Obs & Gynae Flashcards
At what gestation does PV bleeding turn from being referred to as a threatened miscarriage to an antepartum haemorrhage?
- Threatened miscarriage → <24 weeks gestation
- Antepartum haemorrhage → 24 weeks - onset of labour
What are the most common causes of antepartum haemorrhage?
- Placenta praevia (painless PV bleed)
- Placental abruption (sudden onset, severe, continuous pain, woody on palpation)
- Vasa praevia (painless, dark red)
- Local → cervical polyps, vaginitis, cervicitis. Often post-coital.
- Unexplained → in the absence of maternal or foetal compromise, it is managed expectantly.
What are the risk factors of placenta praevia?
- Previous C-Section → key risk factor to remember
- Previous TOP
- Multiparity
- Mother >40 years old
- Smoking
- Previous placenta praevia
How does placenta praevia present?
- 20 week anomaly scan → used to assess the position of the placenta & diagnose placenta praevia.
- Painless vaginal bleeding (antepartum haemorrhage)
- Usually occurs later in pregnancy, >36 weeks
- Examination:
- Non-tender uterus
- Lie & presentation may be abnormal → transverse
- Do not do a digital vaginal examination/speculum as this may provoke a severe haemorrhage
How is placenta praevia managed?
If diagnosed at 20 week scan:
- Repeat transvaginal USS at 32 weeks & then 36 weeks.
- If still present at 36 weeks then:
- Planned delivery between 36-37 weeks → reduce risk of spontaneous labour & bleeding
- Corticosteroids given between 34 & 35+6 weeks
If premature labour or APH:
- Emergency c-section
How does placental abruption present?
History:
- Sudden onset, severe, continuous abdominal pain → most common, posterior abruptions may present with back pain.
- Vaginal bleeding
- Uterine contractions
- Dizziness and/or loss of consciousness
Examination:
- Hypotension & tachycardia → if patient is in shock
- Characteristic ‘woody’ abdomen on palpation → tense all the time, suggests a large haemorrhage
- Abnormalities on CTG
- Foetal heart → absent or distressed
How is a placental abruption managed?
Initial steps:
- Stabilise mother if major/massive haemorrhage
- CTG monitoring of foetus
- USS → useful in excluding placenta praevia, but not great at diagnosing an abruption
- Antenatal steroids offered if between 24 & 34+6 weeks
- Anti-D prophylaxis → if rhesus negative
No signs of foetal distress:
- <36 weeks → observe closely
- > 36 weeks → induce & deliver vaginally
Signs of foetal distress/maternal compromise:
- Immediate c-section, regardless of gestation
If the foetus is dead:
- Induce vaginal delivery, unless the mother is haemodynamically compromised & ongoing massive haemorrhage → C-section indicated in this instance.
How does vasa praevia present?
- Diagnosed during ultrasound in some cases
- APH → painless vaginal bleeding, foetal bradycardia
- In Labour:
- Foetal distress
- Dark-red bleeding following ROM
- Examination → pulsating foetal vessels may be seen through the dilated cervix
How is vasa praevia managed?
For asymptomatic women:
- Corticosteroids from 32 weeks to mature foetal lungs
- Elective C-section for 34-36 weeks
If APH occurs → emergency c-section
What are the definitions of primary & secondary PPH?
- Primary PPH → 3rd stage labour (baby out, pre placenta) to 24hrs of birth
- Secondary PPH → from 24hrs-12 weeks after birth
To be classified as postpartum haemorrhage, there needs to be a loss of:
- > 500ml after vaginal delivery
- > 1000ml after a c-section
What are the causes of PPH?
The 4 T’s
- Tone
- Most common cause of primary PPH (90%)
- Normally contraction of the uterus in 3rd stage causes of compression of intramyometrial blood vessels & bleeding from the placental site stops promptly.
- If there is uterine atony/poor contractility, this compression does not occur
- Trauma
- Bleeding from an episiotomy, vaginal tear, cervical laceration, or rupture of the uterine wall.
- Genital tract lacerations are more common after an instrumental birth
- Tissue
- Retained products of conception (RPOC) is when placental tissue has not delivered within 30mins active management, or 60mins physiological management.
