Obs and Gynae 2 Flashcards
When switching from a traditional POP to COCP what advice should be given?
(with correct prior use) 7 days of barrier contraception is needed
Which contraception is safe to use if on rifampicin (enzyme inducer)
Depo-Provera
How long should you continue giving MgSO4 infusions for in someone with pre-eclampsia after delivery?
Magnesium treatment should continue for 24 hours after delivery or after last seizure
Risk factors for ectopic preg?
- damage to tubes (pelvic inflammatory disease, surgery)
- previous ectopic
- endometriosis
- IUCD/ coil/ IUS
- progesterone only pill
- IVF (3% of pregnancies are ectopic)
When should cervical screening take place if preg?
Unless?
usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
Contraceptives - time until effective (if not first day period)
IUD
POP
COCP
Depot
Implant
IUS
IUD- Immediately
POP- 2 days
COCP- 7 days
Depot- 7 days
Implant- 7 days
IUS- 7 days
Method of termination depending on gestation
- Week + method
2.
3.
- < 9 weeks = Mifepristone + misoprostol (vaginal prostoglandin)
- < 13week =surgical dilation and suction of uterine contents
- > 15 weeks = surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
What do you give for VTE prophylaxis in preg and how long for?
What should be avoided in preg? (2)
- If has 4 or more risk factors then LMWH immediately until 6 weeks after
- If 3 or less risk factors then LMWH from 28 weeks until 6 weeks after
- DOAC and Warfarin
Risk factors for VTE in preg:
(11)
- Age > 35
- Body mass index > 30
- Parity > 3
- Smoker
- Gross varicose veins
- Current pre-eclampsia
- Immobility
- Family history of unprovoked VTE
- Low risk thrombophilia
- Multiple pregnancy
- IVF pregnancy
What anti epileptics are good for preg and what are NOT good for preg
Good- **Lamotragine, carbamazepine and levetiracetam
Bad- Sadium valporate, phenobarbitone, phenytoin
Hyperemesis gravidarum management
Not lost weight=
First line-
Second line-
Lost weight (how much?) =
Not lost weight=
First line- Promethazine or cyclizine (anti-histamine)
Second line- Ondansetron or metoclopramide
Lost weight (> 5% of body weight) =
Hyperemesis gravidarum management
What info do you need to share with mother when discussing:
oral ondansetron (second line)
oral metoclopramide or domperidone (second line) (2)
oral ondansetron- If first trimester, assoc. with a small increased risk of cleft lip/palate.
metoclopramide- may cause extrapyramidal side effects in mum! It should therefore not be used for more than 5 days
What is the criteria to admit someone with hyperemisis gravidarum? (3)
- Continued N+V and is unable to keep down liquids or oral antiemetics
- N+V and Lost > 5% bodyweight or Ketonuria
- Low threshold if you have pre-exisiting comorbidity
Management of +ve GB Strep swab in preg?
It does not require treatment immediately, intrapartum intravenous benzylpenicillin is required to reduce neonatal transmission. alternative would be clindamycin
If mum and baby are struggling with breast feeding- what is the criteria to refer them to a beastfeeding clinic?
Breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
Normal weight loss is between 7-10% in first week
Post-partum contraception
When can you restart these:
At what point do they need contraception?
COCP (2)
- Additional for how long?
POP
- Additional for how long?
IUD or IUS (2)
Lactational Amenorrhoea method
- 21 days post-partum
COCP
- If NOT breast feeding then 3 weeks pp (due to VTE)
- If ARE breast feeding then CANNOT give if < 6 weeks pp
- 7 days of additional barrier after day 21
POP
- Anytime!
- 2 days of additional barrier after day 21
IUD/ IUS
- Can put in during c-section/ within 48hrs of pp
- If not then after 4 weeks
Lactational Amenorrhoea method
- Need to be amenorrhoeic and FULLY breastfeeding (no add feeds) 98% effective up until 6 months pp
Common complication of antero-posterior hysterectomy:
2 chronic
1 acute
Vaginal vault prolapse
Enterocoele
acute- urinary retention
Infomration regarding anti-epileptics and breast-feeding?
All safe apart from barbituates eg. phenobarbital
What drug increases the risk of endometrial hyperplasia?
