obs and gynae passmed Flashcards
How long do menopausal women require contraception for?
<age 50- 2 yrs
> age 50 - 1 yr
Can use IUS
Cottage cheese discharge…
Candidiasis
Non-offensive
Superficial dyspareunia, dysuria, itch, vulval erythema, satellite lesions
No Ix required
Oral fluconazole 150mg single dose
Clotrimazole 500mg IV pessary single dose- alt.
Vulval sx- additional topical imidazole
Recurrent vaginal candidiasis mx
- Oral fluconazole every 3 days for 3 doses
- Maintenance oral fluconazole weekly for 6 weeks
Most common cause of pmb
Vaginal atrophy
10%- endo ca
Mx of premature ovarian failure
COCP until age 51 to prevent osteoporosis & protect against sx of oestrogen deficiency + potential cardiac complications
Ovarian torsion USS signs
- Whirlpool sign- can also be seen when bowel twists and causes a volvulus
- ENlarged ovary in the midline
- Free pelvic fluid
- Doppler- little or no ovarian venous flow and absent or reversed diastolic flow
What is Rovsing’s sign
Palpation to LIF causes tenderness in RIF- appendicitis
What is Rovsing’s sign
Palpation to LIF causes tenderness in RIF- appendicitis
Continuous dribbling UI after prolonged labour-
Vesicovaginal fistulae
Classic features of IBS
ABC- abdo pain, bloating, change in boel habit
Basic ix for infertility
- Semen analysis
- Serum progesterone 7 days prior to next expected period - day 21 for a 28 day cycle
RF for HG
- Twins
- Hyperthyroid
- IVF indirectly due to risk of twins
- Nulliparity
- Obesity
- Personal/fhx
- Smoking decreases HG incidence
Surgical mx for ectopic
Salpingectomy is 1st line for women with no other RF for infertility
(rather than salpingotomy - this would be used if they have previous PID or contralateral tubal surgery & want kids in future- risk of requiring further treatment such as methotrextae +/- salpinectomy)
M rules for ovarian cyst
For assessing whether a cyst found on USS is benign of malignant
M rules:
* Irregular solid tumour
* Ascites
* 4 papillary structures
* Irregular multilocular solid tumour w/ largest diameter >100mm
* Very strong blood flow
Mx for endometriosis
1st line NSAIDs / para
2nd line hormones- COCP/ progestogens
3rd line- gnrh analogues, surgery
If a semen sample is abnormal…
Repeat test ideally 3/12 later
allows cycle of spermatozoa forming
Ix to remmeber in urinary incontinence pts
Urinalysis- rule out UTI or DM that could cause/ worsen sx
Menorrhagia mx
IUS 1st line
(mirena)
mefenamic or tranexamic acid if not requiring contra
Bladder still palpable after urination?
Retention with urinary overflow incontinence
Causes- prostate (male), neurogenic damae to bladder such as complication of diabetes, chronic alcoholism, surgery to pelvic area
RF for ectopic pregnancy
Risk factors (anything slowing the ovum’s passage to the uterus)
* damage to tubes (pelvic inflammatory disease, surgery)
* previous ectopic
* endometriosis
* IUCD
* progesterone only pill
* IVF (3% of pregnancies are ectopic)
Ectopic pregnancy is most common in which location
Which location most likely to rupture
Most common in ampulla
Isthmus more likely to rupture
chocolate cyst
Endometriotic cyst
Most common ovarian cancer
Serous carcinoma
Most common ovarian cyst
Follicular cyst (physiological)
commonly regress after several menstrual cycles
Endometriosis pelvic examination
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Ix for recurrent candida
Blood glucose to exclude diabetes
High vaginal swab for mc&s
1st line for primary dysmenorrhoea
Mefenamic acid
Secondary amenorrhoea in athletic women
Hypothalamic hypogonadism
Meig’s syndrome
Beinign ovarian tumour usually fibroma associated with ascites and pleural effusion
How long can pregnancy test (urinary) remain positive after ToP
up to 4 weeks
Beyond 4 weeks indicates incomplete abortion/ persistent trophoblast
Endo ca in frail elderly women not suitable for surgery, mx?
