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Finals!!! > Obs and Gynae > Flashcards

Obs and Gynae Flashcards

1
Q

What is Lichen Sclerosis and how does it present?

A
  • Benign skin condition.
  • Any age (usually post menopausal)
  • Thin skin
  • White (leukoplakia), Red (inflammation)
  • Perineum/perianal- atrophy in figure of 8 pattern
  • Anatomical shrinkage/ adhesions
  • Extragenital plaques- trunk, back
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2
Q

Investigations and management of Lichen Sclerosis

A
  • Ix: Swabs, vulval biopsy
  • Tx: Emollient creams, shor course steroids, surgery if micturition affected
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3
Q

Presentation of Bartholin cyst

A
  • Cyst/ abscess in posterior forchette.
  • Vulval pain esp walking/sitting
  • Dyspareunia
  • ?Sepsis
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4
Q

Investigations at booking appointment

A
  • Booking = 8-12w
  • Bedside- urine dip, BP, glucose if DM RF
  • Bloods- Type, Rh, haemoglobinopathies, anaemia, RBC autoAb, HIV, HepB, syphilis, rubella
  • Sickle cell and thallaesemia <10w
  • DM eye screening at 1st appointment
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5
Q

What is looked at in dating scan?

A
  • Dating scan= 12w.
  • Looking at:
    • ?Single, viable, intrauterine foetus
    • Crown-rump length. ?Gestation and EDD
    • Nuchal translucency <12w risk of abnormality
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6
Q

When is the anomaly scan and what are you looking for?

A
  • 18-20w
  • Structural abnormalities - anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, emophalmos, cardiac abnormalities, renal agenesis, skeletal dysplasia
  • Trisomies
  • Low lying placenta –> transvaginal USS
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7
Q

Pre-conception care

A
  • Multivitamins, folic acid (400 micrograms) until 12w
  • Lifestyle- stop smoking, no alcohol, optimise BMI, pelvic floor exercises
  • Vit D once preg - 10 micrograms OD in preg
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8
Q

Indications for 5mg Folic Acid

A
  • DM
  • High BMI
  • Coeliac / Malabsorption
  • Sickle cell
  • Epilepsy
  • Prev. FHx NTD
  • Multiple Preg
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9
Q

Indications for growth scans. What are you looking for in growth scans?

A
  • >28w, every month in complicated
    • Hx of IUGR
    • HTN or PMH
    • DM
    • Epilepsy
    • Smoking/ substance misuse
    • BMI >35
    • Multiple Preg
  • Growth - head, abdo circumference, femur length
  • Amniotic fluid
  • Blood flow- umbilical artery (deoxygenated blood from baby to mum). End diastolic flow.
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10
Q

Down’s Screening

A
  • 1st Trimester- Combined test. Nuchal translucency, PAPa (low), betaHCG (high). If risk >1 in 250 –> ?amniocentesis/ chorionic villus sampling
  • 2nd Trimester - Quadruple test. AFP, unconjugated estradiol, betaHCG, Inhibin A, maternal age
  • CVS- 10-13w. Sample of placenta. Complications- miscarriage, amniotic fluid leak, sepsis
  • Amniocentesis- >15w. Complications- miscarriage, amniotic fluid leak, uterine bleeding, maternal Rh sensitisation, sepsis. More accurate + safer
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11
Q

What is term and what are the 3 stages of labour?

A
  • Term= 37-42w
  • Stage 1= 4-10cm. Reg painful contractions. Start partogram. Progress 0.5cm every hour. FHR every 15mins.
  • Stage 2= 10cm - birth. Passive 1-2h –> active. FHR every 5mins.
  • Stage 3= Birth - expulsion of placenta
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12
Q

High risks births that would require continuous monitoring

A
  • Pre-eclampsia
  • Macrosomia
  • IUGR
  • Premature
  • DM
  • Breech
  • Prev. C-section
  • APH
  • Oxytocin
  • Epidural
  • Meconium
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13
Q

What are you looking at to interpret a CTG?

A

DR C BRVADO

  • Define Risk
  • Contractions - rate, duration, rhythm, strength
  • Basline RAte (norm 110-160)
  • Variability >10-15 bpm
  • Accelerations- early/variable/late (?hypoxia)
  • Decelerations
  • Overall assessment and plan
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14
Q

Causes of Non-Progressive Labour

A
  • Powers:
    • Aim 4-5 contractions/10 mins lasting 1 min.
    • Ineffective contractions or hyperactive (oxytocin)
    • Tx- Inefficient –> amniotomy, augmentation, oxytocin. Hyperactive –> reduce oxytocin
  • Passage- Cephalo-pelvic disproportion. Pelvis 13cm at inlet, 11cm at outlet. Tx: assisted, c-sec
  • Passenger:
    • Malpresentation- face, brow (urgent C-sec), breech
    • Unstable lie –> cord prolapse?
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15
Q

What is APH and what might cause it?

A
  • APH= any leed after 24w upto labour
  • Uterine causes:
    • Placenta previa
    • Placental abruption
    • Vasa previa
    • Circumvallate placenta
  • Lower genital tract causes:
    • Ectropion
    • Cervical polyp
    • Cervical carcinoma
    • Cervicitis
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16
Q

Ix and Tx of APH

A
  • Ix:
    • DO NOT DO PV/ SPECULUM EXAM
    • Bedside- CTG, urinalysis
    • Bloods- Hb, G+S/ Cross-match, Rh status, U+Es, LFTs
    • Imaging- USS
  • Tx:
    • ABCDE + Anti-D
    • ?Transfusion
    • ?C-section
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17
Q

What is placenta previa? RF, Presentation, Tx and complications

A
  • = Low lying placenta in 20w scan, PP Dx at 3rd trimester via TVUSS
  • Minor/ major
  • RF: Infection, multiple preg, fertility, smoking, parity, fibroids, prev. PP, age, trauma, abdo surg
  • Presentation:
    • Painless bleeding. Bright red.
    • SNT abdo
    • Displaced presenting part eg transverse lie
  • Tx:
    • Anti-D
    • Manage bleed - ?transfusion
    • Minor >2cm away from os. Vaginal.
    • Major- C-section
  • Complications: PPH, placenta accreta, preterm labour, malpresentation
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18
Q

Vasa previa - presentation, Ix, Tx

A
  • Foetal BVs cross os –> membrane rupture –> BVs rupture
  • Presentation - Membrane rupture w/ painless bleeding
  • Ix- Kleihaeur test - ?foetal blood
  • Tx- Urgent C-section
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19
Q

What is placenta accreta?

