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
PCOS
Common condition. 2/3: Polycystic ovaries on USS, Oligo/an ovulation, clincal excess androgens
Sx: Irregular periods, excess hair growth, obesity, acne, subfertility
Tx: Lose weight, Clomifene, Fertility meds/LOD
Downs syndrome
Inc with maternal age. Trisomy 21
10-11 weeks: Combined test. NT and (HCG and PAPP-A)
14-20: Quarriple test (HCG, AFP, Oestriol, inhibin A)
If high risk then CVS (from 11-14)/ Amniocentesis >15
Antepartal Haemorrhage
Bleeding from 24weeks - birth
Causes: Placenta praevia, Placentral abruption, vasa previa
Placenta previa- low lying placenta. Minor: Distance between OS. Major: Covering OS (lower segment)
Identified at 20 week scan USS. Another scan at 34 weeks
Tx: C section. Elective 39 weeks
Placental abruption- Premature placenta separates from placental wall, higher risk mp, polyhydramnios, pre eclampsia, smoking
sx: painful pv bleeding, abdo pain, fetal/maternal comprimise, woody hard uterus,
Vasa praevia: Umbilical cord bv run near opening of uterus
PPH
Primary PPH: >500ml blood loss within first 24hrs of delivery
Secondary PPH: >500ml after 24hrs delivery
Risk factors: prolonged delivery, mutiparty, prev PPH, assisted delivery
Tone: Uterine atony
Trauma: cervical, vaginal, perineal tears
Tissue: retained placenta/membranes
Thrombin: Coag disorder
PV bleeding: Tachycardia, tachypnea, hypotn
Tx: Resus pt, uterine massage, oxytocin/ergometrine to stimulatr uterine contraction
Examination to exclude retained tissue and perineal trauma
Surgical: intrauterine balloon, uterine artery embolisation, uterine artery ligation, hysterectomy
Pre-eclampsia
Chronic HTN: Women with high BP >140/90 before pregnancy
Gestational HTN- High BP after 20 weeks in pregnancy and goes away after delivery
Preeclampsia- Both chronic and gestational HTN can lead to this condition after week 20 of pregnancy. Sx: HTN, proteinurea
Sx: Headache, Vision problems, abdo pain, oedema, hyperreflexia.
High risk then give aspirin from 12th week pregnancy. E.g if HTN prev pregnancy/chronic HTN, CKD, autoimmune, T1/2 DM
HTN and proteinurea: Oedema, hyperreflexia indicates high risk of seizures.
HELLP: haemolysis, Inc liver enzymes, low platelets
Ix: BP >160/110 severe, urine at routine apt. 24hr urine collection, protein creatinine ratio
FBC (low Hb, platelets), LFT (High ALT and LDH), U&E (high uric acid and Cr), USS- fetal weight and growth, umbilical artery doppler and CTG
Cx: IUGR, preterm, HELLP, Placental abruption, eclampsia, cvd
Mx: Delivery at 37weeks or earlier. IOL/C section. If <34 weeks steroids
Hospital: Monitor BP, urine, meds- labetalol.
If BP severe- labetalol, Mg sulphate to tx eclampsia
Surgical- C section
Induction of labour
Indications for IOL: Postmaturity, PROM, IUGR, Gest diabetes, obstetric cholestasis, pre eclampsia
Types: medical= vaginal PGE2. Oxytocin infusion.
Surgical: membrane sweep, artificial rupture of membrane
Cx: higher risk of instrumental and operative delivery, uterine hyperstimulation, failed induction, cord prolapse, uterine rupture
High risk pregnancy
Diabetes- Inc requirement in pregnancy. Middle/towards end of pregnancy. Rf: High BMI, previous large baby, PMHx GDM, Frist degree relative with diabetes, ethnic, inc age/smoking
If above risk factors offer OGT during pregnancy. OGTT between 24-28wks.
Risk factors for fetus: macrosomia, shoulder dystocia, polyhydramnios, still birth, preterm with low lung maturity
Risk factors for mother: Diabetic neph, retinopathy, inc risk miscarriage, pre eclampsia, operative delivery
Mx: metformin, insulin, IOL at 38/39 weeks is norm
Prgenancy
Antiepileptics are teratogenic. Increased risk of NT defects. Orofacial and heart defects. Seizure frequency can increase due to poor compliance, hyperemesis
Mx: folic acid to reduce NT defects. Continue med in majority to prevent mortaliry and morbidity.
Vit K from 36 weeks to prevent haemorrhagic disease of newborn
Anaemia: Associated with low birth and preterm. Inc risk through preganancy due to iron def and inc risk PPH.
VTE: Thrombophilia- APS ax with inc preg loss and IUGR. LMWH in current DVT or PE.
Thromboprophylaxis if risk factors/following caesrian
Multiple preg
Dichorionic diamniotic. 2 eggs fertilised/1 egg splits soon after fertilisation, own placenta with own amniotic sac. Non identical
Monochorionic diamniotic: fertilised egg splits later. Babies share a chorion but have own amniotic sac - identical
Monochorionic monoamniotic - less common but egg splits later and babies share placenta and chorion
Risks mother: Hyperemesis, anemia, pre-eclampsia, GD, high chance C section/assisted
Child prematurity: If less than 37 may neeed care. problems breathing, feeding, infection
IUGR, twin to twin transfusion syndrome
Mx: consultant lead healthcare team
More visits to antenatal clinic. extra scans. iron and folic acid. low dose aspirin if preeclampisa
IOL/Cs: if 1st cephalic then vag and ecv the other. If not then C section
SGA and IUGR
SGA when birthweight < 10 percentile
Causes: maternal age, prev sga, meds (warfarin/anticonvulsants), TORCH, preeclamp, Diabetes, APS, SLE
Fetal chromosomal abnormalities, congenital abnormalities, infections.
Placental: pre eclamp/abruption
Contraception
COP: Inhibits ovulation, thickens cervical mucus, inhibits implantation,
contra: CVD, Migraine, Prev VTE, Smoker, High BMI, Breat feeding, hormone dependent ca
Benefits: Imp PMS, lighter periods, reduction in endometrial/ovarian ca
Problems: WG, HTN, Headache
POP: Inhibits implantation, thickens cervical mucus.
Contra: Liver disease, current vte, hormone dependent ca
Benefits: Useful if COP contra, amenorrhea
Problems: Erratic bleeding, nausea
Depot provera: Inhibits ovulation, thickens cervical mucus, inhibits implantation. Works as POP.
Benefits: more suitable in those who forget to take pill daily
Problems: menstrual irregularities, delayed return to fertility, weight gain
Implant: Prevents ovulation. Works as pop
Benefits: oligomenorrhoea, amenorrhoea, long term
Problems delayed return to fertility, irregular bleeding
Copper IUD: prevents implantation
Contraindications: menorrhagia, uterine abnormality, PID, cervical/endometrial ca
Benefits: long term
Problems: Inc menstrual flow and dysmenorrhea, ectopic, perforation, pid
Mirena IUS: Prevents implantation.
Contrs: Uterine abnormalities, acute PID, Cervical/endometrial ca
Benefits: Long term. Oligomenorrhea/amen,
Problems: ectopic, perforation and expluson, PID
Emergency: Progesterone only: single dose taken within 72hrs of unprotected sex
Copper IUD: Inserted upto 5 days after unprotected sex
