Obs and Gynae Flashcards
Name 3 hormones that are important in pregnancy
- hCG
- Progestins
- Oestrogens
- hPL, Prolactin, Oxytocin also important
Where is hCG produced?
The trophoblast
Give 2 functions of hCG
- It signals the presence of the blastocyst
2. It prevents the corpus luteum from dying (luteal regression)
Where are progestins produced?
Initially from the corpus luteum and then from the placenta from week 7
Give 3 functions fo progestins
- Prepares the endometrium for implantation
- Promotes myometrial quiescence
- Increases maternal ventilation
How do progestins prepare the endometrium for implantation?
Stimulate the proliferation of cells, vascularisation and the differentiation of endometrial stroma
Where are oestrogen produced?
Initially in the ovary and then from a combination of fetal and maternal sources
Give 2 functions of oestrogens in pregnancy
- Promotes uterine blood flow, myocetrial growth and cervical softening
- Increases sensitivity and expression of myocetrial oxytocin receptors
- Increases water renovation and protein synthesis
- Increases breast and nipple growth
- Promotes a change in the cardiovascular system
What is the main oestrogen in pregnancy?
E3 = indicates fetal wellbeing
What is the role of E2 in pregnancy?
Responsible for proliferation of the endometrial epithelium and it also facilitates progesterone action
What is the role of human placental lactose (hPL)?
- Mobilises glucose from fat
- Acts as an insulin antagonist
- Converts mammary glands into milk secreting tissues
Where is prolactin produced?
Anterior pituitary gland
What is the role of prolactin?
Responsible for milk production
Where is oxytocin produced?
Posterior pituitary gland
What is the role of oxytocin?
Responsible for uterine contractions and milk secretion
Where are FSH and LH produced?
Anterior pituitary gland
What is the main basis of the HPG axis?
Hypothalamus releases GnRH that acts on the anterior pituitary gland
Anterior pituitary release FSH and LH that act on the ovaries
Ovaries produce oestrogens and androgens
What cells in the ovaries does FSH act on?
Granuloma cells –> oestrogen production
What cells in the ovaries does LH act on?
Theca cells –> androgen production
What hormone inhibits prolactin release?
Dopamine (released from hypothalamus to act on anterior pituitary)
Are the changes that occur during pregnancy pathological or physiological?
Physiological changes occur in pregnancy –> resetting of normal physiological values
Give 2 characteristics of maternal physiological changes
- Anticipatory –> precede fetal demands and growth
- In excess of fetal requirements
- Dynamic –> inter-trimester variation
- All enhance placental exchange of nutrients and waste
What happens to maternal renal function in pregnancy?
- Kidneys increase in size (20%)
- Increase in renal blood flow –> increase in GFR (–> decreased plasma urea and creatinine)
- Increased creatinine clearance, glycosuria, aminoaciduria
- Increased UTI risk (progesterone reduced smooth muscle tone –> urinary statis)
What happens to maternal cardiac output in pregnancy?
Cardiac output, HR and stroke volume increase by 30-50%
How does maternal BP change throughout pregnancy?
Biphasic changes
- 16-20 weeks = decrease in peripheral resistance –> decrease in systolic and diastolic pressure
- Late pregnancy = increase in BP
Why does dilution anaemia occur in pregnancy?
Increase in ECF volume causes dilution effects
There is an increase in RBC numbers but RBC concentration decreases per unit volume due to increased plasma volume level (by 50% by term)
Decreased haemoglobin and haematocrit levels
What happens to white blood cells during pregnancy?
Increase in white cells (polymorphonuclear leukocytes)
NO dilution effect seen
Why does thromboembolism risk increase during pregnancy?
Blood becomes hypercoagulable
- Increase in plasma fibrinogen
- Increase in clotting factors (VII, VIII, X)
- Increase in plasminogen activator inhibitor
How does maternal respiratory function change in pregnancy?
- Increase in maternal oxygen consumption (15-20%)
- Increase in tidal volume –> increases minute volume
- Decrease in total lung volume
Why does maternal PCO2 decrease in pregnancy?
Decreases from 4.7kPa to 4.0kPa
Creates much steeper gradient helping the fetal gas exchange
State of compensated respiratory alkalosis
Increase in maternal DPG –> promotes O2 release at low maternal Hb saturations seen in placenta
What GI and Liver changes occur in pregnancy?
- Delayed gastric emptying
- Cardiac sphincter relaxation –> heart burn
- Increased gut transit time
- Reduced CCK secretion
- Reduced gall bladder motility –> obstetric cholestasis and increased risk of gallstones
What is the principle fetal nutrient?
Glucose
Can the foetus produce any of its own glucose?
No, gluconeogenic enzymes are inactivated int he foetus and so all its glucose has to come from its mother
The foetus also has no mechanism to limit uptake of glucose so will always take up glucose even if excessive
In early pregnancy, is maternal plasma glucose high or low?
Plasma glucose is low as it is being stored (glycogen) and deposited (as fat)
In late pregnancy, is maternal plasma glucose high or low?
Plasma glucose is higher, due to maternal insulin resistance and glucose sparing for the foetus
What are the consequences of maternal insulin resistance?
Maternal insulin resistance –> gestational diabetes –> increased risk of macrosomia and shoulder dystocia
Why is the immune response suppressed in a pregnant last?
Prevention of foetal rejection
Give 4 ways in which foetal rejection is prevented in a pregnant lady?
- A TH2 bias is observed
- Syncytiotrophoblast has self:no-self markers so doesn’t stimulate an immune response
- Extra-villous trophoblast cells have modified markers
- Overall immune response is suppressed
Give 3 potential complications if there is not a TH2 bias in pregnancy
- Pre-eclampsia
- IUGR
- Miscarriage
How does the endometrium epithelium become adhesive to the blastocyst?
The blastocyst and endometrium communicate via the release of hormones –> ‘sticky endometrium’
When is a women’s cycle does the endometrium become ‘sticky’?
Between 20-24 days = window of implantation
What reaction occurs when a blastocyst implants into the endometrium?
Primary decidual reaction
What part of the blastocyst facilitates placental formation?
The cytotrophoblast
What does the cut-trophoblast go onto form?
Anchoring villi –> extra villous trophoblast
What can trigger differentiation fo anchoring villi into extra-villous trophoblast?
Hypoxia
What is the role of extra-villous trophoblast (EVT) cells?
EVT invade and remodel spiral arteries (become wide bore, low resistance)
Leads to more hypoxia so more EVT = positive feedback
Why do EVT cells invade and remodel spiral arteries?
To allow for optimum nutrient delivery and blood supply for the baby
Give 3 potential consequences of poor end-vascular remodelling
- Pre-eclampsia
- Preterm birth
- IUGR
Due to reduced acquisition of maternal blood supply for baby
What happens to the cervix during pregnancy?
Cervix increases in softness and vascularity with increase gestation Blue tinge (oestrogen mediated) = Chadwick's sign
Define Screening
Process of identifying apparently healthy individuals who may have an increased risk of developing a disease
What are the Wilson and Jugner screening criteria?
- The condition should be a serious health problem
- The natural history of the condition should be understood
- There should be a detectable early stage
- There should be a treatment available
- Facilities for diagnosis and treatment should be available
- There should be a suitable test
- The test should be acceptable to the population
- There should be an agreed policy on whom to treat
- The cost of testing should be balanced against the benefits
- Screening should be a continuous process not just a one off
When would a woman have her booking appointment and what is the purpose of it?
Before 12 weeks, often 10 weeks
- Obstetric history and examination
- BMI, BP, urine dip, Hb
- Check for HIV, Hep B, Syphilis, Rubella
- General healthy lifestyle advice
- Screen for complications
When should the dating US be done?
Preferably between 11 to 13+6 weeks
- Dates pregnancy, confirms viability, singleton/multiple and picks up any gross structural abnormalities
- Screening occurs –> Crown-rump length (CRL) and Nuchal Translucency (NT)
- Blood test –> including BhCG, PAPPA, infection, rhesus status
What diseases are screening for in the foetal anomaly screening test?
- Down’s (T21)
- Edward’s (T18) –> LBW, small head/mouth/jaw, low set ears, cleft palate, exomphalos
- Patau’s (T13) –> cleft lip/palate, microcephaly ,ear malformations, rocker-bottom feet
What fetal screening tests can be done?
- Combined Test = first trimester (11+2 to 14+1 weeks) –> maternal age, US CRL and NT, blood sample (PAPP-A and free beta hCG)
- Quadruple Test = second trimester (14+0 to 20+0 weeks) –> Blood test (AFP, total beta hCG, oestriol, inhibin A)
Why is the quadruple test sometimes done?
If combined screening is not possible –> if late booking or NT not obtained
ONLY A MARKER OF DOWNS
When is the anomaly US done?
18+0 to 20+6 weeks
Detects major structural abnormalities
What is the threshold for further testing following a fetal anomaly screening test?
If the risk is >1 in 150 then further testing will be done –> chorionic villous sample (CVS - at 10 weeks) or amniocentesis (at 15 weeks)
(NIPT available privately)
What diseases are being screened for in the antenatal infectious diseases screening test?
- HIV –> treat mum and reduce transmission to baby
- Hep B –> see if mum is infected
- Syphilis –> treat mum to prevent congenital syphillis or possible loss of baby
What is the inheritance pattern of sickle cell and thalassaemia?
Autosomal recessive
Name 3 neonatal screening programmes
- Newborn blood spot
- Hearing test
- Newborn and 6-8 weeks physical examination
What is the neonatal newborn blood spot screening test?
Screens for 9 conditions by a heel prick blood test at days 5-8
- Sickle cell disease (can also identify beta thalassaemia major and carriers of sickle cell)
- Cystic fibrosis
- Congenital hyperthyroidism
- Phenylketonuria
- Medium chain acyl-CoA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease
- Isovaleric acidaemia
- Glutaric aciduria type 1
- Homocystinuria
When is the neonatal hearing test done?
Within 4 weeks
- Looking for a response in the cochlea
When are the newborn physical examinations done?
Within 72 hours of birth and repeated at 6-8 weeks by a GP
Give 4 things that a newborn physical examination is looking for
- Eye problems
- Heart defects
- Hip dysplasia
- Undescended testes
Name 3 risk factors that require serial scans from 28 weeks
- Previous SGA baby
- LGA baby
- Polyhydramnios/oligohydramnios
- Smokers
- BMI >35
Serial scans = US every 3 weeks
Name 3 disorders that are exacerbated by pregnancy
- HTN
- Renal disease
- Cardiac Disease (e.g. mitral stenosis)
- Endocrine disease
Name 3 disorders that are specific to pregnancy
- Gestational Diabetes
- Pre-eclampsia
- Obstetric cholestasis
- Acute fatty liver in pregnancy
How can pregnancy affect anaemia?
2 fold increase in iron requirements and 10 fold increase in folate requirements
IDA = ferrous sulphate
Folate deficiency = folic acid
Multivitamins can be taken –> contain iron and folate
Anaemia is associated with low birthweight and preterm delivery
How is asthma affected in pregnancy?
Affected by physiological changes
Main exacerbation risk in 3rd trimester
Most medications are safe in pregnancy –> SABA, ICS, LABA, theophylline, leukotriene antagonists
Make sure to avoid ibuprofen and BB in labour
If a mother has a cardiac condition when can the baby be screened?
20 week ECHO
What are low risk cardiac conditions in pregnancy?
Mitral incompetence Aortic incompetence ASD VSD PDA
What are high risk cardiac conditions in pregnancy?
Aortic stenosis Coarctations of aorta Prosthetic valves Pulmonary HTN Marfan's with aortic root dilation - Pregnancy often discouraged in these patients
What inheritance pattern is associated with obstetric cholestasis?
Autosomal dominant
What symptoms does obstetric cholestasis often present with?
Itching –> often hands and feet and at night
Can have anorexia, malaise, epigastric discomfort, steatorrhoea, dark urine
What might you see on the blood results of a patient with obstetric cholestasis?
Raised AST, ALT and bile acid
What does obstetric cholestasis increase in the risk of?
Premature and Still birth
How is obstetric cholestasis managed?
LFTs weekly
Ursodeoxycholic acid –> improves liver function and itching
Vitamin K
What risks are associated with hyperthyroidism in pregnancy?
Maternal risk = thyroid crisis with cardiac failure m
Fetal risk = thyrotoxicosis due to transfer of thyroid stimulating antibodies (usually resolves after 6 months)
What hyperthyroidism controlling drug is preferred in pregnancy?
Propylthiouracil (PTU) preferred over carbimazole as less teratogenic
What risks are associated with untreated hypothyroidism in pregnancy?
