Obs and Gynae Flashcards
Hyperemesis gravidarum
Upto 1% of pregnancies, General N+V common
Level of HCG related to severity. Higher incidence in multiple preg and molar (non viable egg implants)
Sx: N+V, dehydration, electrolyte imbalance, ketonuria
Tx: Fluids, antiemetics, K replacement, monitor U&E, usually improves by 12 weeks as HCG falls. Severe cases hospital stay and TPN
Miscarriage
Ax: Pregnancy loss less than 24 weeks. Chromosomal abnormalities of fetus. Recurrent miscarriage ax with APS/uterine abnormalities
Threatened: Pain and bleeding with closed cervical OS and viable pregnancy on US
Inevitable: Pain and bleeding open cervical OS
Missed (minimal signs. Dx on USS)
Incomplete: Retained products of conception of USS
Complete: Products of conception passes. Cervical OS closes
10-20% of clinical pregnancies. Majority in first trimester
Ectopic pregnancy
Ax: 1% pregancies. Tubal most common site. When a fertilised egg impants itself outside of the womb
Associated with PID, Previous surgery/ectopic, coil/IUD, assisted reproduction
Can rupture and bleed into abdominal cavity
Sx: Lower abdo pain, bleeding, syncope
Ix: USS will show no intrauterine pregancy and may show adnexal mass, TVUS, hcg, progresterone, fBC, Diagnostic laparotomy
Tx: IM methotrexate if stable and minimal sx with no bleeding
Lap salpingectomy of affected tube and ectopic, salpingostomy where incision made into tube and extract ectopic
Menorrhagia
Ax. Heavy menstrual bleeding. Causes- fibroids, DUB, Coagulopathies, Liver, kidney, thyroid, malignancy, adenomyosis, polyps, endometriosis
Ix: FBC, TFT, TV USS, Endometrial biopsy if indicated (hyperplasia)
Tx: medical: Tranexamic/mefanamic acid, COP, Mirena coil (1st), progresterone, GnRH analogues,
Surgical: Fibroid resection, endometrial ablation, uterine artery embolisation, myomectomy/hysterectomy
Amen/Oligomenorrhea
Ax: Amenorrhoea- primary - absence of mensus by 14/16 without/with secondary sexual characteristics respectively
Secondary: Absence of menstruation > 6 months in a woman previously menstruating
Oligo= interval of more than 35 days between periods, causes pregancy, PCOS, Hyperprolactin, Ovarian failure/menopause, thyroid disease
Mx: Tx cause. Primary/Ovarian failure- COP to prevent oteoporosis from low estrogen
Premenstrual syndrome
PMS refers to the physical and emotional symptoms that occur in the 1-2weeks prior to period.
Symptoms vary and resolve around start of period
Sx: Acne, tender breasts, bloating, fatigue, irritable, mood changes
Pelvic pain
Ax: PID- Bilateral pelvic pain, discharge, dysmenorrhea, fever, post coital/IMB
Ectopic
Ovarian cyst torsion/rupture/haemorrhage- sudden unilateral pelvic pain, fever/vomiting
Endometriosis
(Other urological, pyelonephritis, appendicitis, diverticulitis, IBS/D)
Endometriosis
Ax: Endometrial tissue present outside the uterus. Usually pelvic organs and peritoneum.
Sx: Dysmenorrhoea, dysparenea, pelvic pain, ovulation pain, infertility, tenderness, palpable nodules
Ix: Pelvic USS, MRI pelvis, Diagnostic laparoscopy is gold standard
Tx: NSAID, Analgesia, COP/Progesterone, Mirena IUS,
Surgical: Laparoscopic ablation of lesions. Hysterctomy and bilateral salpingoophrectomy
Prolapse
Ax: Organs within pelvis are held together by ligaments and muscles called pelvic floor. If these support structures are overstretched organs can prolapse from natural position into vagina
Causes: Pregnancy and giving birth. Age (Post menopausal), overwight, caugh/straining
Mild can be asx, discomfort, heaviness, bladder, bowel, sexual problems
Cystocele: Ant wall- ant repair
Rectocele- post wall- post repair
Uterovaginal - hysterectomy. Vault prolapse post hystectomy
Mx: Lifestyle changes- lose weight, avoid heavy lifting, dec intra abdo pressure
Pelvic floor exercise: Vaginal hormone tx- estrogen cream
Pessery - helps support pelvic organs
Surgery- Pelvic floor repair - ant/post wall prolapse
Sacrospinous fixation. Lift and attach uterus/vagina to bottom of spine
Incontinence
Ax: Involunatry passage of urine.
