obs & gynae Flashcards
Causes of postpartum haemorrhage
(4 T’s)
Tissue (retained placenta)
Tone (uterine atony)
Trauma
Thrombin (coagulation disorders, DIC)
Complications of multiple pregnancy
(HI PAPA)
Hydramnios (poly)
Intrauterine growth restriction
Preterm labour
APH
Pre-eclampsia
Abortion
Postpartum haemorrhage risk factors
(PARTUM)
Prolonged labour/ Polyhydramnios/ Previous C-section
APH
Recent Hx of bleeding
Twins
Uterine fibroids
Multiparity
Criteria for forceps delivery
(FORCEPS)
Foetus alive
Os dilated
Ruptured membrane, Rotation complete
Cervix take up
Engagement of head
Presentation suitable
Sagittal suture in AP diameter of inlet
what should all women with heavy menstrual bleeding recieve ?
full blood count to check for anaemia
Migraine during pregnancy - what should you give and what should you not ?
paracetamol 1g is first-line
NSAIDs can be used second-line in the first and second trimester
avoid aspirin and opioids such as codeine during pregnancy
uti in pregancy - how to manage ?
o 1st line = nitrofurantoin 50mg QDS or 100mg modified-release BD for 7 days
Avoid in women at term.
o 2nd line (if no improvement after 48 hours) =
Amoxicillin (only if culture results available and susceptible) 500mg TDS for 7 days
Cefalexin 500mg BD for 7 days
N.B. trimethoprim is a folate antagonist and contraindicated throughout pregnancy.
Trimethoprim is contraindicated in the first 12 weeks of pregnancy as it is a folate antagonist and can increase the risk of neural tube defects
22 week preg woman has high BP, clonus, brisk reflexes - what initial meds ??
- magnesium sulphate
- labetolol
pre eclampsia vs eclampsia
in eclampsia it is presecnce of seizure
what is Anencephaly
is a fatal condition where a baby is born without parts of the brain and skull.
type of NTD
make sure to take folic acid
how much in cm do you expect a primipip to progress in 1st stage of labour ?
0.5cm per hour
nuchal translucency scan measures what fluid ?
lymph
ovarian cyst with hair teeeth and random stuff?
mature cystic teratoma
features of molar pregnancy
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen
bleeding in first / early 2nd trimester, hyperemesis, uterus large for dates, high BP, high b-HCG
molar pregnancy
classify early and late miscarriage ?
Miscarriages can be classified as follows:
Early miscarriage: < 13 weeks
Late miscarriage: 13-24 weeks
outline Complete miscarriage
Both fetus and all pregnancy tissue have been expelled from the uterus
Bleeding stops and further treatment is not needed. cervical os closed / uterus empty
more common < 12 weeks (placenta unliekly to have developed)
outleine Incomplete miscarriage
Fetus and parts of the membranes are expelled from the uterus
Placenta is not fully expelled and bleeding persists
Surgical management is often needed to remove the remaining products of conception (manual vacuum aspiration)
more common 12-24 weeks
outline Missed miscarriage
Usually identified via ultrasound with a small for dates uterus
Fetus in the uterus that did not develop or has died
Often do not have typical clinical symptoms of pain or vaginal bleeding
outline Threatened miscarriage
Viable pregnancy with symptoms (such as vaginal bleeding) and a closed cervical os
75% of threatened miscarriages will settle
Carry a higher risk of preterm delivery and preterm rupture of membranes
return for further asssessment if bleeding persists > 14 days
outline Inevitable miscarriage
Non-viable pregnancy with vaginal bleeding and an open cervical os
Progresses to an incomplete or complete miscarriage
this will progress to complete/incomplete miscrraige
define Recurrent miscarriage
Occurs in 1% of patients
3 or more consecutive miscarriages
Offered a referral for further investigation
examination findings in ectopic pregnancy
Examination findings
* abdominal tenderness
* cervical excitation (also known as cervical motion tenderness) - excrutiatting pain on bimanual
* adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
medical and surg management for miscarriage ?
med = o Offer vaginal misoprostol (or oral preparation)
surg = manual vacuum aspiration
(NB Vaginal or sublingual misoprostol if often used to ripen the cervix to facilitate cervical dilatation for suction insertion )
miscarriage risk factors
- Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight
define ectopic pregnancy
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
how does ectopic preg present ?
abdo pain
amenorhhea
vaginal bleeding
- peritoneal bleeding –> shoulder tip pain
- dizziness, fainting, syncope
types of management for ectopic ?
expectant - make sure you do serial bHCG measures
medical - IM methotrexate (if able to attend follow up)
surgical - salpingectomy / salpingotomy
indications for surgical mx for ectopic ?
- Significant pain
- Ruptured ectopic
- Adnexal mass > 35 mm
- Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
- Serum β-HCG > 5000 iU/L
indications for medical mx for ectopic ?