Early fetal loss and impaired neurodevelopment
Higher dose of thyroxine often needed during pregnancy, especially in first trimester (T4 needed for fetal brain development <12 weeks)
What diabetic medications can be used during pregnancy?
Insulin and metformin are safe
All other oral hypoglycaemics are contraindicated
ACEi and statins also contraindicated
Name 3 maternal complications due to diabetes
- DKA
- Pre-eclampsia
- Progression of retinopathy (screened twice at least throughout pregnancy)
- Hypoglycaemia
Name 3 possible fetal complications due to maternal diabetes
- Miscarriage
- Stillbirth
- Premature labour
- Macrosomia –> shoulder dystocia
- Neonatal hypoglycaemia, hypocalcaemia, polycythaemia
- Polyhydramnios
- Respiratory distress
- Fetal abnormalities
What happens in women with gestational diabetes when extra glucose crosses the placenta?
Insulin, GF and GH’s are produced –> foetal growth is stimulated and fat and glycogen are deposited
How is gestational diabetes diagnosed?
Oral Glucose Tolerance Test at 28 weeks 75mg glucose given - Fasting plasma glucose >5.6 OR - >7.8 after 2 hours
How is gestational diabetes managed?
Diet and exercise = first line
Metformin = 2nd line
Insulin = 3rd line
OGTT 6 weeks postpartum to ensure it has resolved after medications have been stopped following delivery
How can epilepsy in pregnancy be managed?
- Preconception counselling
- Manage triggers and control seizures
- Medications often teratogenic –> sodium valporate (swap to lamotrigine)
- Alpha fetoprotein, anomaly scan, fetal ECHO (22-24 weeks)
- High dose folic acid throughout (before conception if possible)
- Vitamin K from 36 weeks
Name 3 possible fetal complications due to being on sodium valproate during pregnancy
- Nueral tube defects
- ASD
- Cleft palate
- Hypospadias
- Learning difficulties and autism
Define Chronic HTN
HTN diagnosed before pregnancy or before the 20th week of gestation and nor resolved postpartum
Define Gestational HTN (Pregnancy Induced HTN)
New HTN after 20 weeks gestations which resolves after birth
NO proteinuria
>140/90
Define Pre-eclampsia
New HTN after 20 weeks with proteinuria (>0.3g protein/24hours)
What is eclampsia?
Preeclampsia (gestational HTN + proteinuria) and generalised tonic clonic seizures
Describe the pathophysiology behind pre-eclampsia
Spiral arteries do not remodel –> arteries are tight leading to increased resistance in the placenta –> placental ischaemia –> RAAS activated –> poor renal perfusion, HTN, proteinuria and oedema –> pre-eclampsia
Give 4 risk factors for developing preeclampsia
- Previous pre-eclampsia
- Age >40 or teenage
- Primipatiry
- Multiple pregnancy
- Long birth interval (>10 years)
- Existing medical conditions –> HTN, renal disease, Dm, antiphospholipid anitbodies
Give 3 signs of pre-eclampsia that are detected at the kidneys
- GFR and renal blood flow decrease
- Raised uric acid
- Proteinuria
Give 3 symptoms of pre-eclampsia
- Visual disturbances
- Headaches
- Epigastric pain
- Weight gain
- Vomiting
Give 3 signs of pre-eclampsia
- HTN
- Proteinuria
- Retinal Vasospasm
- RUQ tenderness
- Ankle clonus or brisk reflexes
- Oedema
How is preeclampsia classified?
Mild, moderate, severe - Severe = severe HTN (>160/110) and/or symptoms and/or biochemical and/or haematological impairment OR Early = <34 weeks Late = >34 weeks
Management of preeclampsia
- Restrict activity and regular BP, urine and biochemistry checks
- Labetalol (not in asthmatics) +/- nifedipine
- IV MGSO4 (neuroprotection) = reduces frequency of eclampsia
- DELIVERY = CURE
Give 3 indications for delivery in preeclampsia
- Gestational age >38 weeks
- Platelet count <100,000 cells/mm3
- Progressive deterioration in liver and renal function
- Suspected placental abruption
- Persistent severe headaches, visual changes, N+V, epigastric pain
- HELLP syndrome or eclampsia
- Severe fetal growth restriction
- Oligohydramnios
Give 3 possible maternal complications due to pre-eclampsia
- Eclampsia
- CVA
- HELLP (Haemolysis, elevated liver enzymes, low platelets)
- Liver failure
- Renal failure
- DIC
- Pulmonary oedema
Give 3 possible fetal complications due to pre-eclampsia
- IUGR
- Preterm brith
- Placental abruption
- Hypoxia
When and why is aspirin prescribed in pregnancy?
150mg from 12 weeks OD if 1 high risk factor or 2 moderate risk factors
Moderate Risk Factors
- 1st pregnancy
- > 40 y/o
- Pregnancy interval >10 years
- BMI >35 (at first visit)
- FHx of preeclampsia
- Multiple pregnancy
High Risk Factors
- Hypertensive disease in previous pregnancy
- CKD
- AI (like SLE or antiphospholipid syndrome)
- Type 1 or 2 diabetes
- Chronic HTN
Give 2 signs of polyhydraminos
- Increased abdominal size that is out of proportion for weight and gestation (increased SFH)
- AFI >20 on USS
- Maternal dyspnoea and faint foetal heart sounds
Give 3 causes of polyhydramnios
- Maternal diabetes
- Fetal abnormalities (duodenal atresia)
- Multiple pregnancy
Give 3 potential consequences of polyhydramnios
- Cord prolapse
- PPH
- Preterm labour
- IUGR
Describe the 3 stages of labour
Stage 1 = Cervical remodelling, dilation and uterine contractions
Stage 2 = Full dilation to delivery of foetus
Stage 3 = Placental delivery
Describe the 3 stages of labour
Stage 1 = Cervical remodelling, dilation and uterine contractions
Stage 2 = Full dilation to delivery of foetus
- can have a passive hour once fully dilated = contractions slow down
Stage 3 = Placental delivery
What are the 2 phases of Stage 1 labour?
Latent phase = irregular contractions that vary in length and strength, cervix begins to dilate and efface up to 4cm (hours)
Active phase = established labour, stronger and more regular contractions, cervix becomes fully effaced and dilates up to 10cm (primi woman = 0.5cm/hour)
What causes myometrial contractions?
Oxytocin release –> increased intracellular Ca2+ –> myometrial contractions
Name an oxytocin analogue that can induce labour
Syntocin
Name 2 drugs that can inhibit uterine contractions
- Nifedipine (CCB)
2. Atosiban (oxytocin antagonist)
Why can nifedipine inhibit uterine contractions?
It is a CCB so blocks rise of intracellular calcium –> inhibiting muscle contraction
Define Lie in terms of the foetus during pregnancy
Relationship between the longitudinal axis of the uterus and longitudinal axis of the foetus
Can be longitudinal, transverse or oblique lie
Define Presentation in terms of the foetus during pregnancy
Anatomical part of the foetus which presents itself first though the birth canal
Define Position in terms of the foetus during pregnancy
relationship between a defined area of the presenting part (the denominator) and the mothers pelvis
- Occiput = denominator in a fully flexed head
- Chin = denominator in fully extended head (face presentation)
- Brow = denominator in partially extended head (brow presentation)
- Sacrum = denominator in breech presentation
Define Attitude in terms of the foetus during pregnancy
Relationship of the fetal head and limbs to the fetal trunk –> flexed or extended
What are the 3 key participants in labour?
- Passage = maternal boney pelvis and soft tissues
- Passenger = fetus –> size, presentation, postion, anomalies
- Power = uterine contractions and maternal effort
What is cervical ripening?
Increased softening, distensibility, effacement and dilatation of the cervix and occur prior to the onset of labour and in the latent phase
Primiparous = process completed before first active stage of labour
Multiparous - can take place at the same time as dilation
Explain moulding
Overlapping of fetal skull bones during labour to help reduce the size of the head
Briefly describe the mechanism of labour
- Engagement and descent
- Flexion
- Internal rotation = fetal head turns 90 degrees
- Extension = head extends once occiput beneath suprapubic arch
- Restitution = align head with shoulders
- External/lateral rotation
- Delivery of body
Briefly describe the mechanism of labour
- Engagement and descent
- Flexion
- Internal rotation = fetal head turns 90 degrees
- Extension = head extends once occiput beneath suprapubic arch
- Restitution/external/lateral rotation = align head with shoulders
- Delivery of body
Why is there often delayed cord clamping?
Allows baby to transition
Increase in RBC, iron and stem cells
Reduces the need for inotropic support
What are the 2 membranes associated with the placenta?
- Amnion = bag around baby
- Chorion = membranes around the placenta
Need to examine placenta and membranes after to ensure they are intact –> left in can cause severe PPH
When is there shared antenatal care between the hospital and the community?
High risk women
- Underlying medical conditions –> HTN, DM, epilepsy, RA, asthma, ITP
- Complications in previous pregnancy –> Previous CS/preeclampsia/PPH/SGA/preterm/3rd/4th degree tear
- Complications in current pregnancy –> preeclampsia, breech, GDM, multiple, PP
- Issues with women herself –> high/low BMI, smoking, alcohol, drugs, old/young
How are babies monitored antenatally?
- USS
- Intermittent auscultation –> with handheld doppler or pinned stethoscope (listen to fetal heart)
- CTG
What fetal measurements are taken antenatally on US?
Growth/estimated fetal weight measurements
- Abdominal circumference
- Head circumference
- Femur length
Liquor volume (amniotic fluid index)
Umbilical artery dopplers (pulsatility index)
Give 2 methods used for monitoring the fetal heart rate
- Intermittent auscultation –> low risk
2. Continuous monitoring, cardiotocgraphy (CTG) –> high risk patients
During labour when should intermittent auscultations be performed?
Every 15 minutes in the 1st stage
Immediately after a contraction for at least 1 minute or every 5 minutes in 2nd stage
Give 2 disadvantages of intermittent auscultation
- Variability and decelerations can’t be detected
- Long term monitoring is not possible
- Quality of FHR can be affected by maternal HR and movement
Give 2 advantages of continuous monitoring of the FHR
- Gives lots of information –> variability, accelerations, decelerations
- Long term monitoring possible
- Monitors FHR and uterine contractions
CTG: what is a normal baseline HR?
110-160 bpm
CTG: what is a non-reassuring baseline HR?
100-109 bpm
CTG: what is an abnormal baseline HR?
<100bpm or >180 bpm
CTG: what is normal variability
5-25 bpm
CTG: what is non-reassuring variability?
<5 for 40-90 minutes
CTG: what is abnormal variability?
<5 for >90 minutes
CTG: what is an acceleration?
An increase in the baseline HR by 10-15 bpm
Presence of accelerations is reassuring
CTG: what is a deceleration?
A decrease in the baseline HR by 10-15bpm
Presence of decelerations are non-reassuring
CTG: What are early decelerations?
Decelerations seen just before a uterine contraction
They may be due to fetal head compression
CTG: What are late decelerations?
Decelerations seen just after uterine contraction
They may be due to placental insufficiency/hypoxia
They are more concerning than early decelerations
CTG: What are variable decelerations?
Mixture of early and late decelerations
Can often be cord compression
CTG: how would you determine if a CTG was overall normal, suspicious or abnormal?
- Normal = everything is normal and accelerations are present
- Suspicious = one non-reassuring feature
- Abnormal = >2 non-reassuring features and/or >1 abnormal feature
How do you define a normal CTG?
- Baseline HR = 110-160 bpm
- Variability >5
- Accelerations present
- No decelerations
What is the gold standard method for direct FHR monitoring?
Scalp ECG
Give a disadvantage of a scrap ECG for monitoring the HFR
- Invasive
- Membranes need to be broken and cervix >2cm
- Risk of scalp injury and perinatal infection
When is a fetal blood sample taken?
If there is a pathological CTG but don’t want to get baby out straight away (e.g. contracting >4 in 10)
How do you interest FBS samples?
Look at pH or lactate
Normal pH = >7.25
Borderline pH = 7.21-7.24 –> repeat after 30 minutes
Abnormal pH = <7.2 –> consider C section
How do you interpret FBS samples?
Look at pH or lactate
Normal pH = >7.25
Borderline pH = 7.21-7.24 –> repeat after 30 minutes
Abnormal pH = <7.2 –> consider C section
Define prematurity
Babies born alive between 24 and 36+6 weeks
What is preterm labour?
Persistent uterine activity AND change in cervical dilatation and/or effacement before 37 weeks
What organs are most likely to be affected in babies that are premature?
Lungs and the brain
Name 3 things that can be given to a premature baby to increase survival rates
- Antenatal steroids
- Artificial surfactant
- Ventilation
- Nutrition
- Antibiotics
How is preterm delivery classified?