- This presence of tissue prevents effective uterine contraction & partial placental separation results in bleeding from the placental bed.
- Thrombin
- Coagulopathies can cause PPH, DIC is important to be aware of.
- DIC can occur in association with a number of different causes → maternal sepsis, placental abruption, PPH (blood loss causes DIC, DIC exacerbates blood loss).
How is a primary PPH managed initially?
Key questions to answer:
- Has the placenta been delivered & is it complete?
- Is the uterus firmly contracted?
- If so, is the bleeding due to trauma?
Management to stabilise the patient:
- A-E approach
- Insert two large-bore cannulas
- Bloods → FBC, U&E, clotting screen, group & save
- Fluids as required
- O- blood if rapid blood loss
- Oxygen
What management is considered during a primary PPH?
-
Mechanical
- Rubbing the uterus → if atonic, stimulates uterine contraction. Bimanual compression may also be performed.
- Catheterisation → bladder distension prevents uterus contractions
- Placental delivery → if still present, a gentle attempt at umbilical cord traction should be tried. If still retained, regional block/GA will be required for manual removal of placenta. A hand is passed into the uterus through the cervix to strip off the placenta.
-
Medical
- Oxytocin → IV bolus of 5 IU, followed by an infusion of 50 IU in 500ml crystalloids.
- Tranexamic acid → IV, antifibrinolytic that reduces bleeding.
- Other oxytocics to stimulate uterine contraction→ IV/IM ergometrine, IM carboprost, sublingual misoprostol.
-
Surgical
- Intrauterine balloon tamponade → insert an inflatable balloon into the uterus to press against bleeding
- B-Lynch suture → suturing the uterus to compress it
- Uterine artery ligation → ligation of one or more of the arteris supplying the uterus to reduce blood flow
- Hysterectomy → last resort, but could save a woman’s life
What are the two most common causes of a secondary PPH?
RPOC or infection (endometritis)
What are the risk factors of endometrial cancer?
- Develops due to the presence of unopposed oestrogen (oestrogen without progesterone) → stimulates the endometrial cells & increases the risk of endometrial hyperplasia & cancer.
- Endogenous Risk factors:
- Obesity → due to aromatisation in body fat of peripheral androgens to oestrogens. 1/3 of cases are linked to obesity.
- Nulliparity
- Early onset menses, late menopause
- PCOS → lack of ovulation
- Anovulatory menstrual cycles
- Exogenous Risk Factors
- Tamoxifen → oestrogenic effect on endometrium
- HRT, without progesterone therapy
- Non-oestrogen risk factors → Type 2 diabetes (increased insulin production, which stimulates endometrial cells), Lynch syndrome
How does endometrial cancer present?
- Abnormal uterine bleeding → post-menopausal, heavy, intermenstrual, post-coital, or unscheduled bleeding whilst on HRT
- Increased vaginal discharge → blood-stained, watery or purulent (pyometrium)
- Advanced disease → pelvic pain, oedema, rectal bleeding, weight loss, fatigue
What are the 3 key investigations for suspected endometrial cancer?
- Transvaginal ultrasound for endometrial thickness → normal <4mm post-menopause
- <5mm normal if HRT is being taken
- Pipelle biopsy → sample of endometrial tissue to examine for hyperplasia or cancer.
- Hysteroscopy with endometrial biopsy
How does an ectopic pregnancy present?
Typically presents from 5 weeks gestation upwards.
- If unknown pregnancy → missed period, dizziness/fainting
- Abdominal pain, usually bilateral
- Vaginal bleeding
- Shoulder tip pain → peritonitis
Examination:
- Cervical motion tenderness → pain when moving the cervix during a bimanual examination
- Rebound tenderness → peritonitis
- Signs of hypovolaemic shock
How is an ectopic pregnancy managed?
Do a pregnancy test in all women with abdominal/pelvic pain if appropriate.
- A-E approach to stabilise the patient if required.
All ectopic pregnancies need to be terminated, as it is not viable. There are 3 options:
- Expectant → if clinically stable & serum hCG <1500 & mass <35mm
- Monitor serum bHCG & perform serial USS to monitor pregnancy until it spontaneously resolves.