A
  • Placenta attached to myometrium –> gets left behind.
  • RF: Prev. c-section
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20
Q

Placental abruption - RF, presentation, Ix, Tx, complications

A
  • = Placenta separates from uterus whilst baby still in womb.
  • RF: ECV, trauma, pre-eclampsia, parity, smoking, prev PA, anatomy, IUGR, multiple preg, AI, alcohol, drug s
  • Presentation:
    • Any stage of preg.
    • Painful APH. Dark blood.
    • Signs of shock - inconsistent w/ blood loss
    • Concealed/ revealed
    • Tender, contracting ‘woody’ uterus
  • Ix- USS to rule out previa
  • Tx:
    • ABCDE, resus, CTG, anti-D
    • Foetal distress –> urgent c-sec
    • No foetal distress- expectant management and induction at 37w
  • Complications: Foetal death, haemorrhage, DIC, renal failure, maternal death, PPH, Sheehan’s (pituitary necrosis secondary to hypovolaemic shock)
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21
Q

Tx of Pre-existing HTN in pregnancy

A
  • = HTN <20w
  • Aim <150/100
  • Stop ACEi/ ARBs
  • Aspirin 75mg
  • Test for proteinuria reg
  • Growth scans 28 + 32w
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22
Q

What is pregnancy induced hypertension, it’s stages and their management

A

= After 20w with no significant proteinuria. Resolves 6w post-partum

  • Mild (<150/100)- no Tx, BP measurement weekly, urine dip each visit, routine bloods only
  • Mod (<160/110)- oral labetalol, BP measurement 2x/w, urine dip each visit, bloods at presentation - U+Es, LFTs, FBC
  • Severe (>160/110)- admission, oral labetalol, BP measurement QDS, urine dip daily. Bloods Presentation + weekly
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23
Q

Pre-eclampsia, Presentation, Ix, Tx

A
  • = >20w with HTN and proteinuria
  • Presentation:
    • HTN
    • Headahce
    • RUQ pain/ vomiting
    • Blurred vision
    • Hyper-reflexia/ Clonus
    • Swelling
    • Fundoscopy- papilloedema
  • Ix:
    • Bedside- urine PCR or 24h urine collection for ?proteinuria, CTG
    • Bloods- U+Es, FBC (platelets), clotting, urate (??DIC)
    • Imaging- growth scan
  • Tx:
    • Antihypertensives: labetalol, nifedipine, methyldopa
    • Cure= deliver placenta. Indications to deliver- Term, IUGR, foetal distress, refractory HTN with 3 drugs at highest dose, changes in bloods, eclampsia, HELLP, DIC
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24
Q

RF for pre-eclapmsia

A
  • High risk: (any one –> 75mg Aspirin 12w)
    • Prev. Pre-eclampsia or PIH
    • DM
    • Pre-existing HTN
    • CKD
    • SLE/ antiphospholipid
  • Moderate risk (any 2 –> aspirin)
    • Age >40y
    • BMI >35
    • Multiple preg
    • Preg interval >10y
    • 1st preg/ 1st preg w/ new partner
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25
Q

Key features of HELLP syndrome

A
  • = Haemolysis, Elevated Liver Enzymes, Low Platelets
  • Haemolysis - LDH. Blood film= gold standard
  • Liver enzymes- LFTs
  • Platelets - FBC
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26
Q

Complications of Pre-eclampsia

A
  • Intracerebral haemorrhage
  • Liver rupture
  • HELLP/ DIC
  • Eclampsia
  • Renal failure
  • Placental abruption
  • IUGR
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27
Q

Key features of eclampsia

A
  • = Seizures
  • Can fit after delivery - don’t discharge until >36 hours post-delivery. Reg BP and fluid restriction.
  • Tx:
      1. BP control
      1. Magnesium sulfate IV –> diazepam –> lorazepam –> intubation
  • Magnesium sulfate toxicity- reduced reflexes/ UO/ RR. Tingling around mouth. Antidote= sodium gluconate
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28
Q

Complications of DM in pregnancy

A

Maternal

  • Infections, UTIs
  • Pre-eclampsia
  • C-section
  • Retinopathy
  • Nephropathy

Foetal

  • Miscarriage, IUD
  • Macrosomia/ IUGR
  • Congenital abnormalities
  • Neonatal hypoglycaemia
  • NTD
  • Heart disease
  • Polyhydramnios
  • Miscarriage
  • Risk DM later in life
  • Shoulder distocia
  • Pre-term
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29
Q

Management of Pre-existign DM in pregnancy

A
  • MDT!!!
  • Pre-conception:
    • HbA1c <43
    • Baseline kidney function, eye check, BP
    • Stop sulfonylureas, statins, ACEi
    • 5mg Folic Acid
  • Antenatal care:
    • Booking by 8w. DM antenatal clinic every 2w.
    • Cardiac scan 24w, growth scans from 28w
    • Glucose monitoring. Increase insulin 2/3?. Aim BM <6.0mmol
    • 75mg Aspirin >12w
  • Intrapartum care:
    • Delivery <29w
    • C-section if est weight >4kg
    • Glucose/Insulin/K+ sliding scale. Aim 4-7mmol/L. Measure every hour
  • Post-partum:
    • Baby- risk of hypo –> feed within 1h
    • Insulin back to normal
    • 6w check - HbA1c, OGTT, FBC
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30
Q

RF for GDM

A
  • Prev. GDM (screen 18w)
  • Prev. foetus >4.5kg
  • Prev. unexplained still birth
  • >35y
  • FDR with DM
  • BMI >30
  • PCOS
  • Race- SE Asia, Caribbean, middle east
  • Polyhydramnios
  • Persistent glycosuria
  • –> OGTT at 24-28w. Fasting –> bloods –> 75g glucose –> bloods 2h later
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31
Q

Treatment of GDM

A
  1. Diet control
  2. Oral hypoglycaemics eg metformin
  3. Insulin
  • Growth scans
  • Delivert 38-41w
  • Do fasting HbA1c at 6w. Annual testing - 40% T2DM later in life
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32
Q

Key features of obstetric cholestasis

A
  • Abnormal sensitivity to oestrogen –> cholestasis
  • Genetic - FHx, S Asia esp
  • Presentation:
    • >28w
    • ITCH - palms and soles, ++ night, excoriations, no rash
    • Jaundice
  • Ix:
    • Monitor CTG.
    • Elevated LFTs (ALP, GGT, Bile acids) –> measure weekly.
  • Tx:
    • 6w follow up. Should have resolved.
    • Induce at 37w (risk still birth)
    • Med- ursodeoxycholic acid, chlorphenamine, Vit K from 36w
    • Cons- topical emollients
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33
Q

Classification of obesity in pregnancy and complications

A
  • BMI 30-34.9= Obese, 35-39.9= Severely obese, BMI >40= Morbidly obese

Maternal

Baby

Difficulty palpating foetus

Macrosomia/ IUGR

Spont + recurrent miscarriages

Foetal/ infant death

Pre-eclampsia

CVD

GDM

T1DM/T2DM

VTE

Cancer

Infections eg wound

Asthma

PPH

Congenital abnormalities

C-section + complications

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34
Q

What is Rhesus Isoimmunisation and Mechanism?

A
  1. Rh -ve mother concieves a Rh +ve foetus (D-antigen)
  2. Sensitising event –> foetal cells can enter maternal blood stream –> maternal antibody response (sensitisation)
  3. Not a prob in 1st pregnancy (IgM can’t cross placenta) –> NEXT PREG –> IgG can cross placenta
  4. Immunodestruction of foetal RBCs –> Rh Haemolytic disease of newborn - RBC destruction, jaundice.
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35
Q

Rhesus sensitising events

A
  • DELIVERY
  • Miscarriage
  • Trauma
  • Placental insufficiency
  • TOP
  • Invasive AN testing eg amniocentesis
  • APH
  • ECV
  • Blood transfusion
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36
Q

How does Anti-D work and when should it be given?

