Obs&Gynae Flashcards
What are the causes of primary post-partum haemorrhage?
4T’s:
Tone - uterine atony
Trauma - perineal tear
Tissue - retained placenta
Thrombin - clotting/bleeding disorder
What is the management of primary PPH?
ABC approach
Mechanical: palpate the uterine fundus and rub it to stimulate contractions
Medical: IV oxytocin slow IV injection followed by IV infusion, ergometrine slow IV or IM
Surgical: if medical options fail to control the bleeding then surgical options will need to be considered - intrauterine balloon tamponade is an appropriate first-line surgical intervention
What is the most common cause of post-menopausal bleeding?
vaginal atrophy - thinning, drying and inflammation of the walls of the vagina due to a reduction in oestrogen following menopause
What is hyperemesis gravidarum associated with?
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
fun fact being a smoker decreases the incidence??
what are the features of acute liver failure in pregnancy?
jaundice
coagulopathy, raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure -> hepatorenal syndrome
fetor hepaticus - sweer, fecal breath
At how many weeks does the anomaly scan occur?
18-20+ 6 weeks
When is the scan performed to confirm dates of pregnancy?
10-13+6 weeks
what is the risk with intrahepatic cholestasis in pregnancy
?
stillbirth - therefore induction at 37-38 weeks
what should you do if you suspect placenta praevia?
ultrasound scan to determine the site of the placenta
What are the features of endometriosis?
chronic pelvic pain
secondary dysmenorrhoea: pain often starts days before bleeding
deep dyspareunia
subfertility
what is the investigation of choice in endometriosis?
laparoscopy is gold standard
what is the treatment of vaginal candidiasis?
clotrimazole
What anticoagulants should be given to people in active cancer?
apixaban
How is urge incontinence treated?
bladder training
How is stress incontinence treated?
pelvic floor muscle training
What are the missed pill rules for desogestrel?
- if less than 12 hrs: no action needed, continue as normal
- if more than 12 hrs i.e more than 36hrs since last pill - further action needed i.e. taking missed pill ASAP, continue, rest of pack, extra precautions i.e. condoms should be used until pill taking re-established for 48 hrs
what warrants continuous CTG monitoring in labour according to NICE guidelines?
- suspected chorioamnionitis or sepsis, or temp of 38 or above
- severe hypertension 160/110
- oxytocin use
- presence of significant meconium
- fresh vaginal bleeding that develops in labour
what SSRIs can be given to breastfeeding women with post-natal depression?
sertraline
paroxetine
what supplements are recommended in women with hyperemesis gravidarum?
thiamine - b1
pabrinex - vitamin b and c
What antibiotic is given for GBS prophylaxis in pregnant women?
benzylpenicillin
What bacterium causes GBS disease?
Strep agalacticae
when should pregnant women be screened for gestational diabetes?
24-28 weeks
What is placenta accreta and what are the different types?
a spectrum of abnormalities of placental implantation into the uterine wall
- placenta accreta: where there is adherence of the placenta directly to superficial myometrium but it does not penetrate the thickness of the muscle
- placenta increta: occurs where the villi invade into but not through the myometrium
- placenta percreta: occurs where the villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to the other abdominal organs such as the bladder or the rectum
what is the non-pharmacological management for premenstrual syndrome?
- diet modification: reduce fat, caffeine, alcohol and increase fibre, fruit and aim for more frequent snacks
- increasing exercise
- vitamin supplementation - vit B
- Stress reduction - relaxation techniques
- CBT
what is the non-pharmacological management for premenstrual syndrome?
- diet modification: reduce fat, caffeine, alcohol and increase fibre, fruit and aim for more frequent snacks
- increasing exercise
- vitamin supplementation - vit B
- Stress reduction - relaxation techniques
- CBT
What are the pharmacological options for managing premenstrual syndrome?
COCP
Danazol
Transdermal oestrogen
GnRH analogues - effectively inducing a menopausal state
Antidepressants - particularly SSRIs and SNRIs
what are the clinical features of molar pregnancy?
vaginal bleeding
nausea
hyperemesis gravidarum
thyrotoxicosis
uterus is larger than expected for gestational age
What is premature ovarian insufficiency?
onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
How should premature ovarian insufficiency be managed?
