obs and gynae 3a Flashcards
detail the steps in the menstrual cycle (hormones)
hypothalamus–>GnRH–> anterior pituitary gland–>Fsh and LH
1) FSH stimulates follicule maturation
2) Oestrogen produced by maturing follicule
3) At low oestrogen levels oestrogen inhibits LH (negative feedback on anterior pituitary)
4) FSH secreted at low oestrogen levels (rise in oestrogen=fall in FSH)
5) Oestrogen levels rise and stimulate LH secretion
6) LH triggers ovulation
7) corpus luteum secretes oestrogen, inhibin and progesterone–> negative feedback inhibiting secretion of FSH (preventing further follicule maturation).
8) Porgesterone stimulates endometrial growth and inhibits GnRH production
9) Corpus luteum degenerates. Fall in progesterone (endometrium shed)–> GnRH not inhibited–> stimulates new cylcle (FSH and LH)
Describe the hormonal changes that occur to allow labour to commence
progesterone and oestrogen DROP
prostaglans RISE- causes uterus to contract
progesterone and oestrogen initially produced by corpus luteum in first trimester, then by placenta
progesterone is a smooth muscle and so inhibits uterine contraction
what is the metabolic disturbance seen in hyperemesis gravidarum
Hypochroraemic alkalosis
management of gestational diabetes melitus
Aim for BM <7.8 post prandial
1) diet and exercise
2) metformin
3) insulin
4) detailed anomaly scan and monitor growth (risk of preterm delivery, miscarriage, cardiac malformations, polyhydramnios, macrosomia, IUGR
5) increased risk of developing T2DM after delivery- screen annually
define pre-eclampsia
raised blood pressure >140/90 AFTER 20 weeks
proteinuria >0.3g/24 hrs
management of pregnancy induced hypertension
=hypertension occurring AFTER 20 weeks
if >150/100- labetalol
weekly BP and urine- excluse Pre-eclampsia
regular growth scans- increased risk of fetal growth restriction
risk factors for pre-eclampsia
PROF CANT DO *Personal history* Renal disease Older Family history *Chronic hypertension* *Autoimmune disease* Nuliparity Twin pregnancies *Diabetes* Obesity
investigations of pre-eclampsia
urine dip- raised proteins
protein-creatinine ratio
fetal US- look for fetal grwoth restriciton
Bloods- U+Ez, LFTs, FBC, GFR- Exclude HELLP
Define HELLP
severe variant of pre-eclampsia
H-Haemolysis
EL- elevated liver enzymes
LP- low platelets
Symptoms: epigastric/ RUQ pain, N+V, dark urine (haemolysis), raised BP, hepatomegaly, bruising
Risk of DIC, placental abruption, renal failure
Deliver is 34 weeks+
Define eclampsia + management
Tonic-clonic seizures and pre-ecampsia- can occur before, during or after pregnancy
ABCDE magnesium sulfate O2 Iv labetalol Delivery by C section once mother stable
What is part of the antenatal screening programme?
1) <10 weeks- sickle cell and thalasaemia blood test
2) Early pregnancy- syphilis, Hep B, HIV blood test
3) 10-14 weeks- combined test for downs, edwards and pataus (nuchal translucency and serum markers
4) 14-20 weeks- quadruple test- If combined test not possible- blood test screens for Downs
5) 18-21 weeks major abnormalities scanned for
If a fetus is small for dates at two dates 2 weeks apart, what does this indicate and what further investigations should be carried out
Fetal Growth Restriction
Ultrasound measurement of amniotic fluid—> if low–>uterine and umbilical artery doppler–indicates placental dysfunction
Management of fetal growth restriction
1) grwoth scans every 2-3 eeks + doppler
2) give corticosteroids for fetal lung maturityup to 35+6 weeks
3) plan birth- normal dopplers induce at 37 weeks/ abnormal dopplers concider LSCS
presentation of ectopic pregnancy
Pain (unilateral, sudden onset), amenorrhoea 6-8 weeks, bleeding, D+V, dizziness and syncope
cervical excitation and adnexal tenderness, abdo distension, rebound tenderness
Serum hCG and urine pregnancy test positive
Transvaginal ultrasound- uterus empty
history of ectopic, PID, previous uterine surgery, IVF, chlamydia, pregnancy despite IUD
management of ectopic pregnancy
1) stabilise patient
2) if asymptomatic/ hCG<3000/ ectopic <3cm on scan/ no fetal heart beat–> MEDICAL MANAGEMENT- IM methotrexate
3) if significant pain/ opossite of above–> SURGICAL MANAGEMENT- Laproscopic salpingectomy
presentation of molar pregnancy
Significantly raised hCG
exaggerated pregnancy symptoms- severe morning sickness and pre-eclampsia
most present with early pregnancy failure- heavy bleeding, molar tissue looks like frogspawn
US- snowstorm effect/ grapes
Management: Terminate pregancy
Management of a missed abortion
1) medical- mifepristone (antiprogesterone- allows contractions) and misoprostol (prostaglandin- brings on contractions)
2) Surgical- evacuation of retained products of conception
3) expectant- rarely
In general, what is the likely diagnosis of an antepartum haemorrhage
1) PAINFUL
2) PAINLESS
1) pain- abruption
2) painless- preavia
What is the name for placenta lying in lower uterine segment?