A
  • Immunoglobulin injected into mother –> binds to D antigen on foetal RBCs –> cannot mount IgG response. No sensitisation.
  • Given at 28w, 34w and <72h after potential sensitising event.
  • Kleihauer test - how much foetal blood in maternal bloodstream = how much anti-D is needed
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37
Q

Signs of foetal anaemia in Rh isoimmunisation

A
  • Ix: Do Doppler of foetal MCA, foetal blood sampling if anaemia likely
  • Polyhydramnios
  • Cardiomegaly
  • Ascites/ pericardial effusion
  • Variability on CTG
  • Hyperdynamic circulation
  • Hydrops and foetal death in severe
  • –> Tx= foetal blood transfusion/ delivery if >36w
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38
Q

Management of Rh Isoimmunisation

A
  • ID risk - determine foetal blood type (paternal blood), Ab testing every 2w (if increased –> look for signs of foetal anaemia)
  • Assess severity - doppler foetal MCA 2 weekly. Anaemia likely –> foetal blood sample
  • Tx:
    • Anti-D to prevent sensitisation
    • Transfuse blood if foetus anaemic. Deliver if >36w
    • Post-natal check - FBC, Bili, Rh status
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39
Q

Causes of maternal collapse and management

A
  • Pregnancy specific - Amniotic fluid embolism, APH, PPH, eclampsia
  • Non-Pregnancy specific - Sepsis, VTE, PE, haemorrhage, drug-induced, hypoglycaemia, MI, arrhythmia
  • Tx:
    • MEOWS >7= senior r/v ASAP
    • ABCDE (don’t lie flat)
    • No response to CPR in 4 mins in >20mins –> perimortem C-section
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40
Q

Key features of sepsis in pregnancy

A
  • Signs and symptoms may be less distinctive. Most common post-natal
  • Commonest cause= GBS
  • Tx: sepsis 6, continuous EFM
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41
Q

Key features of post-partum pyrexia

A
  • Maternal fever >38 in 1st 14d
  • Common sites of infection- UTI, LRTI, mastitis, perineal, c-section wound –> O/E: abdo, breast, IV access sites, chest, legs
  • Pathogens: GBS, staph, E. Coli
  • Ix: Blood, urine, high vaginal and foetal swabs
  • Tx: Sepsis 6. Broad spec ABx
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42
Q

Key features of chorioamnionitis

A
  • = Infection within the womb –> PPROM
  • Common cause: E.Coli, GBS, STI, UTI
  • Presentation:
    • Fever
    • ++ HR and foetal HR
    • Foul smelling vaginal discharge
    • Abdo pain
    • Leukocytosis (high WCC)
    • PPROM
  • Ix and Tx: Sepsis 6. Swabs.
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43
Q

Key features of amniotic fluid embolism

A
  • Defect in amniotic sac –> pressure –> fluid into maternal blood stream –> embolises into pulm. circulation –> blockage of vessels and immunological/ inflammatory reaction –> DIC, foetal hypoxia, still birth
  • Can happen PP (upto 30 mins after delivery)
  • RF: TOP, amniocentesis, placental abruption, trauma, c-section
  • Tx= supportive
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44
Q

Why are pregnant women at increased risk of VTE and how are they risk assessed?

A
  • VTE 10x more common in preg:
    • Change in clotting factors - less factor 11,13 and platelets, more fibrinogen
    • More venous stasis - obstruction and reduced mobility
    • High mortality antenatally, higher risk post-partum
  • All pregnant women assessed for VTE risk at booking, admission, labour and post-natal:
    • 3 or more –> prophylaxis over 28w
    • 4 or more –> Tx throughout preg
    • Postnatal 2 or more –> prophylaxis
  • Risk assessment based on: Prev VTE or FHx in 1st degree relative, co-morbidities, known high risk of thrombophilia, >35y, obesity, parity>2, smoker, gross varicose veins
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45
Q

Presentation, Ix, and Tx of VTE in preg/post-partum

A
  • Presentation- PE, DVT
  • Ix:
    • Bedside- obs, urine dip, measure calves, CTG
    • Bloods- clotting, FBC (platelets), PT, U+Es, LFTs. NOT D-DIMER
    • Imaging - Doppler USS, PE - CXR/ V/Q scan, growth scan
  • Tx:
    • Cons- compression stockings
    • LMWH (based on risk or presentation). Tx - continue 6-8w post partum
    • Prev VTE –> IV heparin
    • Stop anti-coagulation 24h before labour
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46
Q

RF, classification, and presentation of multiple pregnancy

A
  • RF: IVF, FHx, maternal age, W African
  • Presention:
    • ++ Preg Sx, large
    • >1 heart beat (>10bpm)
    • Labda sign on USS
  • Classification:
    • Dizygotic- non-identical.
    • Monosyzgot- single egg splits –> timing determines chorionicity (placentas) and amnionicity (sacs)
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47
Q

Complications of Multiple Pregnancy

A

Mother

  • Miscarriage
  • Anaemia
  • Pre-eclampsia
  • DM
  • APH/PPH

Baby

  • Stillbirth
  • Pre-term labour
  • Malpresentation
  • IUGR
  • Foeto-foetal transfusion syndrome à HF in recipient
  • Congenital abnormalities
  • Cord entanglement/ prolapse
  • Development/social consequences
  • Polyhydramnios
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48
Q

Antenatal care and intrapartum care of multiple pregnancy

A
  • High dose folic acid
  • Aspirin 75mg
  • ?Iron if anaemia
  • 1st trimester scan to determine chorionicity and amnionicity
    • Mono –> 2 weekly scans from 16w
    • Di –> 4 weekly scans from 20w
  • Intrapartum;
    • IV syntocin drop
    • C-section if mono, non-cephalic prsentation of 1st twin, triplets, other RF
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49
Q

Different types of breech presentation

A
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50
Q

Management of Breech presentation

A
  • ECV:
    • >36w (>37 if multiparous)
    • NB prophylactic Anti-D
    • Tocolytic meds + analagesia –> ECV
    • Contraindications- labour, prev c-sec, APH, abnormal uterus, abnormal CTG, multiple preg
    • Risks- placental abruption, cord damage, uterine rupture, PPROM
  • Spon Breech delivery:
    • Trained staff. Lying down on back with manoevers
    • Risks: Anoxia due to prolapsed cord, traumatic injury to aftercomign head, fracture spine/ arm
    • Continuous CTG
  • C-Section:
    • Indications- footling, large, small, narrow pelvis, no trained professionals
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51
Q

Definition of IUGR and classification

A
  • = Estimated weight/ abdo circumference <10th centile of customised growth chart (weight, height, ethnicity, parity, Hx past pregs)
  • Classification:
    • Constitutionally small eg short mum
    • Non-placenta mediated growth restriction - structural/ chromosome abnormality, inborn errors of metabolism
    • Symmetrical - early preg
    • Mixed
    • Asymmetrical- late. Head/ femur length diff
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52
Q