HRT or COCP should be offered to women until the age of average menopause (51)
What is the first stage of labour?
from onset of true labour to when cervix is fully dilated - typically lasts 10-16 hours in a primigravida patient
- latent phase: 0-3cm dilation, normally takes 6 hours
- active phase: 3-10cm dilation, normally 1cm/hr
When to post-partum women require contraception?
after 21 days
lacational amenorrhoea; 98% effective providing the woman is fully breast-feeding, amenorrhoeic and <6 months post–partum
what should be done in pregnancy women with asymptomatic bacteriuria on dipstick?
NICE CKS recommend an immediate antibiotic prescription of either nitrofurantoin, amoxicillin or cefalexin - should be a 7-day course
rationale of treatment is that there is a significant risk of progression to acute pyelonephritis
What is the treatment option for someone with stage 1a cervical cancer who wants to maintain fertility?
cone biopsy
How is CIN treated?
large loop excision of the transformation zone
what are the risk factors for developmental dysplasia of the hip?
- female sex: 6 times greater risk
- breech presentation
- positive family history
- firstborn children
- oligohydramnios
- birth weight . 5kg
- congenital calcaneovalgus foot deformity
which vaccines are offered to women during pregnancy?
influenza and pertussis
what is adenomyosis?
presence of endometrial tissue within the myometrium
more common in multiparous women towards the end of their reproductive years
what are the features of adenomyosis?
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
what is a threatened miscarriage?
painless vaginal bleeding before 24 weeks, but typically occurs at 6-9 weeks
bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
how is a threatened miscarriage managed?
as pregnancy is still viable, conservative management - advise mother to take time off work and rest
what is an inevitable miscarriage?
heavy bleeding with clots and pain
cervical os is open
what is an incomplete miscarriage?
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
what is first-line management for a miscarriage?
expectant management: waiting for a spontaneous miscarriage
waiting for 7-14 days for the miscarriage to complete spontaneously
if expectant management is unsuccessful then medical or surgical management may be offered
what is the medical and surgical management of miscarriage?
medical: vaginal misoprostol - prostaglandin analogue - causes strong myometrial contacts leading to expulsion of tissue - advise them to contact doctor if bleeding hasn’t started in 24 hours - should be given with antiemetics
and pain relief
surgical: vacuum aspiration or surgical management in theatre
what is cervical ectropion associated with?
higher oestrogen levels - more common in younger women, cocp users and pregnancy
how can troublesome ectropion be treated?
cauterisation of the ectropion using silver nitrate or cold coagulopathy during colposcopy
what is a follicular cyst?
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regresses after several menstrual cycles
what is a follicular cyst?
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regresses after several menstrual cycles
what is a corpus luteum cyst?
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears - if this doesn’t occur the corpus luteum may fill with blood and form a corpus luteal cyst
what is a dermoid cyst?
usually lined with epithelial tissue and may contain skin appendages, hair and teeth
most common benign ovarian tumour in women under 30
median age of diagnosis is 30
bilateral in 10-20%
usually asymptomatic - torsion is more likely than with other ovarian tumours
how many episodes is recurrent vaginal candidiasis?
4 or more episodes each year
how should recurrent vaginal candidiasis be treated?
confirm diagnosis: high vaginal swab for microscopy and culture
consider a blood glucose to exclude diabetes
consider the use of an induction-maintenance regime:
- induction: oral fluconazole every 3 days for 3 doses
- maintenance: oral fluconazole weekly for 6 months
Which lymph nodes does metastatic ovarian cancer commonly spread to?
para-aortic lymph nodes
what is post-partum thyroiditis?
where there are changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease - it can involve thyrotoxicosis, hypothyroidism, or both
over time the thyroid function returns to normal, and the patient will become asymptomatic again - a small portion of women with remain hypothyroid and need long-term thyroid hormone replacement
what antibodies may be present in post-partum thyroiditis?
thyroid peroxidase
what is the typical pattern of postpartum thyroiditis?
not all women will follow this pattern however there are thought to be 3 stages:
1. thyrotoxicosis - usually in the first 3 months
2. hypothyroid - usually from 3-6 months
3. thyroid function gradually returns to normal within 1 year
what may you see on blood tests if thyroid is acting abnormally?
hyperthyroid - low tsh, high t3/t4
hypothyroid - high tsh, low t3/t4
how is postpartum thyroiditis investigated?
