post-coital / intermenstrual Unprotected sex with multiple / new partners
Symptoms of ectopic
Unilateral pain + spotting + amenorrhoea
Trying to get pregnant / unprotected sex
Usually occurs at 5-9 weeks gestation
In tubal rupture»_space;> collapse and shoulder tip pain
Symptoms of ovarian pathology (cyst/rupture/torsion/haemorrhoage)
SUDDEN UNILATERAL pelvic pain
Fever & Vomitting
Symptoms of endometriosis
CYCLICAL pelvic pain
DEEP dyspareunia
Dysmenorrhoea
Menstrual disturbance
Symptoms of pyelonpehritis
Fever, chills, rigors
Loin pain
Urinary frequency and Dysuria
Symptoms of appendicitis
Pain periumbilical»_space;> RIF
Anorexia
Young
Symptoms of diverticulitis
Elderly
LIF
Pyrexic
Symptoms of IBD/IBS
Change in bowel habits
Lower abdominal pain
IBD: Blood / Mucus PR
What are the causes of menorrhagia PV bleeding?
DUB (most cases)
Fibroids
Endometriosis
What are the causes of inter-menstrual PV bleeding?
Normal spotting at middle of cycle Breakthrough bleed from contraception Polyps (cervical or endometrial) Ectropion Ectopic Infection / STI / PID
What are the causes of post-coital PV bleeding?
Cervical Trauma
Cervical Cancer
Cervical Ectropion
Cervical Polyp
What are the causes of post-menopausal PV bleeding?
Cervical Cancer (until proven otherwise!) Atrophic Vaginitis (90% of cases)
What categories of questions should you ask in PV bleeding?
Type (menorrhagia/inter/post-coital or menopausal)
Timing (onset, duration, progression, frequency)
Bleeding (pattern, amount, pain)
Anaemia sx (tiredness, breathlessness on exertion)
Thyroid sx (hypothyroidism)
What question should you always ask in a PV bleed systems review?
Weight loss, night sweats, fatigue
For cervical / endometrial cancer
List the possible causes of amenorrhoea / oligomenorrhoea?
Gyne
- Primary amenorrhoea
- Pregnant
- PCOS
- Menopause
Endocrine
- Hyperthyroidism
- Hyperprolactinaemia
- Hypogonadotrophic Hypogonadism
- Cushings
Other
-Progesterone pill
What is primary amenorrhoea?
What are the causes?
Menarche not reached by the age of 16
Most commonly constitutional delay
- Mother and siblings may also have a late start
Other causes
- Testicular feminisation
- PCOS
What are the symptoms of PCOS? What causes these symptoms?
How is it investigated and managed?
Oligomenorrhoea more commonly than amenorrhoea
Hiristuism
Acne
Obesity
Subfertility
Sx due to excessive androgen hormones
Investigated by
- USS
- Blood glucose may show diabetes (insuline resistance)
Manage by
- Weight loss
- Diet
- COCP for hirustism and irregular periods
- Metformin for insulin resistance
- Laparoscopic ovarian drilling
What are the common causes of hypogonadotrophic hypogonadism?
What changes to FSH and LH does this cause?
Anorexia Anxiety Excessive exercise Stress Depression Starvation
Low FSH and LH levels
How is menopause defined?
How is premature menopause defined?
What symptoms may a woman experience during the perimenopause phase (the change)?
Menopause: Periods absent for 12 consecutive months
Premature menopause: Menopause before the age of 40
The change: Hot flushes, profuse sweating, loss of libido, vaginal atrophy, irregular periods
How is menopause investigated?
How are the symptoms of menopause managed?
PV exam - vaginal atropy
Managed
- Topical: lubrican / cream / estrogen for atrophy
- HRT
What are the symptoms of hyperprolactinaemia?
What are the causes?
How is it investigated?
How is it managed?
Galactorrhoea, oligo/amenorrhoea, subfertility, (bitemporal hemianopsia if macroprolactinoma)
Antipsychotic use
Macroprolactinomas (will press on optic nerve)
Pregnancy, breast feeding
Stress
MRI head if visual disturbances
Managed
- bromocriptine (DA agonist)
- surgery if visual defect present
What are some obstetric causes of PV Bleeding?
Miscarriage Ectopic Braxton Hicks Labour Pre-eclampsia Placental abruption Uterine rupture Acute fatty liver of pregnancy
What are the symptoms of a miscarriage?
PV bleeding
Products of conception may be present
Pelvic pain
<24 wks
What are the absolute contraindications of the COCP?
Smoker >35 years <6/52 post-partum Breastfeeding Hypertension Current or past DVT Hx Migraine with aura CVD Current breast cancer Liver cirrhosis
How does the COCP work and prevent conception?
Stops ovulation
Thickens cervical mucus
Thins endothelium
What formulations of the COCP are available and how is each taken?
Pill
- daily
- 3 weeks on 1 week off
Patch
- weekly
- 3 weeks on 1 week off
Ring
- changed after 3 week
- 1 week break between taking out and putting in
What are the SE of the COCP?
Hormonal SE: acne, headaches, weight gain
Blood clots
Increased risk of Breast and Cervical ca
Local irritation with the patch
Pain during intercourse with ring (can be taken out but only for maximum of 3 hours)
What are some benefits of the COCP?
Controls periods, pain and bleeding
What is the rule for missed doses of COCP?
Take ASAP even if with next dose.
If next dose on time then fine.
If missed second dose, take a pill immediately + condom for 7 days
What is the treatment course for the minipill?
What are some of the side effects?
What are some of the pros and cons of it?