- Medical → methotrexate if HCG <5000 & mass <35mm
- Monitor hCG to ensure it is declining & not continuing to rise
- Must not get pregnant within 3 months of the treatment as teratogenic effects can last this long.
- Surgical → if mass >35mm, HCG levels >5000. Give anti-D prophylaxis in all rhesus-negative women
What is a chocolate cyst?
An endometrioma (clump of endometrial tissue) within the ovaries
How is endometriosis managed?
Initial:
- Refer for TVUSS
- Manage endometriosis-related pain
- Consider need for referral
- If initial treatment is not effective or tolerated
- If person has symptoms which are affecting activities of daily living
- If there are persistent or recurrent symptoms
Medical:
- Short trial of paracetamol or NSAIDs
- Hormonal treatment
- COCP → can be used back-to-back to avoid period
- Medroxyprogesterone acetate injection → depot
- Nexplanon
- Mirena coil
- GnRH agonists → as the symptoms of endometriosis tend to improve in a menopause-like state
- Surgical
- Laparoscopic surgery → excise or ablate the tissue & remove adhesions (adhesiolysis)
- May improve fertility
- Hysterectomy
- Laparoscopic surgery → excise or ablate the tissue & remove adhesions (adhesiolysis)
What is the most common cause of PID?
Chlamydia trachomatis
What investigations are done for PID?
STI:
- NAAT swabs for gonorrhoea & chlamydia
- HIV test
- Syphilis test
- High vaginal swab (charcoal swab) → bacterial vaginosis, candidiasis, trichomoniasis
Other:
- Pregnancy test
- Inflammatory markers on bloods
- TVUSS → exclude ovarian pathology
How is PID managed?
Medical
- 1st line outpatient
- 1g IM ceftriaxone once only (gonorrhoea)
- 100mg oral doxycycline BD for 14 days (chlamydia)
- 400mg oral metronidazole BD for 14 days (anaerobes)
- Contact of PID
- Current → 100mg oral doxycycline BD 7 days
- Last 6 months → STI testing
Follow-Up:
- Clinical symptoms should improve within 72hrs of treatment
- Test of Cure is required
- If positive for chlamydia → repeat test 3-5 weeks following treatment
- If positive for gonorrhoea → repeat test 2 weeks later
What investigation is done for chlamydia?
NAAT → chlamydia is too small to be seen on microscopy, so charcoal swabs are not as useful.
- Women → vulvo-vaginal swab, endocervical swab, or first-catch urine sample
- Men → first-catch urine sample, or urethral swab
How is chlamydia managed?
- Doxycycline 100mg → BD for 7 days, 1st line
- Azithromycin 1g single dose → particularly in pregnancy
Other points:
- Test of cure → only required if rectal chlamydia, in pregnancy, persistant symptoms
- Abstain from sex for 7 days of treatment
- Treat co-infections
- Advice about future contraception
- Repeat testing in 3 months if <25yrs old.
How does gonorrhoea present?
People present with symptoms of gonorrhoea more commonly than they do with chlamydia.
- 90% of men & 50% of women are symptomatic.
Signs & Symptoms in Men:
- Urethral discharge → odourless, purulent, green or yellow
- Dysuria
- Rectal GC
- Testicular pain or swelling
- Pharyngeal infection
Signs & Symptoms in Women:
- Altered vaginal discharge → thin, watery, green/yellow
- Dysuria
- Dyspareunia
- Low abdominal pain & pelvic tenderness
- Menstrual irregularities → IMB, menorrhagia, post-coital
What investigations are done for gonorrhoea?
Females:
- NAAT → Endocervical/vaginal swab
- Microscopy & culture → (charcoal) endocervical/urethral swab
Males:
- NAAT → First pass urine
- Microscopy & culture → urethral meatal swab
- Rectal & pharyngeal swab → in MSM
How is gonorrhoea managed?
- Ceftriaxone → IM, 1g, single dose (if sensitivities not known, oral if sensitive to quinolone)
- Test of cure → 2-3 weeks after antibiotics
- Screen for other STIs, especially chlamydia → co-infections are common
- Sexual partner notification & screening
- Treat contacts <2 weeks, test & treat anyone positive >2 weeks prior.