Spontaneous (70%) –> preterm labour, PPROM, cervical weakness, amnionitis
Induced –> medical/obstetric disorder
Give 5 risk factors for having a preterm baby
- Previous preterm birth
- Previous late miscarriage
- APH or other vaginal bleeding
- Multiple pregnancy
- Ethnic group
- Genital infections
- Medical conditions –> HTN, renal disease
- Cervical surgery/weakness
- Lower socioeconomic status
How can preterm birth be prevented?
Progesterone suppositories –> from early pregnancy for those at high risk
Cervical cerclage –> sutures in cervix to keep it closed
Screen for STIs and UTIs
Manage medical disease
How is preterm birth managed?
Steroids Tocolysis (nifedipine or oxytocin receptor antagonist - atosiban) = prevent labour and delivery MgSO4 = neuroprotective if given <34 weeks
What is preterm prelabour rupture of membranes (PPROM) commonly associated with?
Chorioamnionitis = bacterial infection that occurs before or during labour
How do you manage PPROM?
If evidence of chorioamnionitis = steroids, deliver whatever the gestation, broad spectrum Abx
If NO evidence of chorioamnionitis = admit, steroids, Abx
Define small for gestational age (SGA)
Estimated fetal birth weight (EFW) or abdominal circumference (AC) <10th centime on a customised growth chart
Severe SGA = <3rd centile
Define low birth weight (LBW)
Infant with birth weight <2500g
Define fetal growth restriction
Failure of the ferrous to achieve its predetermined growth potential
Give 5 potential causes of FGR
- Poor nutrition and diet
- Alcohol, smoking, drug use
- Gestational Diabetes
- HTN and preeclampsia
- Placental insufficiency
- Multiple pregnancy
- Structural or chromosomal abnormalities
- Poor weight gain during pregnancy
Briefly describe why FGR often occurs
Trophoblasts don’t invade the placental vessels as normal so respond to vasopressors –> restricting nutrients to baby and restricting growth
What investigations might you so if you are concerned about FGR?
Clinical Examination including SFH
USS –> HC, AC, FL, liquor volume
- Serial scans from 28 weeks if SGA
Umbilical artery doppler
What happens if an umbilical artery doppler is abnormal?
Measure pulsatility index (resistance index)
- Raised –> Monitor
- Intermittent absent –> delivery within 24 hours
- Absent –> Consider stat delivery
- Reversed –> deliver stat
Describe the types of FGR
Symmetrical = head size and AC reduced in parallel Asymmetrical = Abdominal circumference reduced, head circumference normal
Name 2 possible causes of symmetrical FGR
- Congenital/chromosomal abnormalities
- Intrauterine infections
- Environmental factors
Name 2 possible causes of asymmetrical FGR
Often due to later onset pathology
- Pre-eclampsia
- Idiopathic
- Essential HTN
- Smoking
How do you manage early onset FGR (<32 weeks)?
Or symmetric FGR at any gestation
- USS to exclude fetal structural abnormality
- Karyotyping of foetus
- Investigate for viral infection
- Corticosteroids
- Intensive and repeated fetal monitoring
How do you manage late onset FGR (>32 weeks)?
- Corticosteroids
- Increased fetal surveillance
- Possible delivery
Give 2 possible short term complications of FGR
- Premature birth
- Hypoxic brain injury
- Need for respiratory support
Give 2 possible long term complications of FGR
Increased risk of developing
- Coronary heart disease
- HTN
- T2DM
- Hyperlipidaemia
Define large for gestational age (LGA)
Estimated birth weight >90th centile as plotted on customised growth chart
Define fetal macrosomia
Birth weight >4000g
- Often associated with those with diabetic mothers
Briefly describe why macrosomia occurs
Glucose not taken up by mum due to insulin resistance –> excessive glucose in blood –> crosses placenta to baby –> baby takes up excessive amounts of glucose –> stimulates babies’ pancreas to produce higher amount of insulin (anabolic hormone) –> increase in size and build-up of fat
How can is fetal macrosomia managed?
Identification with SFH and USS
Rule out diabetes or treat if present
Plan delivery
Give 3 possible complications of fetal macrosomia
- Shoulder dystocia
- Instrumental delivery
- C section
- PPH
- 3rd degree perineal tears
- Neonatal hypoglycaemia –> need early feeding
Give 2 theories behind the induction of labour
- Placental clock theory –> increased CRH release form placenta –> fetal ACTH please –> release of oestrogen, formation fo myocetrial cap junction –> contractions
- Signals from the baby –> increased ACTh or increase fetal surfactant proteins activate amniotic fluid macrophages –> migrate to uterine wall, upregulartion fo inflammatory gene expression stimulating labour
Give 3 indications for artificial induction of labour
- Post Maturity (T+10)
- Pre-eclampsia
- Diabetes
- Growth restriction
- Reduced fetal movements
- PPROM
- In-utero death
How can labour be induced?
- Membrane sweep (natural induction) –> to see if waters can be broken (in woman at term)
- Balloon catheter –> to help ARM to become possible
- Prostin (prostaglandin E2) pessaries –> cervical priming
- Syntocin can help stimulate contractions once membranes have been ruptured
Give 3 non-pharmacological therapies that can be used to help manage labour pain
- Trained support
- Acupuncture
- Hypnotherapy
- Massage
- Hydrotherapy
Give 3 pharmacological therapies that can be used to help manage labour pain
- Gas and air = entonox
- Paracetamol
- Codeine
- Opioids –> pethidine, diamorphine
- Epidural
- Spinal anaesthesia
Give 2 advantages to entonox
- Rapid onset
- Minimal side effects
- Self limiting
Give 3 potential side effects of opioids
- Sedation
- Respiratory depression
- Nausea and committing
- They cross the placenta (as lipid soluble)
Give 3 indications for an epidural
- Maternal request
- Augmented labour
- Twins
- Existing co-morbidities
What anaesthetic can be given as an epidural?
Bupivacaine
How does bupivacaine work as an epidural?
Blocks sodium channels
Why is an epidural useful if a woman needs to go for an emergency C section?
It can be topped up
Where is spinal anaesthesia injected into and at what level?
The CSF
No higher than L2 or L3 (pudendal nerve S2-4 is main nerve involved in labour)
What is used in a spinal anaesthetic in labour?
Bupivacaine AND fentanyl/diamorphine
Give 3 contraindications for regional anaesthetics (epidural or spinal)
- Maternal refusal
- Local infection
- Allergy
Relative CIs - Hypovolaemia
- Systemic infection
- Coagulopathy/thormbocytopenia
Give 2 advantages of using regional anaesthetic when performing a C-section
- Safer
- Can see baby immediately
- Partner can be present
Give 2 disadvantages of using regional anaesthetic when performing a C-section
- Can cause hypotension
- Can cause headaches
- Patient may experience discomfort from pressure sensations
- Failure
Why would general anaesthetic be given for performing a C-section?
- If there is an imminent threat to mother and/or foetus
- Coagulopathy
- Contraindication of local anaesthetic
- Maternal preference
Name 4 maternal obstetric emergencies
- Antepartum haemorrhage (APH)
- Postpartum haemorrhage (PPH)
- Venous thromboembolism
- Pre-eclampsia
- Amniotic Fluid Embolism
Define antepartum haemorrhage
Bleeding from anywhere in the genital tract after 24 weeks of pregnancy until delivery
Give 3 causes of APH
- Placenta praevia/LLP
- Placenta accreta and placenta percreta
- Placental abruption
- Vasa praevia
- Uterine rupture
Give 3 potential complications of APH
- Premature labour
- Need for blood transfusion
- Actor tubular necrosis (+/- renal failure)
- DIC
- PPH
What is placenta praaevia?
Any part of the placenta that has implanted into the lower segment of the uterus
- Major = covering/reaching the os
- Minor = in lower segment/encroaching
Give 2 risk factors for placenta praevia
- Previous CS
- Smoking
- Assisted reproduction
When might placenta praevia be detected?
20 week anomaly scan = placenta must be <20mm from the cervical os
- It can move repeat scan at 32 (major) or 36 (minor) weeks
What is the classical presentation of placenta praevia?
Intermittent PAINLESS bleeding –> increases in frequency intensity
How is placenta praevia managed?
- If mum is rhesus negative then anti-D
- Steroids if <35+6 weeks
- Placenta >20mm from os for vaginal delivery, <20mm from os = elective C-section at 38 weeks
What is placenta accreta?
Placenta is embedded into the uterine wall
What is placenta percreta?
Placenta is embedded through the uterine wall into the surroundings
Define placental abruption
Premature separation of the placenta from the uterine wall
- Can be concealed or revealed
Give 3 risk factors for placental abruption
- Previous placental abruption
- IUGR
- Preeclampsia
- Smoking, cocaine
- Truma –> RTA, domestic abuse
- Multiple pregnancy
What is the classical presentation of placental abruption?
Sudden onset, constant and severe abdominal pain
Bleeding (but can be concealed)
O/E = tense, woody-hard tender uterus
Fetal distress and maternal shock –> shock doesn’t match blood loss observed
Coagulation failure
How is placental abruption managed?
Fetal CTG, FBC, coagulation screen, cross match, U+Es
Steroids, anti D if rhesus negative, fluids
Urgent C-section if fetal distress
Amniotomy and induction fi >37 weeks
Give 2 potential consequences of placental abruption
- Fetal distres
- Maternal shock –> doesn’t match blood loss observed
- Coagulation failure
What is vasa praevia?
Fetal vessels run through the membranes and below the fetal presenting part
What are the possible consequences of vasa praevia?
Painless and moderate bleeding WHEN MEMBRANES RUPTURE
Can lead led to major fetal haemorrhage
What is the main cause of uterine rupture?
Rupture of caesarean section scar (70%)
Name 2 possible signs of uterine rupture
- Pain and tenderness over the uterus
- Maternal tachycardia
- Sudden maternal shock
- Cessation of contractions
- Disappearance of presenting part from pelvis
How do you manage uterine rupture?
Laparotomy and deliver baby by C-section High flow O2 and IV fluid Small rupture = possible repair Cervix or vagina involved = hysterectomy Abx post surgery
Define primary Postpartum Haemorrhage (PPH)
> 500ml blood loss within 24 hours of delivery
Define Secondary PPH
> 500ml blood loss between 24 hours and 12 weeks post delivery
What is minor PPH?
<1500mls and no lineal signs of shock
What is a major PPH?
> 1500mls and continuing bleeding or clinical shock
What can cause PPH?
The 4 T’s
- Tone –> is the uterus contracted? (atonic uterus)
- Trauma –> tears, episiotomy, rupture
- Tissue –> any retained placental tissue/is the placenta complete?
- Thrombin –> check clotting
Give 5 risk factors for PPH
- Large baby
- Nulliparity and grand multiparty
- Multiple pregnancy
- Precipitate or prolonged labour
- Previous PPH
- Operative delivery
How might you manage a PPH?
Atonic uterus = ergometrine and oxytocin
Retained tissue –> removal of placenta or retained tissue
Laparotomy –> stop bleeding, oversewing or insertion of Rusch ballon, compression, internal iliac or uterine artery ligation, uterine artery embolisation, total/subtotal hysterectomy
Give 5 risk factors for a VTE in pregnancy
- Increasing gestational age
- Obesity (BMI >30)
- Smoking
- C-section
- FHx
- Immobility
- Multiple pregnancy
- Previous VTE
- Thrombophilia
- Medical co-morbidities
- Parity 3 or more
When is a woman at the greatest risk of VTE?
Greatest just after giving birth, postpartum period
What medication can be given to reduce a woman’s risk of VTE?
LMWH (Dalteparin)
TED stockings
When is VTE prophylaxis given?
Antenatally
- From 1st trimester is TRAF >4
- From 28 weeks if TRAF 3
Postnatally
- If antennal prophylaxis = continue for 6 weeks
- 10 days if TRAF >2, 6 weeks if additional risk factors
Describe the pathophysiology of rhesus disease
- Fetal Rh+ RBCs leak through the placenta and interact with the mothers blood –> IgM reaction –> sensitisation
- IgM can’t cross the placenta so there is no RBC lysis but memory B cells are created
- On a subsequent pregnancy, IgG may cross the placenta and cause fetal RBC lysis
What are the potential consequences, if left intreated, of a rhesus negative mother having a rhesus positive fetus?
Risk of RBC lysis –> fetal anaemia and death
What is the only antibody that can cross the placenta?
IgG
How can fetal RBC lysis be prevented in rhesus negative mothers?
Anti-D prophylaxis given
- Destroys Rh+ IgG and so no RBC are attacked
- Given at 28 weeks and 72 hours after sensitising event
Name 3 events during pregnancy when sensitisation of rhesus disease may occur
- Miscarriage
- Abortion
- Amniocentesis
- Placental abruption
- During delivery
When can Anti-D not be used?