placenta preavia
diagnosed on ultasound scan
management of placenta preavia
if minor= placental edge >2cm from os
stay at home until 37 weeks as long as mum can get in quickly, deliver at 39 weeks
if major= placental edge <2cm from os
delivery by C section at 39 weeks
Give steroids 24-34 weeks
Placental abruption definition
Part of placenta becomes detached from uterus before dilvery- can be significant maternal bleeding behind
concealed (80%)- blood goes directly into myometrium, blood loss amount easily underestimated
revealed- dark bleeding
placental abruption presentation
PAIN
woody hard uterus
Tender contracting uterus, tachycardia, hypotemsion, fetal distress, poor urine output
complications- fetal death due to placental insufficiency
Name 3 clinical features of normal labour
1) contractions
2) cervical effacement and dilation
3) show- plug of cervical mucus and blood
outline the 3 stages of labour
FIRST STAGE
initiation of contractions–>full cervical effacement and dilation
latent- irregular contractions, dilation up to 4cm
established- regular contractions, dilation up to 10cm
SECOND STAGE
full cervical dilation–> delivery of baby
passive- head decending to pelvic floor- takes up to 2 hours
active- pushing- up to 3 hours
THIRD STAGE
delivery of fetus to delivery of placenta
<500mls blood loss normal
what is given to aid the 3rd stage of labour?
Syntometrine- oxytocin and ergometrine
contaction of uterus and decreased bleeding
what is used in induction of labour
if ruptured membraines but not progressing to spontaneous labour give vaginal prostaglandin and oxytocin infusion
what biomarker indicates an increased risk of prematurity
fetal fibronectin
what can be given to supress premature labour?
Tocolytics- atositiban/ nifedipine
define primary and secondary post partum haemorrhage
Primary= >500mls blood lost in first 24 hours secondary= excessive blood loss 24hrs- 6 weeks after delivery
What are the causes of a primary post partum haemorrhage?
tone- uterine atony (not contracting well)- 90%
tissue- retained POC
Trauma- genital tract trauma
Thrombin- clotting disorders
what are the causes of a secondary PPH
most commonly endometritis +/- retained placental tissue
also C section, prolonged rupture of membranes, manual removal of placenta, extreme of mothers age, lower socioeconomic status
explain the difference between baby blues, post natal depression and puerperal psychosis
BABY BLUES
Seen in around 60-70% of women
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Reassurance and support, the health visitor has a key role
POST NATAL DEPRESSION
Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
PUERPERAL PSYCHOSIS
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Admission to hospital is usually required
There is around a 20% risk of recurrence following future pregnancies
what are the main risk factors for shoulder dystocia?