RF for IUGR

A
  • >35y
  • Infection
  • Nulliparity
  • Pre-eclampsia
  • Prev SGA/ still birth
  • Malnutrition
  • Medical condtion affecting BF eg antiphospholipid, AI, renal, BP, DM
  • Smoking/ substances
  • Low/high BMI
  • DM
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53
Q

Complications of IUGR

A

Early

  • Perinatal asphyxia
  • Meconium aspiration
  • Hypothermia
  • Hyperglycaemia

Late

  • Neurobehavioural
  • FTT
  • Risk of obesity, metabolic syn, T2DM, CVS
  • Jaundice
  • Feeding probs
54
Q

Management of IUGR

A
  • Consultant led
  • 75mg aspirin <16w
  • Serial growth scans - USS and doppler every 2w
  • Serial measurements of fundal height
  • CTG daily 34-36w
  • C-section/ induction at 37w
55
Q

Definition of macrosomia, RF, Tx and complications

A
  • = >90th centile or >9lb 15oz
  • RF: Maternal obesity, DM, ABx, genetics, gestation>40w, hydrops foetalis
  • Tx:
    • Monitor- USS, BMI, fundus
    • Induce 38w latest
    • Screen GDM
  • Risks: cephalo-pelvic disproportion, shoulder, distocia, hypo
56
Q

Definition of pre-term labour and causes

A
  • = Delivery <37w (++ risks <34w)
  • Causes:
    • PPROM
    • Incompetent cervix eg LLETZ
    • Infection- chorioamnionitis, UTI, GBS
    • Over-distended uterus - multiple, polyhydraminos
    • Maternal systemic disease - heart, kidney, DM, stress
    • Foetal abnormalities
    • Uterine abnormalities
    • Iatrogenic - DM, IUGR, Pre-eclampsia
    • Preg complications - placental abruption, placental previa, PIH
57
Q

RF for pre-term labour

A
  • Stressful event
  • Cocaine/ drugs
  • >35y
  • Smking
  • UTI
  • Uterine abnormality
  • Maternal illness
  • Multiple preg
58
Q

Complications of Pre-term labour

A

Early

  • Death
  • Hypothermia
  • Infection
  • Feeding difficulty
  • Hypoglycaemia
  • Brain haemorrhage

Late

  • Hearing loss
  • Cerebral palsy
  • Chronic breathing probs
  • Retinopathy and blindness
  • Resp distress
  • Necrotising enterocolitis
59
Q

Ix and management of Pre-term labour

A
  • Ix:
    • USS
    • Sterile speculum
    • Foetal fibronectin - swab - protein released when membranes start to separate from uterine wall
    • Amnisure test - ?amniotic fluid
  • Tx:
    • Corticosteroids- lung maturity. 2x12mg betamethasone given 24h apart. <35+6
    • Nifedepine - tocolysis. <33+6 (CI- infection, abruption)
    • Magnesium sulphat - foetal neuroprotection (<30w)
    • Prophylacitc ABx
    • Emergency cervical cerclage - <28w. CI if contracting.
    • Delivery - C-section <34w. Involve Paeds
  • Prevention - scan and monitor future preg. Progesterone pessary if cervix shortens. Cervical cerclage.
60
Q

What is PPROM? Ix + Tx

A
  • = Waters break <37w
  • Present: gush of clear fluid
  • O/E: Speculum - pool of clear fluid in post. fornix. Avoid VE
  • ???Chorioamnionitis???
  • Ix:
    • Bedside- steriel speculum, swabs (high vaginal, foetal fibronectin)
    • ?Bloods
  • Tx:
    • Monitor
    • Med: ABx (erythromycin), corticosteroids, magnesium sulphate (neuroprotection), delivery >34w
61
Q

When is labour induced and what are the indications? + Contraindications

A
  • 37w if medical indication or >42w (post-term)
  • Indications:
    • Chrioamnionitis
    • IUD
    • Pelvic girdle pain
    • Post-date >42w
    • PPROM
    • HTN
    • SGA/ IUG
    • Oligohydramnios
    • Placental abruption
    • Non-medical eg social request
  • Contra-indications- anything that CI vaginal delivery eg foetal distress, transverse lie, HIV etc
62
Q

Procedure of induction of labour

A
  1. Assess Bishop’s score (consistency, effacement, dilatation, station)
  2. ARM (amniotomy) or Cervical ripening
    • Prostaglandins- gel/ tape
    • Hydroscopic dilators
    • Balloon catheter
  3. CTG
  4. Oxytocin infusion 0.3-9.6ml/h. Infusion pump.
  5. IVT, G+S
  6. Failed induction –> repeat cycle once –> c-section
63
Q

Complications of induction of labour

A
  • Foetal distress
  • Amniotic fluid embolism
  • PPH
  • Cord prolapse
  • Hyperstimulation
  • Chorioamnionitis
64
Q

Effect of Epilepsy on Pregnancy and visa versa

A
  • Epilepsy control - most stay same.
  • Epilepsy usually not damaging in pregnancy until status epilepticus.
  • Some anti-epileptics can cross placenta –> cardiotoxic, NTD, cleft lip. Esp sodium valproate
65
Q

Management of Epilepsy in Pregnancy

A
  • Pre-conception- swap from sodium valproate to lamotrigine/ carbamazepine. 5mg folic acid.
  • Antenatal- NB 20w anomaly scan, cardiac scan at 24w, growth scans >28w. Vit K injections every day in 3rd trimester w/ carbamazepine (enzyme inducers)
  • Intrapartum- Ensure good pain relief
  • Post-partum- pill might not work with enzyme inducers –> coil/ depo
66
Q

What is an episiotomy and its indications?

A
  • Indications: foetal distress, head is not passing over the perineum depite maternal effort or a large tear is likely.
  • Method: inject local anaesthetic, 3-5cm cut made with scissors from the centre of the fourchette at 45 degree angle
67
Q

Classification of perineal trauma

A
  1. Injury to skin only
  2. Involves perineal muscles (+ episotomy)
  3. Involves anal sphincter complex
  4. Involves anal sphincter and anal epithelium
68
Q

Assisted delivery: Aim, indications, methods, complications

A
  • Aim= reduced time of second stage of labour
  • Indications:
    • Maternal exhaustion
    • Foetal distress (confirmed by FSE)
    • HTN, cardiac disease
    • Breech for aftercoming head
  • Methods:
    • Ventouse - rule of 3s (<30m)
    • Forceps - Keillands. Less maternal effort.
  • Complications: Shoulder dystocia, trauma, haemorrhage, infection, bladder damage, neonatal jaundice
69
Q

Indications of C-Section

A
  • Mum- prev. C-Section
  • Baby- IUGR, cord prolapse, foetal distress
  • Both:
    • Abnormal progress
    • Malpresentation
    • Placenta previa/ abruption
    • Severe APH
    • Pre-eclampsia
    • Other medical conditions
70
Q

Categories of C-Section

A
  1. <30mins - life threatening
  2. <60 mins - Maternal/foetal compromise
  3. By end of day - avoid complications
  4. Elective
71
Q

C-section procedure

A
  • Analgesia- spinal block/ epidural/ GA (emergency
  • 2 types of incision:
    • Classical (vertical) - extreme prematurity, need large incision
    • Transverse lower segment
  • Cut through all layers –> delivery baby and placenta –> stop bleeding –> inspect area –> close
72
Q

Complications of C-Section

A
  • Bleeding and VTE
  • Infection
  • Organ/ bladder damage
  • Scar dehiscence
  • Baby- resp distress, low APGAR
73
Q

What is VBAC and what complications does it bear?