If the mum has already produced Anti-D antibodies
What is Amniotic Fluid embolism?
When liquor enters maternal circulation causing anaphylaxis and sudden dyspnoea
Name 3 fetal emergencies
- Fetal distres
- Cord prolapse
- Shoulder dystocia
What is cord prolapse?
When the cord is presenting before the baby after rupturing of the membranes
Give a potential consequence of cord prolapse
Vasospasm –> hypoxia –> fetal morbidity and mortality
Give 4 risk factors for cord prolapse
- Premature ROM
- Polyhydramnios
- Long umbilical cord
- Fetal malpresentaiton
- Multiparity
- Multiple pregnancy
How can cord prolapse be managed?
- Infused fluid into bladder via catheter (elevated presenting part of cord)
- Trendelenburg position (feet higher than head)
- Constant monitoring
- Transfer to theatre for delivery
WHat is shoulder dystocia?
Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head
Give 3 risk factors for shoulder dystocia
- Macrosomia
- Maternal Diabetes
- Previous shoulder dystocia
- Post maturity
- Prolonged labour
- Obesity
How should should shoulder dystocia be managed?
HELPERR H = call for Help E = evaluate for Episiotomy L = Legs in McRoberts (hyperflexed at hips with thigh abducted and eternal rotated) P = suprapubic Pressure E = Enter pelvis R = Rotational manoeuvres R = Remove posterior arm
Give 3 potential maternal complications of shoulder dystocia
- Vaginal tear
- PPH
- PTSD
- Bladder/uterine rupture
Give 3 potential fetal complications of shoulder dystocia
- Hypoxia
- Cerebral palsy
- Brachial plexus injury (Erb’s palsy)
- Fractured humerus or clavicle
Define puerperium
The period from placental delivery to 6 weeks after birth (postnatal period)
Name 3 features of puerperium
- Return to pre-pregnancy state
- Initiation/suppression fo lactation
- Transition to parenthood
Give 2 endocrine changes that occur during puerperium
- Reduced placental hormones (BhCG, progesterone, oestrogen)
- Increase in prolactin (for lactation)
Give 3 physiological changes that occur during the puerperium
- Involution of the uterus
- Decidua sheds as lochia
- Lactation
Describe the physiology behind the involution fo the uterus in puerperium
There is muscle ischaemia, autolysis and phagocytosis –> involution the uterus
The decider sheds as lochia, what are the 3 stages of the process called?
- Lochia rubra (days 0-4)
- Lochia serosa (days 4-10)
- Lochia alba (days 10-28)
What is the name of the breast milk that is produced at birth?
Colostrum
What does colostrum contain?
- Protein rich
- VItamin A
- NaCl
- Growth factors (stimulate development of infant gut)
- Antibodies (passive immunity)
- Lactoferrin (antimicrobial)
Describe the physiology of lacation
Baby suckles –> sensory impulses from nipple to brain –> prolactin secreted from anterior pituitary –> milk produced my lactocytes –> oxytocin released from posterior pituitary –. my-epithelial contraction –> milk ejection
Name 3 minor things woman are at risk of during puerperium
- Infection
- PPH
- Fatigue
- Anaemia
- Backache
- Haemorrhoids/constipation
Name 3 major things woman are at risk of during puerperium
- Sepsis
- Severe haemorrhage
- Pre-eclampsia
- VTE
- Prolapse
- Incontinence
- Depression
- Post dural puncture headache
Name 3 members of a postnatal MDT
- Midwives
- Breastfeeding support workers
- Doulas
- Nurses
If complex –> obstetricians and paediatricians too
Define sepsis
Infection +systemic manifestations of infection
- Severe sepsis = sepsis + sepsis induced oran dysfunction or tissue hypoperfusion
- Septic shock = prestige of hypoperfusion despite adequate fluid replacement therapy
Give 3 risk factors for sepsis in pregnancy
- Obesity
- Diametes
- Anaemia
- Amniocentesis/invasive procedures
- Prolonged SROM
- Vaginal trauma/CS
What can cause sepsis in pregnancy?
- Endometriosis
- Skin and soft tissue infections
- UTI
- Chorioamnionitis
- Pneumonia
- Gastroenteritis
- Pharyngitis
What are the main symptoms/signs of sepsis in pregnancy?
3T’s white with sugar
- Temperature = <36 or >38
- Tachycardia = >90 bpm
- Tachypnoea = >20 bpm
- WCC = >12 or <4 x10^9
- Hyperglycaemia = >7.7 mmol
What is the management of sepsis?
Sepsis 6 = BUFALO
- Blood cultures + FBC, U&E, clotting, glucose, CRP, ABG
- Urine output
- Fluid resuscitation
- Antibiotics (broad spec)
- Lactate (>2 = sign of organ failure)
- Oxygen (high flow)
Describe the physiology of a post dural puncture headache
Accidental dural puncture –> CSF leakage and decreased pressure in fluid around the brain
Give 3 symptoms of a post dural puncture headache
- Headache is worse on sitting/standing
- Neck stiffness
- Photophobia
How would you treat a post dural puncture headache?
- Lying flat
- Analgesia
- IV fluids
- Epidural blood patch
Define postnatal urinary retention
Abrupt onset of aching or aches inability to completely micturate, requiring urinary catheterisation, over 12 hours after giving birth
OR
Not voiding spontaneously within 6 hours of vaginal delivery
Give 3 risk factors for urinary retention postnatally
- Epidural analgesia
- Prolonged 2nd stage of labour
- Forceps/Ventouse delivery
Give 3 red flag signs that a mother may be developing mental health problems postnatally
- Recent significant change in mental state
- Thoughts or act of self harm
- Estrangement form the infant
Give 3 symptoms of postnatal depression
- Depression
- Irritable
- Tired
- Sleepless
- Appetite change
- Anxious
- Negative thoughts
Psychosis = depression, mania, psychosis
Give 2 risk factors for postpartum psychosis
- FHx of mental health disorders, particularly postpartum psychosis
- Diagnosis of bipolar disorder
- Traumatic birth or pregnancy
Name 2 risk factors for postpartum PTSD
- Perceived lack of care
- Poor communication
- Perceived unsafe care
- Perceived focus on outcome over experience of the mother
Name how postpartum PTSD can present
- Anger
- Low mood
- Self-blame
- Isolation
- Intrusive and distressing flashbacks
Name 2 possible consequences of postpartum PTSD
- Women may delay or avoid future pregnancies
- Request C section to avoid vaginal delivery
- Avoidance of intimate physical relationships
- Impact on breastfeeding
Define maternal death
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
What is a direct maternal death?
Death relating from obstetric complications of pregnancy, labour or puerperium (haemorrhage, genital sepsis, suicide)
What is indirect maternal death?
Death resulting from pre-existing disease/disease that developed in pregnancy but not a direct result of obstetric causes (cardiac disease, malignancies)
What are the 3 most common causes of maternal death?
- VTE
- Haemorrhage
- Pre-eclampsia
Suicide = leading cause of direct deaths occurring 6 weeks to 1 year after the end of pregnancy
Why can ovarian cysts cause pain?
- Haemorrhage into cyst with sudden increase in size/rupture into the peritoneal cavity with spillage of blood
- Twist so blood supply is reduced, can be intermittent as it untwist (can stop hurting if necrotic)
How can you treat ovarian cysts?
- Remove ovary (reduces fertility and may have cyst on other ovary)
- Remove cyst –> laparotomy or laparoscopy
Define miscarriage
The loss of a pregnancy before 24 weeks gestation
In approximately what percentage of pregnancies does miscarriage occur?
20%
What is a threatened miscarriage?
When a lady experiences bleeding +/- abdominal pain but the cervical os is closed
What is an inevitable miscarriage?
What a lady experiences heavy bleeding, clots, pain and the cervical os is open
Define complete miscarriage
When all products of conception leave the body
Define incomplete miscarriage
Bleeding +/- pain with a possible open cervix
- some products of conception remain in the uterus
Define recurrent miscarriage
> 3 consecutive miscarriages
Give 4 potential causes of miscarriage
- Abnormal fetal development
- Uterine abnormality
- Incompetent cervix
- Placental failure
- Multiple pregnancy
Give 3 risk factors for miscarriage
- Age >30
- Smoking
- Excessive alcohol consumption
- Uterine surgery
- Poorly controlled diabetes
What investigations might you do to determine whether someone has had a miscarriage?
Transvaginal USS
Serum hCG
Describe the management of a miscarriage
- Expectant (natural) –> no heavy bleeding or early gestation (<8 weeks)
- Medical
- Surgical –> manual vacuum aspiration
What is medical management of a miscarriage?
Mifepristone (anti progesterone) followed 36-48 hours by misoprostol (synthetic prostaglandin)
- only misoprostol if <12 weeks
What is an ectopic pregnancy?
Implantation of a concepts outside the uterine cavity
What is the most common site of an ectopic pregnancy?
Fallopian tube = 90-95%
Give 3 risk factors for an ectopic pregnancy
- History of infertility or assisted conception (IVF)
- History of PID
- Endometriosis
- Pelvic or tubal surgery
- Previous ectopic
- IUCD in situ
- Smoking
What are the signs/symptoms of an ectopic pregnancy?
Often asymptomatic Amenorrhoea Lower abdominal pain (in women of reproductive age = ectopic until ruled out) Vaginal bleeding D+V, dizziness, shoulder tip pain
What investigations might you do to confirm an ectopic pregnancy?
TVS/USS –> establish location
Serum progesterone
Serum hCG –> associated with lower levels (repeat 48 hours after)
Laparoscopy
How is an ectopic pregnancy managed?
- Expectant management used under strict criteria –> strict follow up
- Medical management of IM methotrexate –> ensure liver and renal function satisfactory
- Surgical if criteria aren’t met —> laparoscopy preferred to laparotomy
What is gestational trophoblastic disease (GTD)?
GTD describes a group of pregnancy related tumours
- These tumour can be pre-malignant and often benign (molar pregnancies) or malignant (choriocarcinoma and invasive mole)
What is a molar pregnancy?
A type of GTD
- Occurs when there is an abnormality in chromosomal number during fertilisation
- Non-viable fertilised egg implants and fails to come to term
- Grows into a mass in the uterus
Describe a partial molar pregnancy
Where an ovum is fertilised by two sperm –> produces cells with 69 chromosomes (triploidy)
Describe a complete molar pregnancy
Where one ovum without any chromosomes is fertilised by 1 sperm which duplicates
- There are 46 chromosomes all of paternal origin
Give 3 risk factors for GTD
- Maternal age <16 or >45
- Multiple pregnancy
- Previous GTD
- OCP
Give 3 symptoms of molar pregnancies
- Vaginal bleeding in early pregnancy
- Abdominal pain in early pregnancy
- Hyperemesis and hyperthyroidism in late pregnancy due to high levels of BhCG
What investigations might you do in someone to determine if they have GTD?
URine and blood BhCG –> very high
USS –> compete mole = snow storm appearance
What is the treatment for molar pregnancies?
Suction curettage
Chemotherapy
What is hyperemesis gravidarum?
Excessive vomiting associated with dehydration and ketosis in pregnancy
- Tends to settle by 15 weeks gestation but ca continue into 2nd and 3rd trimesters
Which placental hormone is associated with hyperemesis gravidarum?
BhCG –> very high levels (like multiple pregnancies)
How is hyperemesis gravidarum managed?
Rehydrate with IV fluids
Vitamins, frequent small meals
Antiemetics
What forms of contraception can be given anytime after brith?
- Contraceptive implant
- Contraceptive injection (depot provera)
- Progesterone only pill (POP)
- Male condoms
- Female condoms
- Natural family planning and lactational amenorrhoea
What forms of contraception can be given 3 weeks after birth?
- COCP
- Contraceptive patch
- Contraceptive ring
If not breastfeeding and no medical risks/exclusion criteria
6 weeks if breast feeding or VTE risk factors
What forms of contraception can be given 4 weeks after birth?
- IUD
- IUS
If not fitted in the first 24 hours post delivery
How does POP work as a contraceptive?
It thickens cervical mucus to prevent sperm penetration and suppresses (thins) the endometrium
Give 2 advantages of the POP as a contraceptive?
- Prevents oestrogen side effects (breast tenderness)
2. Suitable for smokers, those with obesity, those at increased risk of VTE
Give 3 disadvantages of the POP as a contraceptive?
- Less effective than the COCP
- Increased risk of ectopic pregnancy
- Disrupts menstrual pattern –> amenorrhoea, infrequent bleeding, spotting, prolonged bleeding
- Functional ovarian cyst may develop
How long does the contraceptive implant last?