Tamoxifen- ER+ hormonal treatment in breast cancer for Pre-menopausal women
What is the dose of folic acid you prescribe someone preg?
2 options! and until what week?
BMI < 30 = 400mcg from now until 12th week
BMI > 30 = 5mg from now until 12th week
Pre-menstrual depression/ cyclical depression management
Mild = Conservative (4)
Mod =
Severe =
Mild = Conservative- sleep, exercise, small balanced meals rich in carbs
Mod = New COCP- drospirenone 3 mg and ethinylestradiol 0.030 mg
Severe = SSRI. Can be taken continuously or just in luteal phase
What is ondansetron and why is it used in preg?
When counselling a patient on it, what do you need to mention?
serotonin 5-HT3 receptor antagonists- used in hyperemesis gravidarum
Safe in first 12 weeks gestation
associated with a small increased risk of cleft palate/lip - the MHRA advise that these risks need to be discussed with the pregnant woman before use
Trans males assigned female at birth on testosterone, contraception advice
Cannot use…
COCP or any oestrogen containing contraception if on testosterone as it can antagonise effect
Rubella in preg
Somone is preg and not had MMR vaccine, IgG rubella negative, what is your advice?
Keep away from anyone who has rubella and receive MMR vaccine when post-nata
What are the option for delivery in HIV preg?
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
What is the Hb cut off for first trimester iron supplements?
110
Hep B and pregnancy
How would you determine if baby is high risk of HepB? (2)
What should be offered to the baby and when?
Management
1.
2.
3.
4.
- mothers who are hepatitis B surface antigen positive
or 2. are known to be high risk of hepatitis B
Managment
1. At birth - Hep B vaccine
2. At birth - 0.5ml of HepB IG within 12 hours of birth
3. Further vaccine at 1-2 months
4 further vaccine at 6 months (maybe 12 months)
Management of pre-term labour (NOT PPROM!) therefore membranes are intact
1.
2. Give… 3/5 examples
3.
- Admit for observations (obvs check if membranes have ruptured)
- Give tocolytic such as Nifedipine, MgSO4, Terbutalinem Indomethacin, Atosiban (oxytocin antag)
- Give steroids to help fetal lungs mature
Don’t need to give abx if membranes haven’t ruptured
KNOW THE DIFFERENCE IN MANAGEMENT FOR STRESS AND URGENCY INCONTINENCE!
Stress: From coughing
1. First-line:
2. Second-line: Med and MOA
3. Surgery-
Urgency: Over-active bladder
1. First-line:
2. Med (first line med = ) BIG CI!
eg 2
eg 3
eg 4 if they are frail
Stress
- First-line: 6 weeks pelvic floor exercises 8 contractions performed 3 times a day for 3 months at least
- Second-line: Duloxetine (SNRI) increase in SE and NA in pudendal nerve, stims urethra striated muscle in sphincter enhanced.
- Surgery- retropubic mid-urethral tape procedures
Urgency: Over-active bladder
- First-line: Bladder retraining min 6 weeks
- First line med = antimucarinic - Oxybutynin (AVOID IN ELDERLY FRAIL WOMEN)
eg 2. tolterodine
eg 3 darifenacin
eg 4. If frail… mirabegron (a beta-3 agonist)
Investigations for any urinary incontinence:
1
2
3
4
- bladder diary for at least 3 days
- Urine dip MC + S
- Pelvic exam for any prolapse using a Sims’ speculum
- Urodynamic studies
-
- If > 50yo Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea
- If < 50yo stop after 2 years of amenorrhoea
Explain the different criteria for Categories of C-sections
C1- Criteria
Baby delivered within…
C2- Cause
Baby delivered within…
C3- Cause
Baby delivered within…
C4
C1- immediate threat to the life of the mother or baby
Examples:
- suspected uterine rupture
- major placental abruption
- cord prolaps
- fetal hypoxia
- persistent fetal bradycardia
Baby delivered within… 30 mins
C2
- maternal or fetal compromise which is not immediately life-threatening
Baby delivered within… 75 minutes
C3
delivery is required, but mother and baby are stable
Baby delivered within… 24 hours/that day
C4
elective caesarean