A
  • = Vaginal Birth After C-section
  • Risk = 1 in 200 of scar dehiscence
  • Contraindications- classical incision, prev rupture
74
Q

What is shoulder dystocia, RF and management

A
  • = When normal downward contraction fails to deliver shoulders once head isi delivered –> excessive traction on neck can damage brachial plexus (Erb’s)
  • RF: baby >4kg, Prev SD, induction of labour, BMI and DM, instrumental delivery
  • Tx:
    • GET HELP ASAP!
    • Gentle downward traction, legs hyperextended onto abdo wall (McRobert’s Manoever)
    • –> Wood screw manoever. Episiotomy + internatl manoever
    • Last resort= symphysiotomy, replacement of head and c-section
75
Q

Post-Partum Haemorrhage classification

A
  • Primary= <24h of delivery
  • Secondary= >24h-6w. Cuases- endometriosis, retained placenta, gynae pathology
  • Minor= 500-1000mL (>1000mL after c-section)
  • Mod= 1000-2000mL
  • Severe= >2000mL
76
Q

RF for PPH

A
  • APH
  • Prev PPH
  • Prev C-section
  • Instrumental delivery
  • Coagulation defect
  • Uterine eg fibroise
  • Prolonged induction of labour
  • Multiple Preg
77
Q

Causes of PPH

A
  • Trauma - Perineal, vaginal, instrumental delivery, c-section, uterine rupture.
  • Tone - BMI >35, multiparity, maternal age >40y, P. Previa, macrosomia, shoulder distocia, uterine abnormalities, prolonged labour, polyhydramnios/ over-distention
  • Tissue - P. Previa, retained placenta, morbidly adherent placent, p abruption
  • Thrombin - DIC, sepsis, anticoagulants, coagulopathies
78
Q

Management of PPH

A
  • Aim= stop bleeding!
  • ABCDE + resus. Including cross-match
  • Tone- ergometrine, misoprostol
  • Trauma - examine + suture
  • Tissue - examine placenta, manual removal <60mins. IV oxytocin.
  • Thrombin - check clotting and correct
  • Laparotomy + hysterectomy may be needed.
79
Q

When do you treat iron deficiency anaemia in preg?

A

Hb <11 g/dL

80
Q

Oligohydramnios - causes, Ix, Tx, complications

A
  • Causes:
    • Leakage of amniotic fluid - SROM, PPROM
    • Reduced foetal urine production - IUGR, renal abnormalities, post-dates
    • Obstruction to foetal UO - poor urtheral valves
  • Ix: USS + doppler, speculum, ?SROM - bloods + vaginal swabs
  • Tx the cause
  • Complications related to cause/ reduced vol - lung hypoplasia, limb abnormalities
81
Q

Polyhydramnios - Causes, Tx, complications

A
  • Causes:
    • Increased foetal UO - maternal DM, FFTS, foetal hydrops
    • Inability to swallow/ absorb amniotic fluid- GI obstruction eg duodenal atresia (Down’s), neuromuscular abnormalities, facial obstruction
  • Tx- Cause. Severe- amnioreduction/ NSAIDs
  • Complications- pre-term labour, malpersentation, maternal discomfort
82
Q

Differentials for vaginal discharge, their presentation and Tx + Ix

A
  • Chlamydia - ++ mucopurulent and yellow, pelvic pain, bleeding. Tx= Azithromycin
  • Gonorrhoea - ++ Mucopurulent, thick, white. Dysuria, pelvic pain, friable cervix. Tx= Ceftriaxone + azithromicin
  • Bacterial vaginosis - thin, watery, white/grey. FISH. Tx= Metronidazole
  • Candida- itchy, white, curd like. Vulval soreness/ pain. pH <4.5. Tx= clotrimazole/ fluconazole
  • Trichomonas (STI)- frothy, offensice yellow/green. Fish. Strawberry cervix. Tx= Metronidazole + partner Tx
  • Ix: Speculum, high vaginal and endocervical swabs, pelvic USS, MSU, biopsy
83
Q

What is Fitz-Hugh Curtis syndrome?

A

STI –> PID –> liver capsule inflammation

84
Q

Key features of cervical ectropion

A
  • Columnar epithelium of endocervix visible as red area around the os
  • Normal in preg, puberty, OCP
  • Presentation- ASx, discharge, PCB, prone to Inf
  • Ix- smear, colp
  • Tx- cryotherapy
85
Q

Key features of cervical polyps

A
  • = benign tumours of endocervical epithelium. Usally >40y
  • Presentation- ASx, IMB, PCB, PMB
  • Tx- avulsion + surg removal
86
Q

What are fibroids, their types and RF

A
  • = Leiomyomata. Benign growth of uterine muscle. Growth dependent on oestrogen and progesterone.
  • RF:
    • Oestrogen exposure (reduced risk COCP)
    • Obesity
    • Black
    • FHx
    • Age
  • Types:
    • Intramural
    • Submucosal (into cavity) ++ bleeding
    • Subserosal - just outside the uterus
87
Q

Presentation of fibroids

A
  • ‘Dragging’ sensation
  • IMB
  • Pelvic pain
  • Menorrhagia
  • Bloating/ distention
  • Infertility
  • Acute pain - torsion, degeneration
  • Dyspareunia/ dysmenorrhoea
  • ?Feel on bimanual
  • Sx of pressure on other organs - urinary/bowel
  • ASx?
88
Q

Ix and Tx of fibroids

A
  • Ix:
    • Bedside- clinical examination, urine
    • Bloods- FBC
    • Imaging - USS +/- TV
  • Tx:
    • Sx + <3cm:
      • Mirena coil, POP
      • NSAIDs
      • Tranexamic acid, mefanamic acid
      • Progesterone days 5-26 of cycle
      • GnRH agonists –> artifical menopause to shrink fibroids. <6m pre-surg.
    • Large fibroids, Sx/ not responding:
      • Myomectomy (preserve feritlity)
      • Hysterectomy
      • USS to ablate
      • Embolisation
      • Ablation
89
Q

When is cervical cancer screening carried and what do the results mean?