there should be a low threshold for testing thyroid function in women presenting with suggestive symptoms, particularly post-natal depression - thyroid function tests are performed 6-8 weeks after delivery
how is post-partum thyroiditis managed?
patients with abnormal tfts in the postpartum period require referral to an endocrinologist for specialist management - typical treatment is with:
- thyrotoxicosis - symptomatic control such as propranolol (non-selective beta blocker)
- hypothyroidism - levothyroxine
symptoms and thyroid function tests are monitored, and treatment is altered or stopped as the condition changes and improves
women with post-partum thyroiditis require annual monitoring of thyroid function tests, even if the condition has resolved - monitoring is to identify those that go on to develop long-term hypothyroidism
which part of the pituitary is damaged in Sheehan’s syndrome?
anterior pituitary gland
which hormones are affected by sheehan syndrome?
TSH
ACTH
FSH
LH
GH
Prolactin
how does sheehan syndrome present?
presents due to a lack of hormones produced by the anterior pituitary, leading to signs and symptoms of:
- reduced lactation - lack of prolactin
- amenorrhoea - lack of LH and FSH
- adrenal insufficiency and adrenal crisis, caused by low cortisol
- hypothyroidism with low thyroid hormones
what is the management of sheehan’s syndrome?
managed under the guidance of a specialist endocrinologist - will involve replacement for the missing hormones
- oestrogen and progesterone as hormone replacement therapy for female sex hormones until menopause
- hydrocortisone for adrenal insufficiency
- levothyroxine for hypothyroidism
- growth hormone
what is endometritis?
inflammation of the endometrium usually caused by infection - can occur during post-partum period as infection introduced during or after labour and delivery - process of delivery opens uterus to allow bacteria from vagina to travel upwards and infect endometrium - more commonly occurs after c section
how does post-partum endometritis present?
- foul smelling discharge or lochia
- bleeding that gets heavier or does not improve with time
- lower abdominal or pelvic pain
- fever
- sepsis
how is post-partum endometritis diagnosed and managed?
- vaginal swabs - chlamydia and gonorrhoea if there are risk factors
- urine culture and sensitivities
ultrasound may be considered to rule out retained products of conception
septic arthritis will require hospital admission and septic 6, including blood cultures and broad spectrum IV abx - a combo of clindamycin and gent is often recommended
patients presenting with milder symptoms and no signs of sepsis may be treated in community with oral antibiotics
when should pregnant women start taking folic acid?
should be started before conception until 12 weeks
this is because the neural tube forms in the first 28 days
which grps of women should take a higher dose of folic acid?
- previous child with NTD
- diabetes mellitus
- women on antiepileptics
- obese - BMI >30
- HIV +ve taking co-trimoxazole
- sickle cell
if a woman reports reduced foetal movements what should be done?
if between 24 and 28 weeks - a handheld doppler should be used to confirm presence of foetal heartbeat
if past 28 weeks - handheld doppler should be used to confirm foetal heartbeat - if no heartbeat detected, immediate ultrasound should be offered - if foetal heartbeat present, CTG should be used for at least 20 minutes to monitor foetal heart rate
what are the side effects of gnrh agonists?
long term use can lead to loss of bone mineral density
what are the causes of premature menopause?
idiopathic: most common cause, there may be a family history
bilateral oophorectomy: having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
radiotherapy
chemotherapy
infection e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
what are the causes of premature menopause?
idiopathic: most common cause, there may be a family history
bilateral oophorectomy: having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
radiotherapy
chemotherapy
infection e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
what may you see on bloods in a pt with premature menopause?
raised FSH, LH - elevated FSH should be demonstrated on 2 blood samples taken 4-6 weeks apart
low oestradiol
what is classed as having a “high chance” of downs syndrome and what should be offered to these women?
high chance = 1 in 150 chance or less e.g. 1 in 100
if a woman has a high chance result she will be offered a second screening or a diagnostic test
the second screening is NIPT - non-invasive, analyses small dna fragments that circulate in the blood of a pregnant woman
diagnostic tests are amniocentesis or chorionic villus sampling however these are more invasive
when should contraception be restarted after taking ulipristal?
after 5 days
how long does it take for different contraceptives to become effective?
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
What is pelvic inflammatory disease?
infection and inflammation of the female pelvic organs usually as a result of ascending infection from the endocervix - commonly chlamydia, also gonorrhoea
what are the features of PID?