3 years
- Progesterone only so works similarly to POP
How often do you need to get the contraceptive injection?
IM injection every 12 weeks
- Progesterone only so acts similarly to POP
How long does lactational amenorrhoea act as a contraceptive for following pregnancy?
Until menses return
- Less effective if don’t exclusively breastfed
How does the COCP work as a contraceptive?
Prevents ovulation, suppressed LH and FSH, thickens cervical mucus and thins the endometrium
Give 5 advantages of the COCP as a contraceptive
- Reversible
- Reliable
- Regular cycle
- Reduces menorrhagia
- Helps with acne
- Reduces post-menopausal symptoms
Give 3 disadvantages to the COCP as a contraceptive
- No protection against STIs
- Headaches/migraines
- Breakthrough bleeding for first 3-6 months
- Increased risk of breast and cervical cancer
- Increased increase of VTE, MI and ischaemic stroke
What is the IUD and how long does it last?
Copper coil –> causes foreign body reaction within uterus preventing implantation and sperm transport
Lasts 5-10 years
Give 2 advantages of the IUD
- Non hormonal
- Lasts 5-10 years
- Effective immediately
- Effective as emergency contraception
Give 2 disadvantages of the IUD
- May cause menstrual irregularities, spotting, IMB
- Menorrhagia, dysmenorrhoea
- Increased risk of PID in first 20 days of insertion (STI screen prior)
- Risk of ectopic pregnancy
- Perforation at insertion
What is an IUS and how long does it last?
Mirena coil = hormonal
Causes endometrial atrophy, thickens cervical mucus, may suppress ovulation
Lasts 5 years
Give 3 side effects of an IUS
- Acne
- Brest tenderness and pain
- Headache
- Change to menstruation –> irregular, prolonged or frequent bleeding for 3-6 months after insertion
- Risk of ectopic pregnancy
What type of drug group particularly needs to be thought of when prescribing hormonal contraception?
Anti-epileptic drugs
What are the Fraser guidelines?
A doctor can proceed to give contraceptive advice and treatment to someone <16 provided they are satisfied in the following criteria
- The patient will understand the advice
- The doctor cannot persuade the patient to inform their parents
- The patient is very likely to continue having sexual intercourse with or without contraception
- If the patient does not receive contraceptive advice their physical/mental health will suffer
- It is in the patients best interests to receive contraceptive advice and treatment without parental consent
Define menstruation and the menstrual cycle
Menstruation = Monthly bleeding from female reproductive tract induced by cyclical hormonal changes
Cycle = Interval between 1st day of last period and 1st day of next
Average cycle = 28 days
Name the phases of the menstrual cycle
Follicular phase
Ovulation = day 14
Luteal/Secretory Phase
Post luteal = implantation or no implantation
What happens in the follicular phase of the menstrual cycle?
Low oestrogen and progesterone stimulates GnRH from hypothalamus
GnRH stimulates anterior pituitary to release FSH and LH
FSH –> proliferation of granulosa follicular cells
LH –> proliferation of granulosa cells in follicles
Oestrogen released from granulosa cells –> stimulates endometrium growth
At low levels oestrogen inhibits release of FSH and LH from anterior pituitary
Inhibin released from granulosa cells –> inhibits anterior pituitary
What happens during ovulation in the menstrual cycle?
Oestrogen production reaches threshold = no longer negative feedback
LH surge causes weakening in follicle wall = mature ovum released
Ovulation occurs 36 hours after LH surge (+ve feedback)
What happens in the luteal/secretory phase of the menstrual cycle?
FSH and LH cause follicle to degrade into corpus luteum
Corpus luteum produces high amounts of progesterone and some oestrogen
Progesterone stimulates endometrium growth –> ready for blastocyst
Corpus luteum suppresses FSH and LH production from anterior pituitary
What happens in the post luteal phase of the menstrual cycle?
Implantation = embryo produces beta human chorionic gonadotrophin hormone which preserves corpus luteum and endometrium
No implantation = low FSH and LH levels cause corpus luteum atrophy which stops progesterone production and menstruation occurs
Which hormone is responsible for thickening the endometrium?
Oestrogen
Which hormone is responsible for thinning the endometrium?
Progesterone
A surge in which hormone leads to ovulation?
LH
Approximately how much blood is lost in menstruation?
60-80ml
Define menorrhagia
Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle that interferes with the physical, emotional and social QOL
Define Abnormal uterine bleeding
Any menstrual bleeding from the uterus that is either abnormal in volume, regularity, timing or is non-menstrual (PCB, IMB, PMB)
Give 3 causes of menorrhagia
- Fibroids
- Uterine polyps
- Endometriosis/adenomyosis
- Hypothyroidism
- Infection
- Ovulatory problems –> PCOS, perimenopause
- Malignancy or hyperplasia
- Coagulopathy
Give 5 questions that you should ask when taking history from a lady who is presenting with menorrhagia
- How much blood?
- How many pads? Flooding?
- Clots?
- Duration of bleeding?
- Pain? –> when this occurs during cycle?
- Impact on ADLs and QOL?
- Any associated symptoms –> thyroid? clotting? drugs (warfarin)?
What investigations might you do on a woman presenting with menorrhagia?
- FBC, B12/folate/iron, TSH, STI screen
- Smear if due
- TVS
- Endometrial biopsy if >45 and IMB or unresponsive to treatment
Describe the management of menorrhagia
- Minera
- Anti-fibrinolytics –> tranexamic acid
- NSAIDs –> mefenamic acid
- Progesterones –> depo-provera injection or oral (noresthisterone)
- COCP
- Endometrial ablation
- Myomectomy = resection of fibroids
- Uterine artery embolisation
- Hysterectomy
Define primary amenorrhoea
No menses by the age of 16 in the presence of secondary sexual characteristics or by 14 in girls with no secondary sexual characteristics
Define secondary amenorrhoea
Cessation of menses for 6 months in women with previously normal and regular menses, or for 12 months in women with previous oligomenorrhoea
Give 3 hypothalamic causes of amenorrhoea
- Functional disorders –> eating disorder, stress, excessive exercise
- Non-functional –> SOL, surgery, radiotherapy, Kallman’s syndrome (primary GnRH deficiency
- Reduced GnRH
Give 3 pituitary causes of amenorrhoea
- Prolactinoma
- Other pituitary tumours –> acromegaly, Cushing’s
- Sheehan’s syndrome (infarction fo pituitary often due to PPH)
- Surgery
Give 3 ovarian causes of amenorrhoea
- PCOS
- Primary Ovarian Failure
- Turner’s syndrome (45X)
Give 2 uterine/genital outflow obstruction causes of amenorrhoea
- Imperforate hymen
- Transverse vaginal septum
- Cervical stenosis
- Mullerian agenesis
Give 3 physiological causes of amenorrhoea
- Pregnancy
- Lactation
- Menopause
Give 3 important questions to ask in a amenorrhoea history
- Sexual history
- Galactorrhoea or androgenic symptoms (weight gain, hirsutism)
- Menopausal symptoms
- Previous genital tract surgery –> IUD, LLETZ
- Issue with eating/excessive exercise
- Drug use –> especially dopamine antagonist (psych)
- Fhx
Give 3 important tings to look for in an amenorrhoea examination
- BMI
- Secondary sexual characteristics
- Stigmata of endocrinopathies or Turner’s
- Evidence of virillisation –> deep voice, male pattern balding, cliteromegaly
- Abdominal masses
- Imperforate hymen, blind ended vaginal septum, absence of cervix or uterus
What investigations should be done in a woman complaining of amenorrhoea?
- Pregnancy test
- FSH/LH
- Testosterone and sex hormone binding globulin
- Prolactin
- TFTs
- Pelvic USS
- Karyotype
Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if FSH/LH levels came back abnormal?
Could indicate a pituitary problem
Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if GnRH levels came back abnormal?
Could indicate a hypothalamic problem
Name 3 possible complications of amenorrhoea
- Osteoporosis
- Infertility
- CVD
- Psychological distress
- PCOS –> DM, CVD, endometrial hyperplasia
- Gonadal tumours in presence of Y chromosome
What is androgen insensitivity syndrome?
When a person is genetically male but phenotypically female. They have intra-abdominal gonads and their cells don’t respond to male hormones e.g. androgens
Define Oligomenorrhoea
Menses occurring more than 35 days apart
Define primary and secondary dysmenorrhoea
Primary = painful menses with no obvious organic cause Secondary = painful menses due to underlying condition
Define chronic pelvic pain
Lower abdominal pain for >6 months that does not occur exclusively with menstruation, intercourse or pregnancy
Define acute pelvic pain
Sudden, unexpected pain for <6 months
Name 3 pregnancy related causes of acute pelvic pain
- Ectopic pregnancy
- Miscarriage
- Ovarian cyst rupture/haemorrhage/torsion
Name 3 gynaecological causes of acute pelvic pain
- PID
- Abscess
- Ovarian cyst rupture/haemorrhage/torsion
Name 3 gastrointestinal causes of acute pelvic pain
- Appendicitis
- Constipation
- Bowel obstruction
- Peritonitis
Name 3 Genito-urinary causes of acute pelvic pain
- UTI
- Renal stones
- Urinary retention
Name 2 MSK causes of acute pelvic pain
- Disc prolapse
2. Nerve entrapment
Name 3 gynaecological causes of chronic pelvic pain
- Endometriosis/adenomyosis
- Fibroids
- Adhesions
- PID
- Ovarian cysts
- Prolapse
Name 3 gastrointestinal causes of chronic pelvic pain
- IBS
- Constipation
- Inflammatory bowel
Name a genito-urinary cause of chronic pelvic pain
Interstitial cystitis
Name MSK causes of chronic pelvic pain
- Nerve entrapment
2. Referred MSK pain
What investigations might you do on a patient presenting with pelvic pain?
- Urinalysis, MSU, pregnancy test, bloods
- Pelvic USS -> fibroids, ovarian cysts, endometriosis
- Laparoscopy -> endometriosis, adhesions
- Hysteroscopy -> fibroids
- MRI -> adhesions, adenomyosis, fibroids
- STI screen
If pain fluctuates with the menstrual cycle what is the diagnosis likely to be?
Endometriosis or Adenomyosis
What is endometriosis?
A chronic oestrogen dependent disease where there is growth of endometrial tissue outside the endometrial cavity
Why does endometriosis tend to get better after menopause?
Endometriosis relies on oestrogen so when oestrogen levels fall after menopause, symptoms of endometriosis tend to improve
In what group of people is endometriosis most common?
Young, nulliparous women (25-35)
Describe the aetiology of endometriosis
The cause of endometriosis is thought to be due to retrograde menstruation and a genetic component
Lymphatic spread may also be responsible
What anatomical areas are most likely to be affected by endometriosis?
The pouch of Douglas and the uterosacral ligaments
Give 5 risk factors for developing endometriosis
- Early menarche
- Late menopause
- Delayed childbearing
- Short cycles
- Obstruction to vaginal flow
- Genetic predisposition
Give 2 factors that are protective against endometriosis
- COCP
2. Multiparity
Give 5 symptoms of endometriosis
- Cyclical pain –> dysmenorrhoea and dyspareunia
- Bleeding
- Lump
- Dysuria
- Dyschezia (pain on defecation)
- Infertility
- Haematuria, rectal bleeding, or bleeding form umbilicus during menstruation (severe)
- Endometrioma = endometriosis in ovary (cyst) that bleeds into ovary during menstruation
What investigations might you do in a woman with suspected endometriosis?
- Digital examination
- TVS
- Diagnostic laparoscopy
- Hysteroscopy
What is the gold standard investigating for diagnosing endometriosis?
Diagnostic laparoscopy
What grading classification is used in endometriosis ?
AFS classification
What non specific protein marker might be raised in a woman with endometriosis?
CA125
- Non-specific –> raised in anything that irritates with peritoneum
- Often raised in ovarian cancer
What medications can be given to treat endometriosis?
Abolish cyclicity - OCP - GnRH agonists +/- HRT Thin endometrium - POP/Depot provera - Mirena
Give 3 advantages of using the OCP to treat endometriosis
- Cheap
- Effective
- Minimal side effects
- Predictable an reliable
Often 3 packs taken back to back (try-phasing) then a bleed then 3 packs etc.
How to GnRH agonists work in treating endometriosis?
GnRH is normally released in a pulsatile way, GnRH agonists are given continuously in order to stop ovulation and triggers an ‘artificial menopause’ (this is reversible)
GnRH agonist -> huge release of FSH/LH -> down-regulation of FSH/LH -> no oestrogen release
Give 3 side effects of GnRH agonist being used to treat endometriosis
- Osteoporosis
- Hot flushes
- Mood swings
How can GnRH agonist side effects be prevented in the treatment of endometriosis?