fetal macrosomia
maternal high BMI
Diabetes mellitus
prolonged labour
first line anti-hypertensive for pre-eclampsia in women with severe asthma
nifedipine
what blood markers are measured in the combined and quadruple antenatal screening test for Downs
Combined- B hCG (raised) and PAPP-A (pregnancy associated plasma protein )(low)
quadruple- AFP (alpha fetoprotein) (low), unconjugated oestrodial (low), beta hCG (high) inhibin A (high)
List some lifestyle advice to give to a couple who are struggling to conceive
regular intercourse folic acid supplements smoking cessation lose weight and healthy diet decreased alcohol consumption exercise manage any pre-existing medical conditions
List some likely causes of infertility due to disorders in ovulation
HYPOTHALMIC
hypothalmic gonadism- anorexia, stress, exercise
Kallman’s syndrome
PITUITARY
hyperprolactinaemia
pituitary damage
psychotropics
OVARIAN
PCOS
premature ovarian failure
OTHER
hypo/hyperthyroidism
androgen secreting tumour
When investigating infertility, at what day would progesterone be measured and what would indicate ovulation had occured
Day 21 progresterone
>30 suggests ovulation has occured
what is the most common cause of infertility in women?+ symptoms
PCOS
weight gain, hirsutism, irregular periods, polycyctic ovaries on ultrasound scan
Management of PCOS infertility +side effects
Clomifine citrate
= antioestrogen–>increases indogenous FSH–>stimulates follicule mauration
increased risk of multiple pregnancies
hot flushes, labile mood, pelvic pain
also manage with metformin, laproscopic ovarian drilling, gonadotrophins, weight loss
If tubular damage is the suspected reason for infertilty, what are the likely causes, how to investigate, and management
1) Infection- PID, STIs- do chlamydia screen and high vaginal swab
2) Previous surgery- salpingostomy and adhesions - from previous ectopic/ other disease- Tx: tubual catheterisation
3) endometriosis- laproscopic surgery to remove endometriosis lesions
List the common causes of menorrhagia
dysfunctional uterine bleeding fibroids polyps chronic pelvic infection ovarian tumour cervical (post coital bleeding) and endometrial malignancy (post menopausal bleeding)
Symptomatic management of menorrhagia
1) Mirena IUD- decreases bleeding- local release of progesterone- endometrial atrophy
2) Antifibrinolytics- transexamic acid- decreases blood loss
3) NSAIDS- mefanamic acid
4) progestens
5) GnRH agonists
6) Surgery- endometrial ablation, hysterectomy
Typical presentation of endometrial cancer
Plus management
POST MENOPAUSAL BLEEDING
obese, diabetes, nuliparity, early/late menopause, HRT, Breast cancer treated with tamoxifen, PCOS
–>all high oestrogen:progesterone
COCP and pregnancy protective- increased progesterone exposure
Management:
totaly hysterectomy with bilateral salpingo-oophrectomy
Adjuvant radiotherapy
Progesterone therapy- in advance disease- palliation of symptoms
Investigation of endometrial cancer
Transvaginal ultrasound- thickness >4mm
endometrial biopsy
hysteroscopy
presentation of cervical cancer
Typical patient and risk factors
POST COITAL BLEEDING
watery vaginal dischage, IMB/PMB, menorrhagia, weight loss, bowel disturbance in late disease
or
incidental finding on cervical smear/ CIN treatment
RISK FACTORS
HPV infection, aged 25-34, multiple sexual partners, smoking, lower social class, developing countries, previous CIN, oral contraceptive pill, immuno-suppression, non-attendance at cervical screening
Investigations for cervical cancer
examination- irregular cervical surface, irregular massess that bleed on contact
Biopsy- 70% squamous cell carcinoma
CT abdo+ pelvis, MRI pelvis for staging
Ovarian tumour presentation
Investigations
LATE presentation
aged 75-84
vague symptoms (ovarian=overall)- systemic presentation: abdo distenstion, weight loss, PV bleeding, urinary symptoms
risk factors:
BRCA1 and BRCA2 gene
increased ovulations: early menarche, late menopause, nuliparity
Investigations
Ca125 raised
ultrasound abdo and pelvis
presentation of firbroids
risk factors
Menorrhagia
infertility
pain
mass- can press on bladder–> frequency/ press on veins–> oedematous legs and varicose veins
RISK FACTORS
age, family history, afrocaribbean, oestrogen(enlarge in pregnancy, COCP, atrophy after menopause)
management of fibroids
1) hyerectomy- definitive cure, but not if fertility preservation important
2) myomectomy
3) GnRH agonist- shrinks fibroid via down regulation of oestrogen- desensitises anterioir pituriary to GnRH, so less FSH and LH so less oestrogen
common causes of secondary dysmenorrhoea
Secondary= due to pelvic pathology
Endometriosis, PID, Adenomyosis, fibroids
Pain precedes period and may be relieved by end of period
(Primary= no organic cause, pain starts with menstruation- treat with NSAIDS and COCP)
Presentation of endometriosis
Cyclical pelvic pain, gets better after periods
Chronic pelvic pain
Deep Dyspareunia
Subfertility
Woman of reproductive age, early menarche and low parity
Investigations of endometriosis
Endometrial laproscopy and biopsy- chocolate cysts?
Transvaginal ultrasound- cysts, thick walls, blood inside
Management of endometriosis
1) MEDICAL- ovarian suppression
- COCP
- GnRH analogue
- Mirena IUD
2) SURGICAL
- lesion ablation laproscopically
- hysterectomu
Definition of adenomyosis
Endometrium in myometrium PAIN, regular heavy menstruation enlarged boggy uterus It is more common in multiparous women towards the end of their reproductive years. diagnose with MRI
Causes and risk factors of pelvic inflammatory disease
CAUSES
- ascending endocervical infection- chalmydia, ghonorrhoea, uterine instrumentation
- descending abdo infection- appendicitis
RISKS
<25, previous STIs, multiple sexual partners
Presentation of PID
Treatment
constant/ intermittent pelvic PAIN
bleeding- irregular periods, IMB, PCB,
vaginal discharge (due to vaginal infection)
fever (sometimes)
Antibiotics- ceftriaxone
what investigations should be carried out for
a) acute pelvic pain
b) chronic pelvic pain
ACUTE
- urine analysis/ MSU
- pregnancy test
- FBC- infection
- urgent ultrasound- miscarriage/ectopic
- high vaginal swab
CHRONIC
- sexually active- screen for chlamydia and gonorrhoea
- Ca125- ovarian cancer?