Progestogen therapy
Diagnostic criteria of pcos
PCOS should be diagnosed if 2/3 of the following criteria are present:
* Infrequent or no ovulation
* Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosteron
* Polycystic ovaries on ultrasonography or increased ovarian volume
Normal pH of vagina
4-4.5
Which pts with uterine fibroid can have medical mx
<3cm
Not distorting uterine cavity
* give IUS/ tranexamic acid/ COCP
Hyperemesis gravidarum, diagnostic criteria triad
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
What is the mechanism of action of metformin in PCOS?
Increases peripheral insulin sensitivity
How can tamoxifen precipitate endometrial hyperplasia
Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.
most common identifiable cause of postcoital bleeding
Cervical ectropion
Termination of pregnancy mx?
Oral mifepristone and vaginal prostaglandins - medical mx if < 9 weeks
<13 wks- surgical dilation and suction of uterine contents
> 15 wks- surgical dilation and evacuation of uterine contents or late medical aboriton (induces mini labour)
Long-term complications of PCOS
- Subfertility
- Diabetes mellitus
- Stroke & transient ischaemic attack
- Coronary artery disease
- Obstructive sleep apnoea
- Endometrial cancer
What is the risk malignancy index?
Pre-surgical crtieria for ovarian cancer
Based on:
1. USS findings
2. Menopausal status
3. CA125
How does ovarian cancer spread initially?
Initially by local invasion
Stage 1- confined to ovary
Stage 2- local spread within pelvis
Stage 3- spread to abdomen, beyond the pelvis
Stage 4- distant mets
Ovarian cyst presentation?
- Unilateral dull ache which may be intermittent or only occur during intercourse.
- Torsion or rupture may lead to severe abdominal pain
- Large cysts may cause abdominal swelling or pressure effects on the bladder
Mx of primary dysmenorrhoea (no pelvic pathology)
- NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
- combined oral contraceptive pills are used second line
Criteria for expectant mx of ectopic
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Amsel’s criteria for diagnosis of bacterial vaginosis
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
* thin, white homogenous discharge
* clue cells on microscopy: stippled vaginal epithelial cells
* vaginal pH > 4.5
* positive whiff test (addition of potassium hydroxide results in fishy odour)
Trichomonas vaginalis mx
Offensive musty frothy green discharge
Strawberry cervix- erythematous with pinpoint areas of exudation
Oral metronidazole
How to diagnose adenomyosis
MRI pelvis (not seen on laparoscopy as occurs within the wall of the uterus_
Protective factors for endo ca
- multiparity
- cocp
- smoking
RF for ectopic
Risk factors (anything slowing the ovum’s passage to the uterus)
* damage to tubes (pelvic inflammatory disease, surgery)
* previous ectopic
* endometriosis
* IUCD
* progesterone only pill
* IVF (3% of pregnancies are ectopic)
Criteria to diagnosis pcos
the Rotterdam criteria state that a diagnosis of PCOS can be made if 2 of the following 3 are present:
* infrequent or no ovulation (usually manifested as infrequent or no menstruation)
* clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
* polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
Who to perform a CA125 in in primary care?
- abdominal distension or ‘bloating’
- early satiety or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- ESP if age >50
What is the upper limit of expected bhcg in intrauterine pregnancy during wks 9-12
300,000
postmenopausal women with atypical endometrial hyperplasia
A total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable due to the risk of malignant progression
snowstorm appearance uss
hydatidiform mole
menorrhagia
mirena coil 1st line
Pts with secondary dysmenorrhoea
REFER THEM ALL TO SECONDRARY CARE
HIV pts cervical screening
Annual cervical cytology
painless lump following stopping breastfeeding..?