HRT ‘add back’ therapy –> small dose of oestrogen prescribed alongside GnRH agonist
What is the surgical treatment for endometriosis?
- Laparoscopy with ablation or excision
- Hysterectomy with bilateral salpingo-oophrectomy
- Only if completed family
What is adenomyosis?
Invasion of endometrial tissues into the myometrium
Give 3 risk factors for adenomyosis?
- Multiparity
- Uterine surgery
- Previous C section
Describe the epidemiology of adenomyosis and compare it to that of endometriosis
Adenomyosis = older, multiparous women Endometriosis = younger, nulliparous women
Give 3 symptoms fo adenomyosis
- Menorrhagia
- Dysmenorrhoea
- Dyspareunia
Pain is typically cyclical
What investigations might you do for suspected adenomyosis?
- TSH
- TVS
- MRI
Adenomyosis is difficult to diagnose with imaging, histology at hysterectomy is definitive
What is the treatment for adenomyosis?
Analgesia –> NSAIDs, TXA
Ovulation suppression –> tricyclic COCP, minera coil, GnRH analgoues
Surgery = hysterectomy and oophorectomy –> CURE
What are fibroids?
Benign smooth muscle tumours of the uterine myometrium (leiomyomas)
What hormone is thought to stimulate fibroid development?
Oestrogen
How are fibroids classified?
According to their position in the uterine wall
- Intramural
- Submucosal
- Subserosal
What type of fibroids are most common?
Intramural = fibroids to the myometrium
Describe the location of submucosal fibroids
Fibroids growing into the uterine cavity
Describe the location of subserosal fibroids
Fibroids growing outwards from the outwards
Give 4 risk factors for the development of fibroids
- Obesity
- Early menarche
- FHx
- Increasing age (during reproductive ages)
- Low parity
Give 4 symptoms of fibroids
- Pain
- Infertility/sub-fertility
- Menorrhagia
- Pressure symptoms –> urinary frequency (if on bladder)
- Iron deficiency anaemia
- IMB
What investigations might you do to determine if a patient has fibroids?
- TVS
- Hysteroscopy
- MRI
- Diagnostic laparoscopy
What treatments can you have for fibroids?
- Conservative –> watch and wait
- Medical
- NSAIDS +/- TXA
- hormonal therapy (COCP, Mirena, GnRH agonists) - Surgical –> hysteroscopic resection, myomectomy, hysterectomy
What is the gold standard treatment for uterine fibroids?
Hysterectomy
- If patient if young and wants children = myomectomy
Give 3 differentials for uterine fibroids
- Endometrial polyps
- Cancer
3, Endometriosis/adenomyosis - Chronic PID
What are endometrial polyps?
Overgrowth of glandular tissue within lining of the womb (as extension of endometrium)
Who is most likely to get endometrial polyps?
Women aged 40-50 when oestrogen is high
- Also seen in post menopausal women on tamoxifen
What is Pelvic Inflammatory Disease (PID)?
Inflammation of the upper genital tract (cervix, uterus, Fallopian tubes)
What can cause PID?
Infection –> gonorrhoea, chlamydia that ascends from the endocervix
What are the risk factors for PID?
- Young age
- Multiple sexual partners
- Not using barrier contraception
- Surgical TOP
- IUCD (especially inserted within the last 20 days)
- Previous STIs
Give 3 symptoms of PID
- Bilateral lower abdominal pain (can be chronic)
- Deep dyspareunia
- Abnormal vaginal bleeding –> PCB, IMB, menorrhagia
- Purulent vaginal or cervical discharge
- Asymptomatic –> present with subfertility or menstrual problems
Give 2 signs of PID
- Lower abdominal tenderness (usually bilateral)
- Cervical motion tenderness and adnexal tenderens = cervical excitation (on bimanual exam)
- Fever >38 (can be pyrexial)
What investigations might you do in someone with suspected PID
Bloods –> FBC, WCC, CRP, ESR, cultures
HSV and endocervical swabs
Pelvic Us –> exclude abscess or ovarian cyst
Diagnostic laparoscopy
Describe the treatment of PID
IM ceftriaxone 500mg followed by PO doxycycline 100mg BD and PO metronidazole 400mg BD for 14 days
Name 2 possible complications of PID
- Abscess
- Pyosalpinx (obstructed and dilated Fallopian tubes by pus)
- Subfertility
- Ectopic pregnancy
What is the role of p53?
p53 = tumour supressor gene
- Transcription factor that regulates cell division and death
What is the role of Rb?
Rb = tumour supressor gene
- Alters the activity fo transcription factors and so controls cell division
If there is a mutation in either p53 or Rb what might happen?
Uncontrolled cell growth may occur –> cancer
What are the roles of oncogenes?
Oncogenes stimulate excessive cell growth and cell division –> cancer development
Give an example of an oncogene
HER-2
What is the most common type of gynaecological cancer?
Endometrial cancer
What is the pathophysiology behind endometrial cancer?
Unopposed oestrogen leads to endometrial hyperplasia and so increased risk of endometrial adenocarcinoma
Give 5 risk factors for developing endometrial cancer
- Obesity = unopposed oestrogen
- Diabetes
- Nulliparity
- Late menopause and early menarche
- HRT (oestrogen only) m
- Pelvic irradiation
- Tamoxifen
- PCOS
- Genetic –> HNPCC
What is the most common type of endometrial cancer?
Endometrial adenocarcinoma
What is the red flag symptom for endometrial cancer?
Post menopausal bleeding
- Any PMB at all = 2WW
What investigations might you do if you suspect that a woman may have endometrial cancer?
- Pelvic and abdominal examination
- TVS = measure endometrial thickness
- Endometrial biopsy
- Hysteroscopy
How thick should the endometrium be, postmenopausally?
<4mm
- If >4mm = endometrial biopsy
What type of staging is used for endometrial cancer?
FIGO staging
- Stage 1 = confined to endometrium in the womb
- Stage 2 = limited to uterine body and cervix
- Stage 3 = extension to uterine serosa, peritoneal cavity +/- lymph nodes
- Stage 4 = extension beyond true pelvis and/or involvement of bladder/bowel mucosa
Describe the treatment for endometrial cancer
- Hysterectomy +/- pelvic lymph node removal
2. Adjuvant radiotherapy (vault brachytherapy) and progesterone therapy
Define adenocarcinoma
A malignant tumour of glandular epithelium
Why is the incidence of cervical cancer decreasing?
- Screening = cervical smears
2. HPV vaccines
Name 2 oncoproteins associated with HPV
- E6 = blocks p53
2. E7 = blocks Rb
Which oncoprotein blocks p53?
E6
Which oncoprotein blocks Rb?
E7
Give 5 risk factors for HPV and so cervical cancer
- Early age intercourse (<16)
- Multiple sexual partners
- STIs
- Smoking
- Multiparity
- OCP
- Persistent high risk HPV infection
What is the most common type of cervical cancer?
Squamous (90%)
What type of staging is used for cervical cancer?
FIGO staging
What is the red flag symptom for cervical cancer?
Post coital bleeding
- Usually asymptomatic and found on cervical smear
What investigations might you do in a patient who you suspect has cervical cancer?
- Vaginal and bimanual examination
- Coloposcopy
- Biopsy
- HPV testing
Describe the treatment for cervical cancer
- Local excision or total abdominal hysterectomy (<2cm)
- Radical hysterectomy with pelvic lymphadenectomy (>2cm)
- Radiotherapy, chemotherapy, palliative care (>4cm)
What must you consider when treating cervical cancer?
Fertility –> does the patent want children in the future?
Give 3 potential risks of performing a radical hysterectomy
- Bowel problems
- Sexual problems
- Bladder problems
- Lymphoedema
When does cervical screening occur?
Smear tests from 25-50 every 3 years and every 5 years between 50-64
When would someone be referred to colposcopy following a smear?
- Moderate/severe dyskaryosis
- HPV +ve with any abnormal cells
- HPV +ve with normal cells for 2 years in a row
- GP unable to obtain smear
What is done in coloposcopy for cervical cancer screening?
Magnified visualisation of the transformation zone
- Acetic acid = turns abnormal cells white
- Lugol’s iodine = turns normal cells ‘chocolate’ coloured
Biopsy taken if abnormal cells seen
What is the treatment for HPV?
Is just HPV and no abnormal cells then there is NO treatment
- Often own immune system eradicates it
- Stopping smoking can help eradicate HPV
What is the treatment for CIN?
- Low grade (CIN1) = spontaneously regressed in 50-60% cases within 2 years –> conservative monitoring (LLETZ if persistent)
- High grade (CIN II or III) –> LLETZ = removal of abnormal tissue under local
- CGIN (cervicl glandular intraepithelial neoplasia) LLETZ or cone biopsy
What is the most common type of vulval cancer
Squamous
Describe the aetiology of vuluval cancer
Vulval intraepithelial neoplasia (VIN - skin disease) –> Abnormal cells develop in the surface layers of the skin covering the vulva
- It is not vulval cancer but may turn into cancer = pre-malignant
- Usual type is associated with HPV infection
Give 3 symptoms of vulval cancer
- Itching
- Soreness
- Lump
- Bleeding
- Pain on micturition
What investigations would you do for suspected vulval cancer?
Vulval biopsy –> histology
Describe the treatment for vulval cancer
- Surgery –> WLE or radical +- lymphadenectomy
- Radiotherapy
- Chemotherapy
What is the most common type of ovarian cancer?
Epithelial (85%)
- Also sex cord and germ cell
Describe the epidemiology of ovarian cancer
More common in women >50, postmenopausal
Often with late presentation
Give 3 risk factors for ovarian cancer
- Early menarche
- Late menopause
- Nulliparity
- Hysterectomy
- Gene mutation –> BRCA 1/2, HNPCC
Give 4 symptoms of ovarian cancer
- Bloating/IBS like symptoms
- Abdominal pain
- Change in bowel habit
- Urinary frequency
- Bowel obstruction
- Abnormal vaginal bleeding
- Can often be asymptomatic
What investigations might you do for someone with suspected ovarian cancer?
- CA125
- USS
- CT
- Biopsy
- CXR –> mets
What classification if used to stage ovarian cancer?
FIGO
How is ovarian cancer treated?
- Prophylactic surgery for those with identified BRCA mutation = BSO
- Laparotomy and chemotherapy
What types of vaginal cancers can occur?
- Mostly metastases from other gynaecological cancer
- Most common primary vaginal cancer = squamous cell (commonly HPV related)
- Vaginal clear cell adenocarcinoma (young women associated with diethylstilbestrol exposure in utero before 18 weeks gestation)
How do you treat a Bartholin’s cyst?
Blocked Bartholin duct in lower 1/3 of labia major
- Incision and marsupialisation
What HPV are genital warts associated with?
HPV 6 and 11
- Both covered in HPV vaccine with 16 and 18 (cancer)
What is Paget’s disease of the vulva?
Non mammary adenocarcinoma in situ
- Surgical excise and exclude underlying malignancy
When would you refer a couple for infertility invetgtiatlons?
Failure to conceive after 1 year of trying
What would make you consider early referral or investigating infertility?
Is the woman is >35, has a menstrual disorder, previous surgery or previous PID/STI and/or if the man has genital pathology, previous STI, systemic illness or an abnormal genital examination
What pre-conception advice would you give to a couple?
- Intercourse 2/3 times a week
- Folic acid
- Up to date smears
- Smoking cessation and reduce alcohol intake
- Manage comorbidities
- Ensure healthy weight
Name 3 reproductive disorders that are associated with obesity
- PCOS
- Miscarriage
- Infertility
- Obstetric complications
Give 5 causes of infertility
- Male factors (30%)
- Unexplained (25%)
- Ovulatory (25%)
- Tubal (20%)
- Uterine/peritoneal (10%)
- Combined male and female factors
What 3 things are investigated in initial infertility tests?
1 . Ovulation/ovarian function
- Semen quality
- Tubal patency
What infertility investigations would the GP do?
- Hormone profile
- TFT’s and prolactin
- Rubella and chalmydia screen
- Smear
- Semen analysis
Infertility investigations: how can you check ovulation?
Measure mid-luteal progesterone –> around 21 days
- >30 mol/L = ovulation
Infertility investigations: what hormone levels are looked at in order to test ovarian reserve?
- FSH
- Anitmullerian Hormone (AMH)
- Antral follicle count (AFC)
What does a sperm count need to be for further tests to be done?
<5m/ml
- Further tests –> endocrine, karyotyping (Klinefelter’s), CF screen, testicular biopsy, imaging
Infertility investigations: how can tubal patency be investigated?
- Hysterosalpingography (HSG)
- HyCoSy (Hysteroslapingo-contrast-sonograph) = US test with galactose-containing contrast medium
- Laparoscopy and dye (under GA)
How can infertility be managed if there is a mild male abnormality?