- transvaginal ultrasound- endometriosis, ovarian cysts, fibroids
- MRI- adenomyosis
- laproscopy
list some causes of primary amenorrhoea
structural- malformation of genital tract
genetic- Turners, kallmans
low body weight
mullarian agenesis
List some causes of secondary amenorrhoea
hypothalamic-pituitary-ovarian disorders
- stress, exercise, weight loss, athletes
- Hyperprolactinaemia
- Hyper/hypothyroid
- PCOS, ovarian failure
- Pregnancy
- Ashermans- excessive scarring in uterine cavity, often after multiple dilatation and curettage procedures or post TB/ schistosomiasis infection
- drugs- contraceptive pill, antipsychotics, GnRH analogues
what is the classic hormonal imbalance in PCOS?
LH>FSH (Usually FSH>LH)
Presentation of PCOS
Oligomenorrhoea
hypergonadism
polycystic ovaries on US- >12
Subfertility
Typical patient: obese, childbearing age, high BP, Type 2 diabetes, insulin resistance,
Investigations for PCOS
raised free androgen/ testosterone
raised LH/FSH ratio
ultrasound
Management of PCOS
Weight loss COCP Clomifine/ tamoxifen metformin ovarian diathermy
Which STI? asymptomatic or white discharge, dysuria, bleeding PID gram -ve cocci
Investigations
Treatment
Chlamydia
Investigations: NAAT/ PCR
treatment: azithromycin Stat
Which STI?
asymptomatic or
urethetis, vaginal discharge, cervicitis, dysuria, increased risk of premature labour or miscarriage
Investigations
Treatment
Gonorrhoea
Investigations NAAT
Treatment: Azithromycin + IM ceftriaxone
Which STI?
Multiple painful ulcers
fever, myalgia, discharge and dysuria
investigation
treatment
Herpes
investigations: viral swabs
Treatment: Acyclovir
Which STI
Single painful ulcer= chancre
Later serious systemic symptoms
treatment
Syphilis
treatment IM Penicillin
Which infection
cottage cheese discharge
itchy/ inflamed vulva and superficial dyspareunia
Treatment
Thrush
Fluconazole
which infection?
grey/yellow, fishy, thin discharge
clue cells
alkaline pH
treatment
bacterial vaginosis
metronidazole
which STI?
offensive green/grey frothy discharge, vulval irriation, superficial dyspareunia
strawberry lesions on cervix
Trichomonias
metronidazole
Presentation of menopause
hot flushes, insomnia, psychological
breast atrophy, hair loss, atrophic vaginitis, prolapse, urinary symptoms, osteoporosis
investigations of menopause
Low antimularian hormone
raised FSH
Diagnostic test of premature menopause
management
< 40 yo
raised FSH 4 weeks apart
HRT until 50
fertility support
androgen replacement
side effects of combined oral contraceptive pill
- increased risk of breast cancer and cervical cancer (protective of endometrial and ovarian)
- thromboembolic risk
- contraindicated in migraine, stroke, IHD, uncontrolled hypertension
what makes up the triple assessment in the diagnosis of breast cancer?
1) clinical score
- palpable lump, physical changes in breast (eg pau d’orange, nipple indrawing, discharge etc), secondary symtoms eg bone pain, back pain, pathological fracture
2) Imaging score- mammography/ ultrasound
3) Tissue biopsy
possible complications of amniocentesis
what should be given at time
- discomfort and cramping
- vaginal bleeding
- maternal rhesus sensitisation
- amnionitis
- miscarriage 1% risk
- amniotic fluid leakage
give rhesus prophylaxis if appropriate
complications of hyperemesis gravidarum
wernickes encephalopathy
korsakoffs syndrome
mallory weiss tear–> haematemesis
why is it important to date pregnancies
timing of downs syndrome screening
knowing viability of preterm births
timing of induction of labout if post term births
Long term risk of molar pregnancy
chroiocarcinoma- follow up closely
4 complications of IUD insertertion
PID
uterine perforation
device migrating through peritoneal cavity
expulsion of device
