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
Urinary incontinence
- classification
- investigation
- management
Overactive bladder/urge: detrusor overactivity
Stress: coughing/laughing
Mixed: urge and stress
Overflow: bladder outlet obstruction e.g. prostate enlargement
Investigation:
- bladder diary for 3 days
- vaginal examination
- urine dipstick & culture
- urodynamic studies
Mx:
Urge incontinence:
- bladder retraining
- antimuscurinics e.g. oxybutynin
- mirabegron (if elderly & suffering from anti-cholinergic effects)
Stress:
- pelvic floor muscle training
- surgery: mid urethral tape
- duloxetine: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
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
Hyperemesis gravidarum:
- diagnosis triad
- risk factors
- referral criteria
- management
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Risk factors:
- raised b-hCG: multiple pregnancies, trophoblastic disease
- nulliparity
- obesity
- FH
Referral criteria: see triad
Management: PUQE score
first line medication:
- antihistamine: oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine
second line medication:
- oral ondansetron: increase risk of cleft palate
- oral metoclopramide
admission for IV hydration
hCG
- what is it produced by first?
- what secretes it?
- when does it peak?
- what does it do?
Produced by the embryo
Secreted by syncytiotrophoblasts
At its peak 8-10 weeks gestation
Maintains the corpus luteum
Contraception method and thier MOA
COCP:
UKMEC 3
UKMEC 4
UKMEC 3:
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
UKMEC4:
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
Quadruple test for Downs, Edwards and neural tube defects
COCP: missed pill
1 pill missed (any time):
- take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
- no additional contraception
2+ pills missed:
- week 1 (day 1-7): emergency contraception if she had unprotected sex in the pill free interval or week 1
- week 2 (8-14): no emergency contraception
- week 3 (15-21): finish pills and omit pill free interval
Emergency contraception
Levongestrel
- can be taken within 72h
- vomiting within 3h: repeat dose
- start contracpetion immediately
Ullipristal:
- 120h
- caution in severe asthma
- delay breast feeding for a week
IUD:
- 5 days within UPSI
- effective regardless if where it is in cycle
Reduced fetal movements
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
Risks factor of reduced fetal movements:
- posture: more prominent lying down
- distraction
- placental position: anterior placenta prior to 28wks have less awareness of fetal movements
- drugs: alcohol, opiates, benzos
- fetal position: anterior
- body habitus: obese
- aminiotic fluid vol: too high or low
- fetal size
Investigation
>28 weeks:
- handheld doppler
- if no heartbeat: immediate USS
- fetal heartbeat: CTG 20 mins
24-28: handheld doppler
<24 and fetal movements have been felt: handheld doppler
<24 and no movements: referral to maternity
Miscarriage
Missed miscarriage:
- oral mifepristone: weakens attachment to endometrial wall + cervical softening and dilation
- give misoprostol 48h later
Incomplete - single dose of misoprostol
Pregnancy test within 3 weeks
Surgical: if haemorrhage, infection or adverse experience associated w pregnancy (stillbirth)
Management of PMS
Mild - lifestyle advice
Moderate - new gen COCP e.g. Yasmin
Severe - SSRI e.g. floxetine