A
  • 25-49 = 3yearly
  • 50-64 = 5 yearly
  • >65y if haven’t had smear since 50y
  • Results = cellular abnormalities- dyskaryosis mild, mod, severe (risk of CIN)
    • Mild –> HPV testing –> +ve high strain to colp, rest back to 3/5 yearly screening
    • Mod - Colp
    • Severe - urgent colp
  • Colposcopy –> stain with 5% acetic acid –> grades of CIN. 1-3 based on thickness of epithelium. Dx on biopsy
  • CIN= pre-malignant change. CIN II/III excised - LLETZ (risk haemorrhage, pre-term labour)
90
Q

Cervical cancer - RF, presentation, Ix, Tx, complications

A
  • = Squamous cell carcinoma. More common 25-29y.
  • RF= Smoking, ++ sexual intercourse/ multiple partners, immunosuppression, HPV (16, 18) –> vaccinate against HPV.
  • Presentation:
    • IMB/ PCB/ PMB
    • Dyspareunia
    • Offensive discharge
    • Constipation
    • Incontinence/ haematuria
    • Bone pain
    • Fever, lethargy
  • Tx: Radiotherapy, chemotherapy, surgery
  • Complications - bone pain, kidney failure, PE/ DVT
91
Q

Pelvic pain DDx

A
  • Pregnancy - Miscarriage, ectopic, abruption,
  • Abdo- appendicitis, UTI, IBS/IBD, strangulated tumour, constipation
  • Gynae:
    • Endometriosis
    • PID
    • Fibroids
    • Adenomyositis (endometrial tissue in myometrium)
    • Chronic pelvic pain
    • Mittleschmertz (ovulation)
    • Menstruation
    • Ovarian cyst - rupture/ torsion
92
Q

What is PID, cause and RF

A
  • = Inflammation of pelvis/ upper genital tract with source of infection
  • Cause- infection esp chlamydia, gonorrhoea, (E. Coli)
  • RF:
    • <25y
    • Sexually active
    • Hx STI
    • Recent new partner
    • Multiple sexual partners
93
Q

Ix and Tx of PID + complications

A
  • Ix:
    • Bedside - urine dip, preg test, endocervical swabs (NAATS)
    • Bloods- ESR, CRP, WCC
    • Imaging - USS if not responding to ABx ?abscess
  • Tx:
    • Cons- take out coil - ??source of infection. Not if sex in last 7 days. STI screen
    • Med- analgesia, empirical braod spec ABx
  • Complications- ectopic, chronic pelvic pain, adhesions, tubal infertility
94
Q

Endometriosis - RF, Signs + Sx

A
  • = Growth of endometrial tissue outside uterine cavity (oestrogen dependent). Usually 20s.
  • Tissue undergoes menstrual cycle –> bleeding –> inflammation –> adhesions
  • RF:
    • FHx
    • Obstruction to vaginal outflow - FGM, defects in uterus/ tubes
    • Prolonged oestrogen exposure
  • Presentation:
    • Dysmenorrhoea, dyspareunia
    • Chronic pelvic pain
    • IMB
    • Bloating
    • Constipation
    • Rectal bleeding / haematuria
    • Fixed retroverted uterus
    • Adnexal masses
95
Q

Ix and Tx of endometriosis

A
  • Ix: (rule out ddx)
    • Bedside - urine, cervical swabs, preg test
    • Bloods- FBC, CRP, Ca-125
    • Imaging - USS, MRI
  • Tx: ??preserve fertility
    • Medical
      • Suppression of oestrogen for 6m - COCP, GnRH agonists (not pulsatile –> temp menopause).
      • Reduce inflamm - NSAIDs
    • Surgical- laparoscopic removal of tissue/ diathermy, hysterectomy
96
Q

Ectopic pregnancy - key features, RF, presentation, Ix and Tx

A
  • = Implantation of fertilised egg outside uterine cavity.
  • Locations - Tubal, abdominal, ovarian, cervical, c-section scar
  • RF: IUD, PID, endometrititis, PMH ectopic
  • Presentation:
    • Lower abdo pain
    • PV bleed
    • Shoulder tip pain
    • Collapse
    • Peritonism
    • Adnexal tenderness
    • Cervical excitation
  • Ix:
    • Blood- high beta HcG, low progesterone
    • Imaging- TVUSS
    • Special - laparoscopy
  • Tx:
    • ABCDE
      1. expectant
      1. IM methotrexate if betaHcg <5000mIU/mL
      1. Surg- laparotomy
97
Q

Definition of miscarriage and types + RF

A
  • = Expulsion of foetus when incompatible with life <24w
  • RF: infection, STI, SLE, >45y, NSAIDs, methotrexate, fibroids, HTN, PCOS, smoking/ alcohol, DM, obesity
  • Types:
    • Delayed/ missed - on scan
    • Threatened - bleed, os closed
    • Inevitable - os open
    • Complete
    • Incomplete
98
Q

Presentation, Ix and Tx of miscarriage

A
  • Presentation: Pain, Bleeding, contractions
  • Ix:
    • Bedside- urine, preg test, NEWS
    • Bloods - hCG, progesterone (down)
    • Imaging - TVUSS
  • Tx:
    1. Expectant - <6w
    2. Medical - prostaglandin pessary/ tablet
    3. Surgery- ERCP, MVA
    4. Psych support
    • Ix recurrent - Antiphospholipid Ab, karyotyping of foetus, pelvic USS
99
Q

Key features of molar pregnancy

A
  • Trophoblastic cells- villi in lining of uterus –> develops into placenta
  • = Slow growing tumour. Villi swollen with fluid –> clusters that look like grapes. Tumour grows instead of foetus
  • Benign but can develop into malignant GTD –> invasive mole (in muscle layer)
  • Causes:
    • Complete mole - sperm fertilises empty egg
    • Partial mole - 2 sperms fertilise egg
  • Presentation - Often no Sx. PV bleeding, ++ morning sickness –> picked up on scan
  • Ix:
    • Bloods- ++ hCG levels
    • USS - grape like appearance. No foetus.
  • Tx- surgical removal.
100
Q

Key features of hyperemesis gravidarum

A
  • = Excessive morning sickness
  • RF: multiple or molar preg - ++hCG
  • Complications
    • Mum- weight loss, dehydration, electrolyte imbalance, renal failure, muscle wasting
    • Baby- IUGR
  • Ix:
    • Urine - ketones, MSU
    • Bloods- FBC, U+Es, LFTs
    • USS
  • Tx:
    • Admit –> IVT, daily U+Es
    • –> anti-emetics –> corticosteroids
101
Q

Types and presentation of ovarian cyst

A
  • Types:
    • Simple - follicle cont to grow after egg released. May resolve months.
    • Endometrioma - chocolate cyst. Endometriosis
    • Dermoid - hair/ fat. may be v. large
  • Presentation:
    • Usually Asx - incidental
    • Abdo/ pelvic pain
    • Dyspareunia
    • Dysmenorrhoea/ change in cycle
    • Frequency/ urgency
    • Acute- rupture/ torsion
    • Abdo distention
    • Loss of appetitie/ early satiety
102
Q

Ix and Tx of ovarian cyst

A
  • Ix:
    • Bedside- Urine dip, abdo/pelvic exam
    • Bloods- Ca-125
    • USS
  • Tx:
    • <5cm - watchful waiting
    • 5-7cm - USS 1 year
    • >7cm –> further Tx ?surgery
103
Q

What is PCOS and what causes it?