Galactocele
- build up of milk creates cystic lesion
- aspiration yields white fluid
Who gets 5mg folic acid
- fhx ntd
- antiepileptic drugs
- bmi over 30
How to manage placenta praevia
- Rescan at 32 wk
- then scan every 2 weeks if still present
- final scan 36-37weeks
- Elective CS 37-38 wks
- If they go into labour prior to this- emergency CS as risk of PPH
Chickenpox mx in pregnancy
oral aciclovir if more than 20 wks & present within 24hrs of rash
Chickenpox mx in pregnancy
oral aciclovir if more than 20 wks & present within 24hrs of rash
Mx of chickenpox exposure in pregnancy
- if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
- if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
- RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
- if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
cut offs for IDA for who needs iron supplements in pregnancy or pp
115 for non-pregnant women, 110 in early pregnancy, 105 in later pregnancy, and 100 after childbirth.
What secretes HCG and when can it be detected
(HCG) is secreted by the syncytiotrophoblast into the maternal bloodstream, where is acts to maintain the production of progesterone by the corpus luteum in early pregnancy
HCG can be detected in the maternal blood as early as day 8 after conception
how to medically suppress lactation
cabergoline
Mx of obstetric cholestasis
- induction of labour at 37-38 weeks is common practice but may not be evidence based
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
What is HELLP syndrome
- Haemolysis- tea coloured urine
- Elevated LFTs- epigastric/ ruq tenderness
- low plts- bruising, can be rapidly progressive, can result in bleeding into brain/ liver
- typical pt has malaise, nausea, vomiting, headache
What warrants starting continuous ctg monitoring during labour
- suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
- severe hypertension 160/110 mmHg or above
- oxytocin use
- the presence of significant meconium
- fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
Who gets GBS prophylaxis in pregnancy
Intrapartum abx prophylaxis (IAP) for the following:
* GBS in prev. pregnancy
* prev. baby with early or late onset GBS disease
* pre-term labour
* pyrexia > 38C during labour
* benzylpenicillin
define antepartum haemorrhage
Bleeding from the genital tract after 24 w eeks’ gestation.
RF for placenta praevia
- older maternal age
- maternal smoking
- prev pp
- prev cs
- uterine distortion eg uterine fibroids
- assisted reproduction eg ivf
complications of placental abruption
mum- DIC, shock, renal failure, PPH
fetus- death, IUGR, hypoxia
DIC typical picture (can be caused by abruption)
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
schistocytes due to microangiopathic haemolytic anaemia
expected lie and presentation in placenta praevia and abruption?
- Normal in abruption- cephalic and longitudinal lie
- Abnormal in praevia
how to work out estimated date of delivery
month - 3
date + 7
year +1
causes of increased nuchal translucency
- downs
- congenital cardiac abnormality
- other structural abnormality
down syndrome antenatal screening-explain.
- combined test 11-14 wks- increased nuchael translucency, increased bhcg reduced PAPPA
- Triple test 14-20 wks- increased bhcg, reduced afp, reduced oestriol
- quadruple- as above but + increased inhibin-A
- NIPT
- CVS- <15wks
- amnio 15-18wks
gestational diabetes rf
- bmi>30
- ethnic
- fhx 1st degree relative dm
- prev baby >4.5kg
- prev gest diabetes
Screening for gestational diabetes
the oral glucose tolerance test (OGTT) is the test of choice
women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
mx of neonatal hypoG
asymptomatic
* encourage normal feeding (breast or bottle)
* monitor blood glucose
symptomatic or very low blood glucose
* admit to the neonatal unit
* intravenous infusion of 10% dextrose
* NG feeding considered
rf for pre-eclampsia
High rf:
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
Mod rf:
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
1 high or more than 1 mod- 75-150mg aspirin proph from 12 weeks gestation
signs and symptoms pre-eclampsia
H eadache, visual disturbance, nausea and vomiting, epigastric
pain, brisk reflexes, clonus, acute oedem a
signs and symptoms pre-eclampsia
H eadache, visual disturbance, nausea and vomiting, epigastric
pain, brisk reflexes, clonus, acute oedem a
monitoring when giving mgso4 in eclampsia
monitor reflexes (knee and biceps)
mgso4 is given 4g iv bolus over 5-10mins
then 1g everyhr IV
maternal and fetal signs of chorioamnionitis
Maternal: pyrexia, tachycardia, hypotension, offensive discharge,
uterine tenderness.