Stress: Most common: When pressure in bladder too much. Due to weak pelvic floor muscles. Leak when cough, laugh, sneeze, strain. Weakened by childbirth
Urge (Overactive) - urgent desire to pass urine,
Bladder muscle overactive and contracts to early. Feel fuller than is.
Ix: Keep diary, Urinarylsis, Urodynamic studies
Mx: Lifestyle, bladder retraining, WL, Pelvic floor ex. anticholinergics, botox
Stress: Tension free vaginal tape (Mesh), Duloxetine to help muscles around urethra contract, bulking agents to keep bladder entrance closed, colpususpension (move bladder neck from intrapelvic to intraabdo position)
Menopause
Ax: Premenopause is when a woman is experiencing normal periods. Perimenopause is the transition towards menopause. Occurs 3-4 years before. Ovaries start reducing the amount of estrogen.
Menopause roughly around 51. No menstruation for atleast 1 year.
Sx: Hot flushes, night sweats, vaginal atrophy, dryness, dyspareunia, overactive bladder, mood changes, decreased libido, osteoporosis, inc CVD risk
FSH and LH high. Estrogen low
HRT recommended for women with premature menopause or to treat menopausal symptoms
Combined HRT- Oestrogen and progesterone if uterus. Oestrogen only if hysterectomy
HRT can increase risk of VTE, Breast and endometrial cancer, vascular disease
Infections
Gonorrhea- Ceftriaxone
Chlamydia- Doxycycline (azithromycin). Cx - PID, infertility, ectopic, reactive arthiritis
HPV- Cervical cancer. Cervical screening picks up any abnormal cells from HPV before cancerous
25-49: Every 3 years, 50-64 every 5 years
Pelvic inflammatory disease
PID is inflammation of pelvic organs. Usually caused by infection spreading from vagina and cervix to womb, fallopian tubes, ovaries and pelvic area. Chlamydia and gonorrhea common cause
Constant lower abdo pain, discharge, dyspareimoa. pyrecia, cervical excitation, irregular PV bleeding, adnexal tenderness
Medical mx: Mild: oral ofloxacin + metronidazole for 14 days
Mod: IM ceftriaxone and oral doxycycline and metronidazole for 14 days
Cx: Infertility, ectopic, chronic pelvic pain
Gynae malignancy
Cervical CIN: Disordered growth of epithelial lining of transformation zone of cervix. HPV 16 and 18 high risk. Can refer for colposcopy. Inspection under magnification. CIN 2/3 treated with LLETZ
Cervical cancer: Squamous cell. Asx, irregular bleeding, post coital bleeding. OE hard bleeding cervix. Later causes ureteric obstruction, bladder/bowel involvement
Endometrial ca: Cancer within lining of womb, Risk factors- Obesity, tamoxifen, late menopause, HRT
Post menopausal bleeding common,
TVUSS to establish endometrial thickness. Dilation and curettage
Tx: Stage using MRI pelvis
1- TAH and BSO
2- Endocervix TAH and BSO and Radio + lymphadenectomy
3- Pelvicspread- Surgery + radio 4 distant spread- palliative radiotherapy
Ovarian cancer: Most common gynae malignancy. Adenocarcinoma
May be adnexal mass OE. Late stage px with large pelvic mass, palpable lymph nodes and pleural effusion.
Ix: pelvic USS and CA125, Staging MRI pelvic, CT AP
1- Ovaries- TAH and BSO and Omenectomy and chemo
2- 1/both avaries with pelvic extension 1 + lymph node removal
3- Outside pelvis - 2 and chemo prior to surgery
4- Distant 3 + palliative chemo
Subfertility
Primary: Trying to conceive a year but no pregnancy
Secondary: Trying to conceive for more than 1 year with previous hx pregnancy
Causes: Ovarian dysfuntion, PCOS, ovarian failure, Turners, HypoPituitary failure,
Tubal dysfunction - PID, endometriosis, uterine abnormality,
Ix: FSH/LH, oestrogen, prolactin, USS, Karyotype
Male factor: failure of production, klinefelter, CF,
Semen analysis
Tx cause - Ovulation induction - Laparoscopic ovarian drilling, clomifene, GnRH, IVF