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
what are the investigations and management of PID?
a pregnancy test should be done to exclude an ectopic
high vaginal swab
screen for chlamydia and gonorrhoea
management: oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxycycline + oral metronidazole
some guidelines suggest removal of IUD
what is the treatment of chlamydia?
doxycycline 7 days
what are the criteria for expectant management of an ectopic pregnancy?
- size <35mm
- unruptured
- no foetal heartbeat
- hcg <1,000 IU
- compatible if another intrauterine pregnancy
- expectant management involves closely monitoring patient and if b-hcg levels rise again or symptoms manifest then intervention is performed
what are the criteria for medical management of ectopic pregnancy?
- size < 35mm
- unruptured
- no significant pain
- no foetal heartbeat
- hhcg <1,500 IU
- not suitable if intrauterine pregnancy
- medical management involves giving the patient methotrexate and can only be done if patient is willing to attend follow up
what are the criteria for surgical management of an ectopic pregnancy?
- size>35mm
- can be ruptured
- pain
- visible foetal heartbeat
- hcg>5,000 IU
- compatible with another intrauterine pregnancy
salpingectomy or salpingotomy
What subtypes of HPV increase risk of cervical cancer?
16,18, 33
what strains of HPV does the cervical cancer vaccine protect against?
6, 11, 16 and 18
what are the investigations to do if you suspect endometrial cancer?
transvaginal ultrasound for endometrial thickness - normal is less than 4mm
pipelle biopsy - highly sensitive for endometrial cancer
hysteroscopy with endometrial biopsy
what are the stages of endometrial cancer?
1 - confined to uterus
2- invades cervix
3 - invades ovaries, fallopian tubes, vagina, lymph nodes
4 - invades bladder, rectum or beyond pelvis
what is the management of endometrial cancer?
stage 1 and 2 = total abdominal hysterectomy with bilateral salpingo-oophorectomy
other treatment options include:
- radical hysterectomy - removing all pelvic lymph nodes, surrounding tissues and top of vagina
- radiotherapy
- chemotherapy
- progesterone - as hormonal treatment to slow progression of cancer
what are the 2 week wait referral criteria for suspected ovarian cancer?
if physical exam reveals:
- ascites
- pelvic mass
- abdominal mass
what are the 2 week wait referral criteria for suspected ovarian cancer?
if physical exam reveals:
- ascites
- pelvic mass
- abdominal mass
what investigations can be done if you suspect ovarian cancer?
- ca125
- pelvic ultrasound
- ct scan to establish diagnosis and stage of cancer
- histology using ct guided biopsy, laparoscopy and laparotomy
- paracentesis can be used to test ascitic fluid
what is the risk of malignancy index for ovarian cancer?
risk of ovarian mass being malignant, taking into account three things:
- menopausal status
- ultrasound findings
- ca125 level
what is the staging of ovarian cancer?
stage 1 - confined to ovary
stage 2 - spread past ovary but inside pelvis
stage 3 - spread past pelvis but inside abdomen
stage 4 - spread outside abdomen - distant metastasis
what are the investigations for suspected fibroids?
hysteroscopy is initial investigation for submucosal fibroids presenting with heavy menstrual bleeding
pelvic ultrasound is investigation of choice for larger fibroids
MRI scanning may be considered before surgical options, where more info is needed about size, shape and blood supply of fibroids
when is there an increased risk of breast cancer when using hrt?
when there is an addition of progestogen
what should you monitor when giving magnesium sulphate to a pregnant women with eclampsia/pre-eclampsia?
urine output, reflexes, respiratory rate, oxygen saturations
what is secondary amenorrhoea?
cessation of menstruation for 3-6months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
what are the causes of secondary amenorrhoea after excluding pregnancy?
- hypothalamic amenorrhoea e.g. 2ndary stress, excessive exercise
- pcos
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis
- sheehan’s syndrome
- asherman’s syndrome (intrauterine adhesions)
what is mesenteric adenitis?
inflamed lymph nodes within the mesentery - it can cause similar symptoms to appendicitis and can be difficult to distinguish between the two - it often follows a recent viral infection and needs no treatment
what happens do blood pressure during pregnancy?
falls in first half of pregnancy before rising to pre-pregnancy levels before term
what is the treatment of large fibroids causing fertility issues?
myomectomy