Foetal: tachycardia.
bishops score what are the components
pdecs
cervical position
cervical dilatation
cervical effacement
cervical consistency
fetal station
which leg is dvt more comon in pregnancy
Left- The gravid uterus puts greater pressure on the left iliac vein at the
poin t it crosses the left iliac artery, slowing venous return to the
heart.
medical mx for obs cholestasis
- ursodeoxycholic acid
- calamine lotions
- antihistamines- chlorphenamine
risks of obs cholestasis
- still birth
- premature delivery
- sleep deprivation of mother
describe the components of apgar score
appearance - skin colour
pulse rate
grimace (reflex irritability)
activity (muscle tone)
Resp rate
Rf for UC prolapse
polyhydramnios, prematurity, abnormal lie (transverse, oblique),
foetal abnormalities, abnormal placentation, artificial rupture of
membranes, breech presentation, unengaged presenting part.
Manoevres for shoulder dystocia
- mcroberts- hips hyperflexion
- suprapubic pressure
- rubins- hand in vagina to put pressure on post aspect of babys anterior shoulder
- woodscrew- during rubins,
RF shoulder dystocia
Prelabour: previous shoulder dystocia, high maternal body mass
index, large foetus, diabetes
Intrapartum: prolonged first stage of labour, prolonged second stage
of labour, oxytocin augmentation, secondary arrest.
ejection systolic murmur in woman 32 wks pregnant
not to worry
increase hyperdynamic circulation
how do women increase o2 in pregnancy
increase tidal volume
What are the four parameters of a cardiotocograph trace that
represent a reasurring trace
Foetal heart rate 110-160 beats per minute, presence
of accelerations, variability of greater than 5 beats per
minute, absence of decelerations
What are the four parameters of a cardiotocograph trace that
represent a reasurring trace
Foetal heart rate 110-160 beats per minute, presence
of accelerations, variability of greater than 5 beats per
minute, absence of decelerations
Name two contraindications to doing foetal blood sampling
Maternal infection, foetal bleeding disorder, prematurity,
abnormal presentation.
Above what value is considered normal for foetal pH
7.25
A borderline value of 7.20-7.24 usually indicates
a repeat sample after 30 minutes to an hour, while a sample of below 7.20
indicates immediate Caesarean section.
anatomy of epidural
- Epidural space surrounds the spinal column + is separated from the CSF by the dura
- 3 types of nerves pass through the epidural space: sensory nerves (pain fibres), motor nerves (to muscles), sympathetic nerves (control tone in blood vessels)
- Inferiorly – Saccrococygeal membrane
- Superiorly – foramen magnum
- Anterior – posterior longitudinal ligament
- Laterally – pedicles and intervertebral foraminae
- Layers- skin, fat, subcut tissue, supraspinous, interspinous ligaments, ligamentum flavum
monitoring of epidural
BP reading every 5 mins for 20 mins following administration of top up dose, continuous electronic fetal monitoring required if epidural has been sited, pain score
c/i hrt
- Current, past, suspected breast cancer
- Known or suspected oestrogen-dependent cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- Previous idiopathic or current VTE Active or recent arterial thromboembolic disease eg angina or MI
- Active liver disease with abnormal LFTs
- Pregnancy
- Thrombophilic disorder
how to confirm hiv diagnosis
HIV PCR and p24 antigen tests
hb normal ranges in pregnancy
booking >110
28 wks > 105
after birth > 100
what produces progesterone in pregnancy
corpus luteum till 10 wks
after 10wks- placenta
rf ectopic
Risk factors (anything slowing the ovum’s passage to the uterus)
* damage to tubes (pelvic inflammatory disease, surgery)
* previous ectopic
* endometriosis
* IUCD
* progesterone only pill
* IVF (3% of pregnancies are ectopic)
rf for hyperemesis
- First pregnancy,
- young age,
- multiple pregnancy and molar pregnancy (increased levels of bhcg)
- hyperthyroidism,
- previously suffered with motion sickness.