- No significant pain
- Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
- Serum β-hCG < 1500 iU/L
- Not suitable if co-existing intrauterine pregnancy (confirmed by USS)
- Able to return for follow up
indications for expectant mx for ectopic ? *
This can only be done if:
o Size < 35 mm
o Unruptured
o Asymptomatic
o No foetal heartbeat
o Serum hCG < 1000 IU/L (may consider 1000-1500)
o Able to return for follow up
o Compatible if there is another intrauterine pregnancy
mx for gestational trophoblastic disease
1st line: Suction curettage for complete and partial* molar pregnancies
molar pregnancies
Levonorgestrel overview emergency contraception
Must be within 72hrs of UPSI (95% effective 0-24hrs, 84% effective 48-72hrs)
- Class: progestogen
- 1.5 mg single oral dose
- Mechanism: Inhibits ovulation for next 5 days – less effective in late follicular phase (just before ovulation)
- Safe and well tolerated (may cause slight menstrual cycle disturbance) Levonorgestrel
- Can be used more than once in a menstrual cycle if needed
- Warning: If vomiting occurs within 2 hours of dose, should be repeated
Ulipristal acetate overview emergency contraception
Must be within 120hrs of UPSI (95% effective)
- Class: selective progesterone receptor modulator
- 30 mg single oral dose
- Mechanism: Delays ovulation until sperm no longer viable
- Should NOT be used with levonorgestrel
- If patient normally uses hormonal contraception, they should restart it 5 days after ulipristal (and use barrier contraception in the meantime. This is between 2-9 days depending on the type of contraception)
- Caution if severe asthma
- Can be used in more than one cycle if needed
- Warning: If vomiting occurs within 3 hours of dose, should be repeated
Copper Coil (Cu-IUD) emergency contraception overview
Ideally within 120hrs of UPSI or within 5 days after the earliest estimated date of ovulation (99% effective)
- Class: intrauterine contraceptive method
- Most effective method of emergency contraception, only method effective after ovulation
- Mechanism: Spermicide and prevents fertilisation and implantation
- STI screening if at high risk of STI
- May be left in for long-term contraception
- Not known to be affected by BMI/weight or by other drugs
why would you not be able to have copper IUD for emergency contraceptions ?
- Explain that Cu-IUD is most effective and most recommended. If a woman cannot have Cu-IUD (e.g. because of current STI) then explain why
important things to remember for termination of pregnancy
- IMPORTANT: with all abortion patients, discuss the insertion of long-acting reversible contraception (e.g. copper IUD, LNG-IUS, Nexplanon)
- IMPORTANT: 2 doctors need to sign a form agreeing to termination of pregnancy (they don’t both need to see the patient)
important things to remember for fat women taking the morning after pill ?
- Important: for women with a bodyweight > 70 kg or a BMI > 26
o EllaOne is the recommended method (continue oral contraception after 5 days)
o Levonelle: if Levonelle is taken, give a double dose (3 mg) and the woman should start ongoing contraception immediately
PCOS features
Features
* subfertility and infertility
* menstrual disturbances: oligomenorrhoea and amenorrhoea
* hirsutism, acne (due to hyperandrogenism)
* obesity
* acanthosis nigricans (due to insulin resistance)
criteria for PCOS ?
- Diagnosis using Rotterdam Criteria for PCOS (at least 2 of the following)
o Oligo/anovulation (> 2 years)
o Clinical or biochemical features of hyperandrogenism
o Polycystic ovaries on ultrasound (> 12 in one/both ovaries measuring 2-9 mm or ovarian volume > 10cm3)
PCOS mx
- lifetsyle advice (weight/ diet )
- COCP
- treat hirsutism / androgenic sx
if planning pregnancy
1. clomiphene
2. gonadotropins
mx for termination fo pregnancy
medical=
* 200 mcg Mifepristone (oral) followed 24-48 hours later by misoprostol (vaginal, buccal, or sublingual)
surgical
< 14 weeks vacuum aspiration
13- 24 weeeks - dilatation and evacuation (D&E) NB - misoprostol is used to ripen cervix
causes of primary and secondary amenorrhea
Primary amenorrhoea
- gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
* hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
* polycystic ovarian syndrome (PCOS)
* hyperprolactinaemia
* premature ovarian failure
* thyrotoxicosis*
* Sheehan’s syndrome
* Asherman’s syndrome (intrauterine adhesions)
drug for ovulation induction in subfertility ?
- Ovulation induction - clomiphene or FSH
important blood hormones to look at when assessing for subfertitlity
- Look at early follicular phase FSH, LH and oestradiol levels (day 2-3)
- Anti-Mullerian hormone (AMH) is helpful for assessing ovarian reserve
o It is independent of the menstrual cycle
o Produced by granulosa cells and does not change in response to gonadotrophins, so it is the most successful biomarker of ovarian reserve - Mid-luteal progesterone should also be measured to confirm ovulation
- If irregular menstrual cycle: TFTs, prolactin and testosterone may also be useful
outline ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment
Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS
features of bacterial vaginosis + ix + mx
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.