Intrauterine insemination
How can infertility be managed if there is a moderate male abnormality?
IVF
How can infertility be managed if there is a severe male abnormality?
Intracytoplasmic sperm injection
How can infertility be managed is azoospermia is the cause?
- Surgical sperm recovery
2. Donor insemination
Infertility: Give 3 risk factors for anovulation
- Stress
- Low weight
- Excessive exercise
- Kallmann’s and Turner’s syndrome
Give 3 causes of anovulation
- Hypothalamic problems –> low FSH/LH/E2 levels
- Pituitary problems = adenoma, Sheehans, thyroid/adrenal
- Ovarian problems –> PCOS, Menopause
What is the Rotterdam diagnostic criteria for PCOS?
- Anovulation/oligo/amenorrhoea
- Polycystic ovaries seen on imaging
- Increased androgens –> clinically (hirsutism/acne) or biochemical (raised testosterone)
2/3 = diagnosis
How can PCOS be treated?
- Encourage weight loss
- COCP if not wanting to get pregnant
- Symptomatic treatment of acne and hirsutism
- Clomifene/tamoxifen (antioestrogene)
- Metformin
- Gonadotrophin or pulsatile GnRH (if clomifene resistant)
- Ovarian drilling
How does clomifene work in the treatment of PCOS?
Antioestrogen –> leads to increased production of LH/FSH so more follicle stimulation
Can treat menstrual disturbance and has a good pregnancy rate
Give 3 causes of tubal disease
- Infections –> chlamydia, gonorrhoea
- Endometriosis
- Iatrogenic –> adhesions, sterilisation
How can you treat tubal disease?
Laparoscopic tubal surgery –> adhesiolysis, salpingostomy, proximal anastomosis, reversal of sterilisation
Tubal catheterisation
IVF
Briefly describe the process fo IVF
Ovulation stimulation –> egg collection –> insemination –> fertilisation check –> embryo culture –> embryo transfer –> luteal support
Why is only 1 egg transferred in IVF?
To avoid multiple pregnancy
Give 4 risks associated with IVF
- Multiple pregnancy
- Miscarriage
- Ectopic pregnancy
- Fetal abnormality
Give 4 factors that can affect the likelihood of IVF being successful
- Increased age –> reduces egg quality
- Successive cycles/longer duration infertility
- Obesity
- Environmental factors –> smoking, alcohol, caffeine
- Maternal medical problems
Give 3 uterine abnormalities that can affect fertility
- Endometrial polyps
- Fibroids –> especially submucous
- Adhesions
Define menopause
The cessation of menstruation normally around 51 years old
- Diagnosed retrospectively after 12 months of amenorrhoea or 12 months after the onset of symptoms if the patient has had a hysterectomy (straight away if BSO too)
Define peri-menopause
The period leading up to menopause
Characterised by irregular periods and symptoms –> hot flushes, mood swings, urogenital atrophy
A depletion in what hormone is thought to trigger the symptoms of menopause?
A reduction in oestrogen
Give 2 vasomotor symptoms of the menopause
- Hot flushes
- Night sweats
Can impact on sleep, mood and QOL
Give 4 generalised symptoms of menopause
- Mood change/irritability
- Loss of memory/concentration
- Headaches
- Joint and muscle pain
- Dry, itchy skin
Give 3 local effects of menopause
Urogenital atrophy
- Vaginal dryness
- Dyspareunia
- Recurrent UTIs
- PMB
Give 3 possible long term impacts of menopause
- Osteoporosis
- CV disease
- Dementia
Describe how menopause can be managed in a symptomatic patient
- holistic approach, lifestyle advice, reduce modifiable RFs
- HRT, vaginal oestrogens
- Non-hormonal options (clonidine)
- Non-pharmaceutical (CBT)
Give 3 advantages of HRT being used to treat the menopause
- Relief of symptoms
- BMD protection
- Prevents long term morbidity
Give 3 disadvantages of HRT being used to treat menopause
- Increased risk of breast cancer
- Increased VTE risk with oral HRT
- Increased CVD risk
What hormone should be given to women with a uterus who are prescribed HRT?
Progesterone
- Protects the endometrium from the stimulatory effects of unopposed oestrogen
- No need in those who have had a hysterectomy
How can progesterone be prescribed alongside HRT?
Used for 12-14 days every 4 weeks = sequential –> bleeds
OR
Continuous combined, everyday –> no bleeding
When might transdermal HRT be indicated?
- Women with gastric problems (Crohn’s)
- Migraines/epilepsy suffered
- High risk VTE
- Older women
- Medical conditions –> HTN
- Patient choice
Give 3 possible side effects of systemic HRT
Fluid retention, breast tenderness, headaches
Oestrogen –> bloating, leg cramps, nausea
Progesterone –> migraine, mood swings, depression, acne, backache
Combined HRT –> irregular breakthrough bleeding
Weight gain
Give 3 possible non-hormonal treatments for menopause
- Alpha adrenergic receptor agonist = Clonidine –> for vasomotor symptoms
- Low dose SSRI = fluoxetine, citalopram, sertraline –> for vasomotor symptoms
- Anti-epileptics = gabapentin
- Bisphosphonates –> prevention and treatment of osteoporosis
- Non oestrogen vaginal lubricants
Define premature menopause
Menopause before the age of 40
What is premature ovarian failure?
Primary ovarian insufficiency before the age of 40 with associated menopausal symptoms such as night sweats
What can cause premature ovarian failure?
- Idiopathic
- Chromosomal abnormalities
- Enzyme deficiencies
- Autoimmune disease
- Iatrogenic –> bilateral oophorectomy, surgical menopause, hysterectomy, chemo/radiotherapy
What does premature ovarian failure usually present with?
Secondary amenorrhoea or oligomenorrhoea
Often coexisting disease –> hypothyroid, Addisons, DM, chromosomal abnoramlities
What would hormone profile tests show in women with premature ovarian failure?
Low oestrogen and high FSH
What is the diagnostic criteria for premature ovarian failure?
- FSH >25IU/L –> 2 samples 4 weeks apart
AND - 4 months of amenorrhoea
Describe the treatment for premature ovarian failure
Oestrogen replacement –> HRT or continuous COCP
- Until average age of menopause
- Donor eggs for fertility
If a woman goes through the menopause <50 for how many years is she still fertile for?
2 years
If a woman goes through the menopause >50 for how many years is she still fertile for?
1 year
Give 3 contraindications for HRT
- Undiagnosed abnormal PV bleeding
- Breast lump
- Acute liver disease
Define FGM
All procedures involving damaging or removing external female genitalia for non-medical reasons
Give 3 possible gynaecological problems of FGM
- Dysparenuia
- Sexual dysfunction with anorgasmia
- Chronic pain
- Dysmenorrhoea
- Urinary outflow obstruction/recurrent UTI
- PTSD
Give 3 possible obstetric problems of FGM
- Problems with conception and labour
- Increased likelihood of C section
- Increased likelihood of PPH
- Increased likelihood os severe vaginal lacerations
Describe a first degree vaginal tear
First degree = tear within vaginal mucosa only
Describe a second degree vaginal tear
Second degree = tear into sub-cutaneous tissue
Describe a third degree vaginal tear
Third degree = laceration extends into external anal sphincter
Describe a fourth degree vaginal tear
Fourth degree = Laceration extends through external anal sphincter into rectal mucosa
Give 3 risk factors for vaginal tears
- Primigravida
- Macrosomia and shoulder dystocia
- Forceps delivery
- FGM
What laters of the tri-laminar disc forms the male and female genitalia?
Intermediate mesoderm
What does the mullerian duct form?
- Fallopian tubes
- Uterus
- Cervix
- Proximal 1/3 of vagina
What does the cloaca divide into?
- Anorectal canal
2. Urogenital sinus
From what artery are the ovarian arteries branch off?
The abdominal aorta
Where do the L and R ovarian veins drain?
L ovarian vein –> L renal vein
R ovarian vein –> IVS
Describe the hypothalamic gonadal axis
Hypothalamus –> GnRH –> anterior pituitary –> FSH/LH –> Granulosa and Theca cells –> androgens and oestrogen
Define precocious puberty
The onset of secondary sexual characteristics before 8 years old (girls) or 9 years old (boys)
Name 3 possible causes of precocious puberty
Gonadotropin dependent –> maturation of entire HPG axis
- CNS abnormalities –> trauma, pituitary tumours, hydrocephalus
- Cerebral palsy
Gonadotropin independent
- Primary hypothyroidism
- CAH
- Tumour of adrenals or ovaries
Define delayed puberty
Delay in onset of development of secondary sexual characteristics
Name 3 possible causes of delayed puberty
- Constitutional delay
- Chronic systemic disease
- Weight loss, excessive exercise
- Hypogonadotropic hypogonadism
- Pituitary tumours
- Ovarian failure –> Turner’s, Swyer syndrome
What disease must you rule out in girls with delayed puberty and short stature?
Turner’s syndrome
Give 4 differentials for a breast lump
- Breast carcinoma
- Fibroadenoma
- Breast abscess
- Breast cyst
Why is the incidence of breast cancer thought to be increasing?
- Western lifestyle
- Screening
- Increasing life expectancy
Who is offered breast screening?
All women aged 50-71 every 3 years
BRCA carries
High risk young women = MRI screening
What happens at breast screening?
Mammogram = 2 X-rays taken of each breast from different angles
What percentage of women who have a mammogram will be called back for more tests?
Roughly 5% recalled –> US, biopsy
1/4 will have cancer
Name 3 reasons why a women maybe be recalled after a mammogram
- MAss
- Microcalcification
- Asymmetric density
- Enlarged axillary lymph nodes
- Clinical recall = women says she has a lump
- Technical recall = not good enough image
Name 3 modifiable risk factors for breast cancer
- Alcohol intake
- Obesity
- Use of HRT/OCP
Name 3 non-modifiable risk factors for breast cancer
- Early menarche and late menopause
- Breast denisty
- Genetics –> BRCA 1/2
- Not breast feeding
- Early parity and nulliparity
Approximately what percentage of breast cancers are ductal and what percentage are lobular?
- Ductal = 70%
- Lobular = 10%
Give 4 signs that you may find on clinical examination that are suggestive of breast cancer
- Palpable lump –> irregular, hard, fixed, painless
- Discharge from nipple
- Nipple inversion
- Skin changes –> peau d’orange, skin tethering
Breast cancer: what is the triple assessment?
- Clinical examination
- Mammogram
- Core Needle biopsy
What is the first line investigation for younger vs older women with a lump in their breast
Younger women (<35) = USS--> more dense/glandular tissue Older women (>35) = Mammogram --> less dense/fatty breasts - Breast black and lump white on mammogram
Breast cancer: is a P1/2 lump that is described as soft, mobile and regular likely to be benign or malignant?
Benign
- E.g. fibroadenoma
Breast cancer: is a P4/5 lump that is described as hard, fixed and irregular likely to be benign or malignant?
Malignant
How is breast cancer staged?
Stage 1 = confined to breast
Stage 2 = growth confined to breast, mobile lymph nodes in ipsilateral axilla
Stage 3 = locally advanced –> tumour fixed to muscle, ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour
Stage 4 = metastatic –> complete fixation of tumour to chest wall, distant metastases
How can breast cancer be treated?
- Conservative surgery (WLE/lumpectomy) + radiotherapy
- Mastectomy + radiotherapy
- Mastectomy + reconstruction + radiotherapy
- Axillary lymph node removal –> limited removal or clearance
Why might a mastectomy be indicated as opposed to a lumpectomy in someone with breast cancer?
- If the tumour is large relative to size of breast
- If there are multiple tumours
- Patient preference
What should you do to ensure that breast cancer hasn’t spread to the axillary lymph nodes?
A sentinel node biopsy
Name 2 adjuvant treatments that can be given to women with oestrogen receptor +ve cancer
- Tamoxifen (premenopausal)
2. Aromatase inhibitors (post menopausal)
Why might a woman with breast cancer have chemotherapy?
If she has a very aggressive cancer or to shrink a tumour prior to surgery
ER -ve, Her2 +ve, high grade, node +ve
What adjuvant treatment can be given to Her-2 receptor +ve breast cancer patients
Trastuzumab
+/- Pertuzumab
When are bisphosphonates given in women with breast cancer?
Given to post menopausal women with ER +ve disease
Define incontinence
Involuntary leakage of urine
What is the functional bladder capacity?
400ml
Describe the epithelium of the detrusor muscle
Smooth muscle with transitional epithelium
Describe the innervation of the detrusor muscle
Sacral parasympathetic innervation
What is OAB?