- obesity
- fhx
most important bedside test for HG
urinary ketones
how to manage HG
- Admit if continued N&V despite antiemetics and unable to keep anything down, or if ketonuria and weight loss despite antiemetics, or co-morbidity such as uti and unable to tolerate oral abx
- give iv fluids + kcl for dehydration
- give thiamine and folic acid, prevent wernickes enceph
- antacids for epigastric pain relief
- antiemetics: 1st line antihistamines (cyclizine or promethazine), 2nd line ondansetron (cleft lip) or metoclopramide (epses- limit to 5days)
who can have expectant mx for miscarriage
no risk of haemorrhage
no signs of infection
previous traumatic preganncy
causes of recurrent miscarriage
antiphospholipid syndrome
sle
uterine structural abnormalities eg bicornuate uterus or large fibroids
problems with the parental chromosomes
diabetes
thyroid disease
infeciton
cervical incompetence
complications of surgical evac of miscarriage
- infection
- bleeding
- ashermanns syndrome
- cervix injury
- uterine perforation
*
abortion methods
medical: anti progestogen = mifepristone to halt the pregnancy and relax the cervix, followed by misoprostol prostaglandin analogue to soften cervix and cause uterine contractions after 2 days
more doses of misoprostal may be required >10wks
surgical: cervical dilatation
<14 wks: suction of contents
14-24wks: evacuation using forceps
molar pregnancy usss
ultrasound: ‘snow storm’ appearance of mixed echogenicity
define cervical ectropion
columnar epithelium of the endocervix extends out to the ectocervix
#looks red
caused by increased oestrogen exposure- cocp, common during pregnmancy
complications hysterectomy
enterocele
vaginal vault prolapse
bleeding
infection
vte
urinary retention acutely following procedure
sexual dysfunction
why do uterine fibroids cause HMB
hyper oestrogen
large SA causing more bleeding
distorition of uterine cavity causing more bleeding
possible theories regarding the development of endometriosis
retrograde menstruation
lymphatic spread
embryonic cells
metaplasia of cells poutside of the uterine cavity into endometrial cells
most common endometriosis sites
Ovary, fallopian tubes, rectovaginal pouch, uterosacral ligaments, pelvic
peritoneum , umbilicus, lower abdom inal scars, lung
complications endometriosis
infertility
ruptured chocolate cyst
bowel obstruction
pelvic adhesions
chronic pelvic pain
complications endometriosis
infertility
ruptured chocolate cyst
bowel obstruction
pelvic adhesions
chronic pelvic pain
pcos diagnostic criteria
complications endometriosis
infertility
ruptured chocolate cyst
bowel obstruction
pelvic adhesions
chronic pelvic pain
pcos diagnostic criteria
complications endometriosis
infertility
ruptured chocolate cyst
bowel obstruction
pelvic adhesions
chronic pelvic pain
pcos diagnostic criteria
complications endometriosis
infertility
ruptured chocolate cyst
bowel obstruction
pelvic adhesions
chronic pelvic pain
pcos diagnostic criteriarotherdam criteria
pcos diagnostic criteria
infrequent or no ovulation (usually manifested as infrequent or no menstruation)
clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
string of pearls on uss
pcos
why increased risk of endometrial cancer with pcos
usually corpus luteum produces progesterone after ovulation
people with pcos dont ovulate or ovulate less so corpus luteum is not forming as much so not as much progesterone is being produced/ insufficient amounts
they continue to producde oesteogen
= unopposed oestrogen
= endometrial hyperpasioa = risk of endomatriela cancer
if > 3/12 between periods need to investigate for endometrial thickness
why do dermoid cysts occu
derived from primitive germ cells
can differentiate into any tissue
hair, teeth, sebaceous material, bone etc
whirlpool sign usss
ovarian torsion
may also see free pelvic fluid
signet ring cells on histology =?
krukenberg tumours - mets from GI cancer likely stomach. signet rings histology finding
causes of raised ca125 besides ovarian cancer
endometriosis
fibroids
adenomysosis
liver disease
pregnancy
colorectal pancreatic stomach cancer