What should you do if you miss a dose?
Take everyday, at exactly the same time
SE: hormonal, irregular bleeding
-ve: needs taking at exactly the same time
Missed: take immediately (even with next one). If more than >3h late then use condom for next 2 days. Use emergency contraception if had unprotected sex 2-3 days before or after missed pill.
What are the contraindications for the progesterone only pill?
Forgetfulness
Breast cancer
Liver disease
Undiagnosed PV bleeding
What cancers can the COCP protect against?
Ovarian and endometrial
Hint: COCP protects O and E
How does the copper coil work?
Copper is a spermicide
Causes uterine inflammation
Compare the risks of the copper coil with marina coil
Both carry coil insertion risks: infection in first 3 weeks, bleeding, perforation
Copper - may cause heavier periods (think increased uterine inflammation resulting in more bleeding)
Marina - may cause spotting in first 6 months after which periods will be very light / stop
What are the contraindications for both the copper and marina coil?
Both
- pelvic infection
- PID <3 months ago
- Gyne ca
- Small uterine cavity
- undiagnosed PV bleeding
For Copper IUD
- copper allergy
What are the contraindications for progesterone implant / injection?
liver / genital / breast ca
Liver disease
Undiagnosed PV bleeding
How long does the Prog Implant last for?
What are the SE?
What are the + and -?
How is it implanted?
3 years
SE: Hormonal, periods spotting / light / stop
+ can forget about it
- some continue to experience spotting
Placed on inner upper arm
Around 4 cm
Under local anaesthetic
Can feel it after procedure
What checks need doing before and during the insertion of a coil?
When during the cycle can it be fitted in?
STI check prior
Check string present every month
If not had sex since period then can fit any time, or within first 5 days of periods starting
Side effects of prog implant
Hormonal
Periods > stop/ irregular / longer
Weight gain
Time for fertility to return
Osteoporosis (>2y consider, >5y stop)
Drawbacks of prog implant?
- must remember to come back every 3 months
- time for fertility to return
- cannot remove so side effects may last 3 months
How is a vasectomy performed? How long does the procedure take?
What is the failure rate?
What are some side effects and complications of the procedure?
Vas deferens cut and tied by forceps
Local anaesthetics
20 minutes procedure
1/2000 fail
Bleeding bruising infection
Scrotal swelling for first few days
Chronic testicular pain (1-3%)
Irreversible (50%)
After a vasectomy…
How long until intercourse?
When sperm free?
When sperm tests?
Condom sex - whenever you feel ready
May take up to 3 months for all of sperm to be used up
Sperm count test at 8 weeks and then 2-4 weeks later (both must be -ve)
How is tubal ligation performed?
What is the failure rate?
What risks are involved?
Clipping of fallopian tubes under GA
1/200
Surgical risks
Anaesthetic risks
What are some draw backs of condoms as a method of contraception?
Latex allergies
May slip off / break
New one every time
Oil based products may damage latex
Screening tests for what two genetic conditions are done at 10 weeks or earlier?
Sickle Cell
Beta Thalassaemia
Between 8-12 weeks, a screening test for which three infectious diseases is performed?
HIV
Hep B
Syphilis
What additional screening test should be performed on a diabetic pregnant patient?
Eye screening
What is the combined test and when is it performed? What does it screen for?
Nuchal scanning + Blood test for PaPP and BHCG
11-14 weeks
Pataus
Edawards
Downs
When are the newborn checks done and what does it check for?
Within 72 hours of being born
Screens for problems with eyes, heart, hips, genetalia (+testes)
What is the blood spot test and when is it performed?
@5 days old
Screens for rare but serious conditions such as
- CF
- Congenital hypothyroidism
- Sickle cell
- Inherited metabolic diseases
What are the risk factors for miscarriage?
old age uterine malformation bacterial vaginosis thrombophilia chromosomal anomaly
How may an USS differentiate a miscarriage from an ectopic?
Products of conception would be visualised in an USS if a miscarriage. Uterus would be empty if it was an ectopic.
What investigations should you order in the suspected miscarriage patient?
Urine B-HCG to confirm pregnancy
FBC for blood loss
Blood group for rhesus status (if negative, give anti D)
Cross match in case of shock
USS to visualise products vs empty (ectopic)
Serum B-HCG as doubling of levels within 48h indicates a viable intrauterine pregnancy
What is the conservative, medical and surgical management of a miscarriage?
Conservative
- Analgaesia
- Anti-D
- Wait for expulsion
Medical
- Analgaesia
- Misoprostol (pg) for severe vaginal bleeding
- Mifepristone (anti-prog) induces evacuation of uterus
- Anti-D
Surgical
- Suction evacuation
- GA
- Analgaesia
- Oxytocics to facilitate uterine evacuation
- Mifepristone to facilitate uterine evacuation
- Anti-D
When may methotrexate be appropriate in the management of an ectopic pregnancy?
If
- Haemodynamically stable
- hCG <5000
- Unruptured ectopic of <3-4cm
What is the surgical management of an ectopic?
Salpingotomy/salpingostomy - incision made and ectopic removed
Salpingectomy - removal of ectopic WITH fallopian tube
PLUS methotrexate in either case, prevents failure rate in salpingostomies.
What tests should be done after a salpingostomy and a salpingectomy?
B-hCG should be measured after both
What risk factors, if present, require a hospital birth only?
Previous births
- C section
- Six children
- Serious PPH
Current baby
- Twins / multiple
- Breech
- Previa
- Problems with baby
Maternal factors
- Anaemia
- GDM
- Pre-eclampsia
- Age >40yrs
- Obesity