A
  • PCOS= Polycystic ovary syndrome = Hyperandronic anovulation.
  • Pathophysiology:
    • Inappropriate signalling between hypothalamus, pituitary and ovary
    • More peripheral oestogen + GnRH
    • High LH, low FSH
    • More androgens
104
Q

Presentation of PCOS

A
  • Presentation:
    • Oligomenorrhoea
    • Hirsutism
    • Obesity
    • Infertility
    • Weight gain
    • Acne
    • Thin hair
    • Acanthosis nigricans
    • HAIR-AN syndrome= hyperandrogenism, insulin resistance, acanothosis nigricans
105
Q

Ix, Dx and Tx of PCOS

A
  • Ix:
    • Bedside- bimanual - enlarged ovaries
    • Bloods - DHEAS = hyperandrogenisms, fasting lipids, glucose
    • Imaging - pelvic USS
  • Dx= 2/3 of:
    • Oligo-ovulation
    • Excess androgen activity
    • USS - polycystic ovaries
  • Tx:
    • Diet + exercise + weight loss
    • OCP (lowers LH) - aim 3-4 monthly bleeds to reduce risk of endometrial Ca
    • Insulin sensitising agens
    • Clomiphene citrate - ovulation induction
    • Surg - ovarian drilling - reduce steroid production
106
Q

Long term consequences of PCOS

A
  • Endometrial hyperplasia / adenocarcinoma
  • T2DM
  • HTN/ CVS disease
  • Stroke
  • Obesity
107
Q

Key features of ovarian torsion

A
  • = Twisting of ovary aruond its ligamentous supoprt –> loss of blood supply to ovary + fallopian tube
  • Presentation:
    • Abdo pain/ tenderness. IF –> loin/groin/back
    • N+V
    • Low grade fever
    • Peritonitic signs
    • Cervical motion tenderness
    • Plapable adnexal mass
  • Ix:
    • Bedside- urine, preg test
    • Bloods - FBC
    • Imaging - Abdo/ TV USS, CT abdo/pelvis
  • Tx: Surgical. Untwist + fix
108
Q

Most common ovarian cancer and RF

A
  • 90% epithelial
  • RF:
    • High oestrogen exposure
    • Infertility
    • PMH breast cancer
    • FHx BRCA1/2
    • Protective - low ostrogen, parity, OCP, NSAIDs
109
Q

Presentation of ovarian cancer

A
  • VERY VAGUE
  • IBS type Sx - change in bladder/ bowel
  • Abdo pain
  • Ascites/ bloating
  • Loss of appetite and weight. Early satiety.
  • Indigestion
  • Nausea
  • Omental cake - hard and craggy
  • Fatigue
110
Q

Ix and Risk of Malignancy Index for ovarian Ca

A
  • Ix:
    • Urine - dip, preg test
    • Bloods - Ca-125
    • Imaging - USS –> CT for staging
  • RMI= A x B x C. >200 –> MDT, <200= Tx in unit
    • A- USS - solid areas, bilateral, ascites (0-3)
    • B Ca-125 >35
    • C- menopausal status - pre-menopausal= 1, post-menopausal= 3
  • Other causes of raised Ca-125: Preg, endometriosis, fibroids, malignancy, menstruation
111
Q

Tx of ovarian cancer

A
  • Combo of surgery (debulking) + chemo (carboplatin, paclitaxel)
  • Follow up 3 monthly for 2y, 6 monthly for 2y, 1y –> discharge
112
Q

Ovarian cancer 2 ww

A
  • 2ww - Asictes or pelvic/ abdo mass
  • Tests in GP if:
    • Abdo distention
    • Early satiety
    • Pelvic/ abdo pain
    • Urgency/ frequency
    • Weight loss
    • Change in bowel habit
    • New onset IBS >50y
    • –> Ca-125 >35 IU/ml –> USS
113
Q

Most common type of endometrial cancer, RF and presentation

A
  • Pre-malig= hyperplasia
  • Most common= adenocarcinoma
  • RF: Post-menopausal, >45y, high oestrogen exposure, PCOS, tamoxifen, diet. (Smoking protective)
  • Presentation:
    • PMB
    • Pelvic/ abdo pain
    • Discharge
    • Polymenorrhoea
114
Q

Endometrial cancer 2ww referral criteria

A
  • >55y with PMB (? if <55y)
  • Direct access to USS if >55y with:
    • Unexplained PV discharge + thrombocytosis/ haematuria
    • Visible haematuria + low hb, high glucose
115
Q

Ix and Tx of endometrial cancer

A
  • Ix:
    • Pipelle biopsy if >5cm
    • TVUSS
    • Hysterectomy + washings –> histology
  • Tx:
    • Radio/ chemo
    • Hysterectomy
    • Progesterone - PO/ coil. Sx control
116
Q

Definition of primary and secondary amenorrhoea and causes

A
  • Primary amenorrhoea= never had a period. >16y with no periods of secondary sexual characteristics. Causes:
    • Constitutional delay
    • Kallmann’s syndrome - x puberty and smell. Hypogonadotrophic hypogonadism
    • Prolactinoma
    • Anorexia
    • Athletes
  • Secondary amenorrhoea= no period for >6m. Causes:
    • Pregnancy, lactation, ovarian insufficiency, low BMI, hyperthyroid, pituitary tumour, PCOS (oligomenorrhoea)
    • Ix- preg test, BMI, TFTs, LH + FSH, USS, MRI
    • Tx- lifestyle, Tx cause, progesteogens
117
Q

Intermenstrual bleeding - causes, Ix and Tx

A
  • Causes= polyps, STI, ectropion, ovulation, endometrial/ cervical cancer, trauma
  • Ix:
    • Bedside- swabs, bimanual/ speculum, smear
    • Imaging- USS
    • Special - pipelle, colposcopy
  • Tx: Based on cause
118
Q

Menorrhagia - definition, causes, Ix and Tx

A
  • = Subjective. An amount that a woman considers to be excessive
  • Causes:
    • Younger - IUD, endometriosis, bleeding disorder, polyps, PCOS, hypothyroid
    • Older (>35y)- Hypothryoid, fibroids, malignancy, polyps, IUD
  • Ix:
    • Bedside- Hx and exam
    • Bloods- clotting, Hb
    • Imaging- USS, hysteroscopy
    • Special- pipelle
  • Tx:
    • Conservative- Symptomatic
    • Medical- Mirena, NSAIDs, tranexamic acid, OCP
    • Surgical- ablation, hysterectomy
119
Q

Definition of menopause and presentation

A
  • = 12 months consecutive amenorrhoea. Peak 51-52y
  • Early menopause= 40-45y
  • Premature ovarian failure = <40y. Causes: Primary= genetic, AI, enzyme deficiency. Secondary= chemo, radio, inf, hysterectomy
  • Presentation:
    • Vasomotor - hot flushes/ night sweats
    • Anxiety, low mood
    • Osteoporosis (1/3)
    • CVS disease
    • Vaginal dryness
    • Urinary
    • Palpitations
    • Less sleep and palpitations
    • Low libido/ dyspareunia
    • Thin hair, brittle nails
    • Myalgia
120
Q