Features
vaginal discharge: ‘fishy’, offensive
asymptomatic in 50%
Amsel’s criteria for diagnosis of BV - 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)
mx =
asymptomatic = nothing
sompotamic = oral metronidazole
features of vulvovaginal candidiasiss + ix + mx
Features
* ‘cottage cheese’, non-offensive discharge
* vulvitis: superficial dyspareunia, dysuria
* itch
* vulval erythema, fissuring, satellite lesions may be seen
Investigations
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
mx
pregnant = clotrimazole pessary or cream (local)
non-pregnant= itraconazole 200 mg PO BD for 1 day or fluconazole 150 mg PO stat
pathogen + features + ix + mx for PID
Causative organisms
* Chlamydia trachomatis
* + the most common cause
* Neisseria gonorrhoeae
* Mycoplasma genitalium
* Mycoplasma hominis
Features
* lower abdominal pain
* fever
* deep dyspareunia
* dysuria and menstrual irregularities may occur
* vaginal or cervical discharge
* cervical excitation
Investigation
* a pregnancy test should be done to exclude an ectopic pregnancy
* high vaginal swab
* these are often negative
* screen for Chlamydia and Gonorrhoea
mx =
* Outpatient Antibiotic Regimen
o Ceftriaxone 1g IM (single dose),
o Doxycycline 100 mg BD (oral) for 14 days, &
o Metronidazole 400 mg BD (oral) for 14 days
follow up for patient treated for PID
Follow-Up
* If managed as outpatients, should be seen within 72 hours to assess response
* If no improvement, admit for IV antibiotics
* Further follow-up at 2-4 weeks to:
o Ensure resolution
o Reiterate importance of STIs
o Reassure that if compliant, fertility is not affected
* Complications:
o Infertility
o Ectopic pregnancy
o Chronic pelvic pain
outline genital herpes features + ix + mx
There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap
Features
* painful genital ulceration
* may be associated with dysuria and pruritus
* the primary infection is often more severe than recurrent episodes
* systemic features such as headache, fever and malaise are more common in primary episodes
* tender inguinal lymphadenopathy
* urinary retention may occur
Investigations
* nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture
* HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
Management
* general measures include:
* saline bathing
* analgesia
* topical anaesthetic agents e.g. lidocaine
* oral aciclovir
* some patients with frequent exacerbations may benefit from longer-term aciclovir
mx for vaginal prolapse
General lifestyle advice
* Losing weight if BMI >30kg/m2
* Avoiding heavy lifting
* Prevent/ treat constipation
Medical
* Pelvic floor exercises (16-week course)
* Oestrogens – pill, patch, cream or implant (can help with symptom relief + if woman also has signs of vaginal atrophy)
* Vaginal ring pessary (changed every 6 months)
o Side-Effects: unpleasant discharge, irritation, UTI, interference with sex (sex is not possible with a shelf pessary)
Surgical
* No preference regarding preservation of uterus
o Vaginal hysterectomy ± vaginal sacrospinous fixation (removal of the uterus ± stitching the top of the vagina to a ligament in the pelvis)
o Vaginal sacrospinous hysteropexy (cervix is stitched to a ligament in the pelvis)
o Manchester repair (shortening of the cervix to support the uterus)
o Sacro-hysteropexy with mesh (mesh used to attach the uterus to sacral vertebra)
* Preservation of uterus
o Vaginal sacrospinous hysteropexy
o Manchester repair (unless the woman wishes to have children in the future)
* Vault prolapse
o Vaginal sacrospinous fixation
o Sacrocolpopexy (mesh used to attach the vagina to sacral vertebra)
* Colpocleisis = only offered if the woman does not intend to have penetrative sex or they are at high surgical risk (the procedure involves closure of the vagina)
what is ashermanns syndrome and mx
This patient is presenting with secondary amenorrhoea and infertility on a
background of extensive gynaecological surgery. Asherman syndrome is
characterised by the formation of intrauterine adhesions leading to amenorrhoea
due to physical obstruction of the cervix or destruction of the endometrial lining.
It typically occurs in patients who have had several gynaecological operations
(e.g. caesarean section, myomectomy, dilatation, and evacuation). As it causes
amenorrhoea by creating a mechanical obstruction, the hormone profile will be
normal. It is diagnosed by hysteroscopy, during which adhesiolysis can be
performed to help relieve symptoms.
- Surgical breakdown of intrauterine adhesions (hysteroscopic adhesiolysis) + insertion of paediatric Foley catheter or intrauterine device for 4-8 weeks to prevent re-formation
- 2 cycles of cyclical oral oestrogen and progesterone given after to aid endometrial proliferation