Overactive Bladder
- Involuntary detrusor contractions –> urgency
Give 3 symptoms of OAB
- Urgency
- Frequency
- Nocturia
- ‘Key in the door’ urgency
What is stress incontinence?
Leakage of urine due to a weak sphincter
- Any increase in intra-abdominal pressure results in leakage of urine = coughing, laughing, exercise
If a patient has a good bladder capacity and small volume leakage would this be more in keeping with a diagnosis of OAB or stress incontinence?
Stress incontinence
What investigations might you do in a patient complaining of incontinence?
- Bladder diary (frequency/volume chart)
- Urinalysis (particularly for nitrates and leukocytes)
- Residual urine measurement –> catheter or USS
- ePAQ
What investigations might you do in a patient complaining of incontinence?
- Bladder diary (frequency/volume chart)
- Urinalysis (particularly for nitrates and leukocytes)
- Residual urine measurement –> catheter or USS
- ePAQ
- Urodynamics/cystometry
- Contract bladder scan
What is an ePAQ for investigating incontinence?
A questionnaire regarding urinary, bowel, vaginal and sexual symptoms
Describe the non-pharmacological treatments for managing stress incontinence
- Lifestyle changes –> weight loss, stop smoking, reduce caffeine, avoid straining
- Physiotherapy –> pelvic floor exercises
How do pelvic floor exercises work in treating someone with stress incontinence?
Pelvic floor muscle contraction –> urethra compression –> increased urethral pressure –> reduced leakage
- Vaginal cones can also be used
What pharmacological option can be offered to someone with stress incontinence?
Duloxetine (SNRI)
What surgical options can be offered to someone with stress incontinence?
- Sling
- Colposuspension = restores pressure to urethra and supports the urethra by elevating vagina with stutters wither side of bladder neck
Describe the non pharmacological treatments for managing OAB
- lifestyle changes –> weight loss, stop smoking, reduce caffeine, avoid straining
- Bladder drill
- Pads
Name 3 drugs that can used to treat OAB
- Oxybutynin
- Mirabegron = B3 adrenergic receptor agonist
- Botulinum Toxin
How does Oxybutynin work in treating OAB?
Anticholinergic = M2/3 receptor antagonist
- Reduces detrusor muscle innervation and so its activity
Give 3 potential side effects of Oxybutynin
- Dry mouth
- Constipation
- blurred vision
- Cognitive impairment
How does Mirabegron work in treating OAB?
B3 adrenergic receptor agonist
- Relaxes smooth muscle detrusor and increases bladder capacity
How does Botulinum toxin work in treating OAB?
Blocks ACh release and so reduced detrusor muscle contraction
Name 2 possible surgeries that can help treat OAB
- Neuromodulation and sacral nerve stimulation
- Augmentation ileocystoplasty
- Bypass
Describe the physiology of micturition
The bladder fills and stretch receptors are stimulated. Afferent impulses stimulate the parasympathetic action of detrusor muscle; it contracts. The urethral sphincters relax; this is mediated by inhibition of the neurones to them. The PAG is stimulated.
Is the detrusor muscle relaxed or contracted during storage?
Relaxed
- Sphincter contracted
Is the detrusor muscle relaxed or contracted during voiding?
Contracted
- Sphincter relaxed
Define prolapse
Protrusion of the uterus and/or vagina beyond normal anatomical confines
Define Urethrocele
Prolapse of lower anterior vaginal wall, involving the urethra only
Define Cystocoele
Prolapse of the upper anterior vaginal wall, involving the bladder
Define Apical (uterine) prolapse
Prolapse of uterus, cervix and upper vagina
Define Enterocoele
Prolapse of the upper posterior wall of the vagina
Define Rectocele
Prolapse of the lower posterior wall of vagina, involving the anterior wall of the rectum
Name 3 possible causes of prolapse
- Vaginal delivery and pregnancy
- Menopause
- Congenital collagen deficiency
- Chronic elevated abdominal pressure
- Pelvic surgery
Give 3 symptoms of prolapse
- Dragging sensation
- Lump
- dyspareunia
- Urgency, frequency, dysuria
- Constipation
Give 3 symptoms of prolapse
- Dragging sensation
- Lump and pain
- Dyspareunia
- Urgency, frequency, dysuria
- Constipation
How is a prolapse graded?
1st degree = mild –> halfway down (>1cm above hymen)
2nd degree = moderate –> visible at entrance but not out (within 1cm proximal or distal to plan of hymen)
3rd degree = severe –> comes out of vagina (>1cm below plane of hymen but protrude no further than 2cm less than the total length of the vagina)
4th degree = everything out (complete eversion of the vagina)
Describe the management for a patient with prolapse
- Reassurance
- Symptom management –> pelvic floor exercises, physic
- Vaginal pessaries –> ring, shelf, Gellhorn
- Surgery –> sacrospinous fixation, sacrocolpopexy, hysterectomy
Give 5 questions that are important to ask when taking a sexual health history?
- When was last intercourse?
- Regular or casual partners?
- Male or female partners?
- Contraceptive use?
- Type of intercourse?
- How many partners in the last 3 months and 12 months?
Give 3 risk factors for STIs
- Multiples partners
- Concurrent partners
- No barrier protection
- STI in partner
- Other STI
- Younger age (<25y/o)
- Involvement in the sex industry
What STI investigations might you do in a asymptomatic woman?
- Vulvo-vaginal swab for NAAT –> gonorrhoea, chlamydia
- Blood sample –> syphilis and HIV
What STI investigations might you do in a asymptomatic heterosexual male?
- First void urine NAAT –> gonorrhoea, chlamydia
- Blood test –> syphilis, HIV
What STI investigations might you do in a asymptomatic MSM?
- First void urine NAAT –> chlamydia, gonorrhoea
- Pharyngeal swab NAAT –> gonorrhoea, chlamydia
- Rectal swab NAAT –> chlamydia, gonorrhoea
- Blood test –> syphilis, HIV, Hep B (and C if indicated)
Give 5 symptoms of STIs that are seen in women
- Abnormal discharge
- Itching
- Soreness
- Ulcers and lumps
- PCB or IMB
- Dyspareunia
Give 5 symptoms of STIs that are seen in men
- Pain/burning on micturition
- Urethral pain
- Urethral discharge
- Ulcers and bilsters
- Rash
- Testicular pain or swelling
What STI investigations might you do in a symptomatic woman?
- Vulvovaginal swab NAAT –> gonorrhoea, chlamydia
- High vaginal swab –> bacterial vaginosis, trichomonad vaginalis, candida
- Cervical swab
- Dipstick urinalysis
- Blood test –> syphilis, HIV
What STI investigations might you do in a symptomatic heterosexual male?
- Urethral swab
- First void urine NAAT –> gonorrhoea, chlamydia
- Urinalysis
- Blood test –> syphilis, HIV
What STI investigations might you do in a symptomatic MSM?
- Tests for heterosexual male +
- Urethral and rectal slides
- Urethral, rectal and pharyngeal culture plates
Why is contact tracing important with regard to STIs?
- Prevents re-infection
- Break the chain of infection
- Allows treatment of asymptomatic individuals
Who is more likely to get chlamydia?
Women aged 16-20 y/o
Give 3 symptoms and 3 signs of chlamydia
Symptoms 1. Asymptomatic = 70% 2. Dysuria 3. Vaginal discharge (pale, thick) 4. Irregular bleeding --> IMB, PCB Signs 1. Pelvic/abdominal tenderness 2. Cervical motion tenderness 3. Inflamed cervix (Cervicitis) 4. Purulent discharge
What is the treatment for chlamydia?
Azithromycin single dose or doxycycline BD for 7 days
- Erythromycin BD 10-14 days In PREGNANCY
- Contact tracing
Give 3 possible complications of chlamydia
- PID
- Perihepatitis
- Reiter’s syndrome (reactive arthritis)
- Tubal infertility
- Ectopic pregnancy
- During pregnancy = preterm ROM and delivery, neonatal conjunctivitis or pneumonia
Name 3 symptoms of primary Herpes Simplex Virus
- Prodrome –> tingling/itching
- Flu like illness +/- inguinal lymphadenopathy
- Vulvitis and pain
- Vesicles
- Recurrent attacks triggered by stress, sex, menstruation
What investigations would you do for HSV?
- Clinical
- PCR of vesicular fluid = gold standard
- Culture of vesicular fluid
What is the treatment for HSV?
Symptomatic –> analgesia, saline bathing, topic anaesthetic
Oral acyclovir 5/day for 5/7
Give 2 possible complications of HSV
- Meningitis
- Sacral radiculopathy
- Transverse myelitis
- Disseminated infection
Who is more likely to have gonorrhoea?
Men aged 25-30 y/o
Name 3 possible symptoms of gonorrhoea
- Asymptomatic
- Discharge = odourless, purulent, can be green/yellow
- Lower abdominal pain
- IMB or PCB
What is the treatment for gonorrhoea?
Ceftriaxone IM stat + azithromycin stat
Contact tracing
Name 3 possible complications of gonorrhoea
- PID
- Bartholin’s or Skene’s abscess
- Disseminated gonorrhoea –> fever, pustular rash, migratory polyarthralgia, septic arthritis
- Tubal infertility
- Ectopic pregnancy
In PREGNANCY = preterm ROM and delivery, chorioamnionitis, ophthalmia neonatarum (baby)
What is Primary syphilis?
- 10 to 90 days post infection - Painless, genital ulcer (chancre)
- Inguinal lymphadenopathy
What is Secondary syphilis?
- Within first 2 years of infection
- Generalised polymorphic rash affecting palms and soles
- Generalised lymphadenopathy
- Genital condyloma lata
- Anterior uveitis
What is Tertiary syphilis?
- Can take 40+ years to develop
- Neurosyphilis = tabes dorsalis and dementia
- Cardiovascular syphilis = affects aortic root
- Gummata = inflammatory plaques or nodules
How do you diagnose Syphilis?
TTPA
Primary lesion smear –> spirochaetes on dark field microscopy
How do you treat Syphilis?
Benzathine benzylpenicillin single IM dose (used in pregnancy)
- Doxycycline BD for 14 days (CI in pregnancy)
- Erythromycin QDS for 14 days (used in pregnancy)
- Longer in tertiary syphilis
- Contract tracing
Name 3 possible symptoms of Trichomonas
- Asymptomatic
- Frothy, greenish, offensive smelling vaginal discharge
- Vulval itching and soreness
- Dysuria
How do you treat Trichomonas?
Metronidazole 2g oral single dose
Contact tracing
What subtypes of HPV are associated with CIN and cervical neoplasia?
Subtypes 16 and 18
What subtypes of HPV are associated with genital warts?
Subtypes 6 and 11
How can genital warts be treated?
Cryotherapy, trichloroacetic acid, electrosurgery/scissors excision/curettage/laser OR home therapy (podophyllotoxin cream/solution or imiquimod cream)
How are some types of subtypes of HPV prevented?
HPV Vaccination at 12/13 y/o against subtypes 6, 11, 16 and 18
How is bacterial vaginosis diagnosed?
Amsel criteria = 3/4 required
- Homogenous profuse grey-white discharge
- Increased vaginal pH >5.5
- Characteristic fishy smell
- ‘Clue cells’ on microscopy
How is bacterial vaginosis treated?
- Can resolve spontaneously
- Metronidazole 2g single dose or 400mg orally BD for 5 days
- Clindamycin 2% cream vaginally at night for 7 days
Name 3 risk factors for candidiasis (thrush)
- Immunosuppression
- Abx
- Pregnancy
- DM
- Anaemia
Give 3 symptoms of thrush
- Thick, curd like white vaginal discharge
- Vulval itching and soreness
- Dysuria
- Superficial dyspareunia
How do you treat thrush?
ONLY if symptomatic
- Fluconazole sing dose (CI in pregnancy)
- Clotrimazole 500mg pessary +/- topical clotrimazole cream
What shoudl a doctor tell a patient in order for the patient to give fully informed consent?
- Nature of the procedure
- About any reasonable alternative
- Relevant risks, benefits and uncertainties
- The patients understanding should be assessed
What 4 questions can be asked to assess mental capacity?
- Does the patient understand the information?
- can the patient retain the information
- Can they use the information to weigh up options and make a decision?
- Can they communicate their decision?
Until what week can a lady legally have an abortion?
Legal int he UK up to 24 weeks (1967)
- Illegal after that unless there is a substantial risk to the woman’s life or fetal abnormalities
Give 4 risks associated with amniocentesis
- Miscarriage
- Infection
- Trauma
- Bleeding
- Sensitisation reaction
- Preterm labour
What is Sheehan’s syndrome?
Pituitary infarction/necrosis following PPH
- Can lead to reduced TSH, ACH, FSH/LH and so hypothyroidism and genital atrophy
