Obs & gynae Flashcards
Cervical cancer
- subtypes and prevalence
- features
- HPV types
- risk factors
- stages
- management
Squamous cell carcinoma (80%)
Adenocarcinoma (20%)
Features
- during screening
- abnormal vaginal bleeding
- vaginal discharge
HPV - types 16 & 18
Risk factors:
- smoking
- HIV
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill
Stages (see pic)
Management
Stage IA - hysterectomy +/- lymph node clearance (cone biopsy if want to maintain fertility)
Satge IB - radical hysterectomy +/- radiotherapy + chemo
Stage II & III - radio & chemo
Stage IV - radio & chemo (palliative for stage IVB)
Cervical cancer screening
- smear test
- special situations
- management of results
25-49 years: 3 yearly screening
50-64 years: 5 yearly screenin g
Not offered to women over 64
In Scotland every 5 years 25-64
Special circumstances:
- delayed until 3 months post partum
- women who have never been sexually active can opt out
Negative hrHPV: return to normal recall
Positive hrHPV:
- cytology abnormal = colpscopy
- cytology normal = repeat in 12 months
- if hrHPV is now -ve = normal recall
- still hrHPV +ve and cytology normal = repeat in further 12mo
- hrHPV -ve at 24 mo = normal recall
- hrHPV +ve at 24mo = colposcopy
Inadequate:
- repeat in 3 months
- 2 consecutive inadequate samples = colposcopy
Treatment of CIN:
Large loop excision of transformation zone (LLETZ)
Umbillical cord prolapse
- prevalence
- risks
- when do 50% of them occur?
- Mx
1/500 deliveries
Risks: prematurity, multiparity, polyhydramnios, twin pregnancy, abnromal position e.g. breech
50% of the cord prolapses occur due to artificial rupture of membranes
Mx:
- obstetric emergency
- push presenting part back into the uterus
- patient go on all fours
- tocolytics to reduce contractions
- retrofilling the bladder
- C-section
Ectopic pregnancy management
- features
- management
Expectant management: monitoring over 48h and if bHCG levels rise or Sx then intervene
Medical management: give METHOTREXATE to patient
Surgical:
1. SALPINGECTOMY - for women with no risks for intertility
2. SALPINGOTOMY - for women who have infertility risk
Endometrial cancer
- risks
- protective factors
- Sx
- investigation
- management
Risks
- excess oestrogen
- unopposed oestrogen
- tamoxifen
- hereditary NPCC
- metobolic - obesity, DM, PCOS
Protective - multiparity, COCP, smoking
Sx - post-menopausal bleeding
All women >=55 with post-menopausal bleeding sent down 2ww:
- TVUSS (normal endometrial thickness <4mm)
- heterscopy with endometrial biopsy
Mx: surgery
- localised disease treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postoperative radiotherapy
Menopause management
- management with HRT
- risks of HRT and CIs
- management of non-HRT
- stopping HRT
HRT
Combined HRT (for women with a uterus):
- monthly: oestrogen taken daily and progesterone for last 10-14 days of cycle
- 3 monthly
- continuous combined HRT
Oestrogen-only HRT (for women without a uterus)
Contraindications:
- current/past breast cancer
- oestrogen sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
Risks: VTE, stroke, CHD, breast Ca, ovarian Ca
**NON-HRT: **
Vasomotor - fluoxetine, citalopram, venlafaxine
Vaginal dryness - lubricant
Psychological - CBT
Urogenital - vaginal oestrogen for urogenital atrophy
Stopping treatment: 2-5 years
Management of obesity in pregnancy
- 5mg folic acid
- screened for diabetes with OGTT at 24-28wks
- BMI >=35: obstetric-led unit
- BMI>40: anatental consult with obstetric anaethatist
Ovarian cancer:
- risk factors
- Sx
- investigation
- management
Risk factors
- FH: BRCA1 or BRCA2
- many ovulations
Sx: vague
- abdo distension & bloating
- abdo & pelvic pain
- urinary Sx
- diarrhoea
Investigation
- CA125 >35: USS abdo pelv
- USS
- diagnostic laparotomy
- risk of malignancy index(RMI): USS findings, menopausal status & CA125 levels
Management: surgery & platinum based chemo
Placenta praevia