Ix and Tx of menopause

A
  • Ix= Usually clinical.
    • High FSH/ LH, low oestrogen/ progesterone - primary ovarian failure
    • Rule out DDx: Preg, PCOS, thyroid, TB, malignancy, infection
  • Tx:
    • Cons- lifestyle- less caffeine and alcohol, smoking cessation, weight loss
    • Med:
    • Non-hormonal
      • Dryness - lubricants
      • OP- caclium, vit d, bisphosphonates
      • SSRI for vasomotor - venlafaxine/ clonidine
    • HRT:
      • No-uterus- Oestrogen only cont.
      • Uterus - Oestrogen + progesterone. Cyclical or continuous (no period for 1y or 2y if younger)
      • Topical creams/ pessaries
      • Patch if high VTE risk
121
Q

HRT - risks, benefits, contraindications, when to stop

A
  • Risks: breast Ca, endometrial Ca, VTE, GB disease, Sx after stop
  • Benefits: Less Sx, protective against OP/ CVS disease/ colorectal disease. Muscle bulk and strength
  • CI: Prev breast/ ovarian Ca, undiagnosed vaginal bleeding, ,HTN, endometrial hyperplasia
  • Stop: Annual r/v. >70y Risks > Benefits
122
Q

Options of Contraception

A
  • Family planning - rhythm, ovulation, coitus interruptus
  • Barrier - condom, diaphragm. Less STIs
  • IUD/ IUS
  • OCP
  • Injectable hormonal contraception - Depo = progesterone, implant= ethongestrel, patch
  • Sterilisation - female= interruption of fallopian tubes, male= vasectomy. NB councelling
123
Q

Key features of intrauterine devices for contraception

A
  • IUS= Mirena: Lasts 5y
    • Progestagen- endometrial atrophy, thick mucus. Highly effective. Useful when oestrogen CI.
    • Reversible.
    • SE: PV bleeding, amenorrhoea, hormonal (nausea, bloating, headache, breast) - usually settle 6m
  • IUD= Copper coild. Lasts 8-10y
    • Foreign body - prevents implantation.
    • Can be used as emergency
    • SE: PV bleed, inf, IUD expulsion, dysmenorrhea
  • Complications:
    • PID
    • Perforation
    • Ectopic
    • Heamorrhage
    • Infection
124
Q

Key features of OCP

A
  • COCP:
    • Oestrodiol + progestoagen –> prevent ovulation, thicker cervical mucus, thin endometrium
    • SE: spotting, hormonal
    • Risks: VTE, stroke, CVS disease, breast/ cervical Ca
    • CI: Smoker >35y, hemiplegic migraine, bruit >40y, VTE, stroke, HTN, inherited thrombophilia, current breast Ca
  • POP:
    • Norethisterone/ levongestrel - prevents ovulation, thin endometrium, thick mucus
    • SE: menstrual disturbance, hormonal Sx
125
Q

Emergency contraception options

A
  • Levongestrel PO - within 72h. SE: N+V, erratic PV bleed
  • Ulipristal - 120h after sex
  • Copper IUD
126
Q

Definition of subfertility and male/ female factors

A
  • = After 2 years with regular unprotected sex and no known reproductive pathology
  • Female factors:
    • Age
    • Systemic illness eg rubella
    • Poor nutrition/ ++ exercise
    • Stress
    • Tubal- congenital, IBD, PID, chlamydia
    • Uterine - fibroids, endometriosis
    • Cervical - infection
    • Disorders of ovulation - Kallman’s, PCOS, premature ovarian failure, pituitary adenoma
  • Male factors:
    • Semen - Azospermia, test. cancer, alcohol, smoking, genetics
    • BMI
    • Idiopathic
    • Infection
    • Mechanics
    • Retrograde ejaculation
    • Azopermia - steroids, Kallman’s, pituitary adenoma, vasectomy, orchitis, chemo/radio, chlamydia, gonorrhoea
    • Heat
    • Tight underwear
127
Q

Male and female investigations of subfertility

A
  • Female:
    • Ovulation- hormone levels, cervical mucus, USS
    • Ovarian reserve- USS antral follicle count
    • Tubal patency - STI screening, hystero-salpingography, USS hystero-contrast, hysteroscopy
  • Male:
    • Semen analysis after 3d abstinence
    • Sperm DNA
    • Auto-Ab testing
128
Q

Subfertility Tx

A
  • Anovulation- clomiphene 2-6d of cycle for 6m. Risk of ovarian hyperstimulation (abdo pain, D+V, distention, weight gain)
  • Hypotrophic hypogonadism - GnRH
  • Tubal- surgery/ IVF
  • IVF:
    • Eligability: <40y= 3 cycle, >40y= 1 cycle. Must have been trying 2y, BMI <30, no children already, non-smokers
    • Intrauterine insemination
    • IVF + embryotransfer + ICSI
  • Male infertility rarely treatable
129
Q

Prolapse - Definition, types, RF, causes

A
  • = Bulging >1 pelvic organs
  • Types:
    • Cystolcoele (front vaginal wall)
    • Rectocoele (back vaginal wall)
    • Uterine (stage 1-4)
    • Procidenture
  • RF: Age, chronic cough/ constipation, heavy lifting, obesity, childbirth
  • Causes= weak pelvic floor:
    • Multiple vaginal deliveries/ big babies
    • Obesity
    • Smoking
    • Gynae syrg
    • FHx
    • Chronic cough/ COPD
    • Hypermobility/ Marfan’s
    • Fibroids
130
Q

Presentation of prolapse + Ix

A
  • Vaginal:
    • Dragging sensation, bulge
    • Difficulty retaining tampons
    • Spotting, discharge
    • Difficulty with intercourse - pain, flatus
  • Urinary:
    • Incontinence/ frequency/ urgency
    • Incomplete voiding/ weak stream
    • Manual reduction before voiding
    • Recurrent UTIs
  • Bowel:
    • Constipation/ straining
    • Urgency, incontinence
    • Flatus
    • Incomplete evaculation
    • Manual reduction
  • O/E with Sims speculum
131
Q

Tx of prolapse

A
  • Cons - watch and wait, X smoking, weight loss, physio, Tx cough/ constipation
  • Pessary - ring/ gellhorn. Replace every 6m
  • Med- topical oestrogen
  • Surg:
    • Bladder- colposuspension
    • Uterine - hysterectomy/ fixation
    • Rectocoele - post. colporrhaphy
    • Pelvic floor repair
132
Q

Methods of TOP + complications

A
  • Medical (<13w)
    • Mifepristone + Prostaglandin
    • Mifepristone= antiprogesterone –> contractions and bleeding
    • Misoprostol= Prostaglandin E1 analogue –> contractions
    • Gemeprost- softens cervix
  • Surgical
    • 7-13w= Suction
    • >13w= dilatation + evacuation
    • Misoprostol/ mifepristone/ gemeprost prior to surgery
  • Management:
    • Before:
      • Councelling
      • Bloods- Hb, blood group, Abs
      • USS- gestation
    • After: Anti-D, follow up 2w
  • Complications- bleeding, infection, uterine perforation, cervical trauma, failed, retained products, N+V, diarrhoea, psychological

Finals!!! (19 decks)

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