- associations
- clinical features
- diagnosis
- grading
- management
Low lying placenta covering the lower uterine segment
Associations: multiparity, multiple pregnancy
Clinical features:
- shock
- NO PAIN
- lie and presentation may be abnormal
Diagnosis:
- TVUSS
- usually picked up at routine 20 week abdo USS
Grading (see pic)
Management:
if low lying placenta at 20 week scan:
- rescan at 32 weeks, limit activity
- still present at 32, scan every 2 weeks
- 36-37 week scan determine method - grades 3/4 have elective C section
Placenta praevia with bleeding: emergency C-section
Placental abruption
- epidemiology
- causes
- features
- Mx
1 in 200 pregnancy
Cause:
- proteinuric HTN
- cocaine
- multiparity
- maternal trauma
- increasing maternal age
Clinical features
- shock
- pain
- woody uterus
- fetal heart absent or distressed
Management:
fetus alive & <36 weeks:
- distress: immediate C-section
- no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
fetus alive & >36 weeks:
- fetal distress: immediate C-section
- nil distress: induce vaginal delivery
PPH
- definition
- causes
- risks
- management
- secondary
PPH blood loss >500ml
Causes: 4 Ts
Tone (uterine atony)
Trauma
Tissue
Thrombin
Risks - previous PPH, prolonged labour, pre-eclampsia
Management:
1. ABC
2. mechanical: rub the uterus
3. medical: IV oxytocin + ergometrine Carboprost IM
4. Surgical: intrauterine balloon tamponade 1st line, then B-lynch suture and ligation of uterine arteries
5. hysterectomy last resort
Secondary: 24h-6weeks after due to tissue or endometritis
Pre-eclampsia
- definition
- risks
- management
Pre-eclampsia:
1. new-onset HTN
2. proteinuria
3. oedema
Risks (see picture)
Mx:
- women with >1 high risk factor or >2 moderate risk factors should take aspirin 75mg-150mg daily from 12 week gestation until birth
Initial assessment:
- women with BP >=160/110 are likely to be admitted and observed
Further management:
- oral labetalol
- nifedipine if asthmatic
- delivery of the baby is definitive
Gestational diabetes
- risk
- screening
- diagnostic threshold
- management
- management of pre-existing diabetes
- targets for women
Risk factors:
- BMI >30
- previous macrosomic baby >4.5kg
- first degree relative
- south asian, black carrib, middle eastern
Screening:
- OGTT at 24-28 weeks
Diagnosis: 5,6,7,8
- fasting glucose is >= 5.6 mmol/L
- 2-hour glucose is >= 7.8 mmol/L
Management:
- fasting glucose <7 diet and exercise
- fasting >=7L: insulin
Mx of pre-existing:
- weight loss
- folic acid 5mg/day pre-conception to 12 weeks
- anomaly scan at 20 weeks
Targets (see picture)
Termination of pregnancy
- medical options
- surgical options
- general issues
- abortion act
Medical:
- mifepristone followed by misoprostol 48 hours later
- pregnancy test 2 weeks later
Surgical
- vacuum aspiration
NICE recommend that women are offered a choice between medical or surgical abortion up to and including 23+6 weeks’ gestation
General issue:
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation
Abortion act: pregnancy cannot exceed 24 weeks
Uterine fibroids
- diagnosis
- management
Diagnosis: TVUSS
Mx:
asymptomatic: no treatment
menorrhagia secondary to fibroids:
- LNG-IUS
- NSAIDs e.g. mefenamic acid
- tranexamic acid
- COCP
- oral/injectiable progestogen
treatment to shrink/remove:
- GnRH agonists
- surgical: myomectomy
- uterine artery embolisation
Ameorrhoea:
- primary vs secondary
- causes
- investigation
- Mx
PRIMARY - failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
SECONDARY: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Causes (see picture)
Investigation
- exclude pregnancy
- gonodatrophins: low levels indicates a hypothalamic cause, raised suggests ovarian problem or gonadal dysgenesis
- prolactin
- androgens: raised in PCOS
- oestradiol
Mx: treat underlying cause
Contraception method and thier MOA
Quadruple test for Downs, Edwards and neural tube defects