- Education
- Abstain from sex for 7 days of treatment of all partners
- Encourage barrier contraception
What are fibroids & what are the different types?
= benign tumours of the smooth muscle of the uterus, also known as uterine leiomyomas
Types:
- Intramural → within the myometrium (uterine muscle). As they grow, they change the shape & distort the uterus
- Subserosal → just below the outer layer of the uterus, and they can grow outwards & become very large, filling the abdominal cavity
- Submucosal → means just below the lining of the uterus (endometrium)
- Pedunculated → on a stalk
How are fibroids managed?
- Medical
- Symptomatic management → NSAIDs, tranexamic acid
- Mirena coil → depending on the size & shape of the fibroids & uterus
- COCP
- Cyclical oral progesterones
If <3cm:
- Endometrial ablation
- Resection → of submucosal fibroids during hysteroscopy
- Hysterectomy
If >3cm - gynae referral and:
- Surgical
- Uterine artery embolisation
- Interventional radiologist inserts a catheter into an artery, usually the femoral artery, into the uterine artery.
- Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid.
- This starves the fibroid of oxygen.
- Myomectomy
- Surgically removing the fibroid via laparoscopy or laparotomy
- Only known treatment that improves fertility
- Hysterectomy
- GnRH agonists → may be used to reduce the size of fibroids before surgery
What is red degeneration? How does it present, and how is it managed?
= ischaemia, infarction, & necrosis of the fibroid due to disrupted blood supply
- More likely to occur in larger fibroids (>5cm) during the 2nd/3rd trimester of pregnancy
- May occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply & becoming ischaemic → may also occur due to kinking in the blood vessels as the uterus changes shape & expands during pregnancy
- Presentation:
- Severe abdominal pain
- Low-grade fever
- Tachycardia
- Vomiting
- Management
- Supportive → fluids, red, analgesia
What is pre-eclampsia?
= new-onset hypertension after 20 weeks of pregnancy, which co-exists with 1/more of the following features:
- Proteinuria
- Maternal organ dysfunction → renal, liver, neurological, haematological, uteroplacental dysfunction.
- Placental dysfunction
How does pre-eclampsia develop?
- Poorly understood
- Normally in pregnancy, the trophoblast implanted in the endometrium sends signals to the spiral arteries in that area to remodel & breakdown → this leaves pools of blood calls lacunae.
- Lacunae form around 20 weeks gestation, and allow for increased blood flow through the uterine vascular system.
- In pre-eclampsia, this formation of lacunae is inadequate, resulting in high vascular resistance of the vascular arteries & resultant poor perfusion of the placenta.
- This placental hypoxia causes oxidative stress which leads to systemic pro-inflammatory cytokine release in systemic circulation.
- Cytokines cause maternal peripheral endothelial dysfunction.
What are the risk factors for developing pre-eclampsia?
High risk:
- chronic HTN
- previous gestational HTN
- diabetes mellitus
- CKD
- autoimmune disease (SLE, anti-phospholipid syndrome)
Moderate risk:
- >40yrs old
- 1st pregnancy
- multiple pregnancy
- Pre-pregnancy obesity, BMI >35
- 1st degree relative had pre-eclampsia
What are the symptoms of pre-eclampsia?
- Asymptomatic
- Headache
- Visual disturbance, blurriness
- Nausea & vomiting
- RUQ/epigastric pain → liver swelling
- Oedema → arms, legs, face, due to increased vascular permeability
- Dyspnoea → pulmonary oedema
- Reduced urine output → reduced GFR
- Rapid weight gain → fluid
What are the signs of pre-eclampsia?
- Hypertension
- Oedema
- Epigastric/RUQ tenderness
- Hyper-reflexia & clonus
- Papilloedema
What investigations are done for pre-eclampsia?
Bedside:
- Blood pressure → HTN >140/90
- Urine dipstick → proteinuria
Laboratory:
- FBC → platelets may be low
- U&Es → raised urea/creatinine, low eGFR
- LFTs → raised ALT/AST
- Clotting profile → may be deranged if DIC
- Placental growth factor (PlGF) → supports normal trophoblastic growth, therefore if PlGF is low, then pre-eclampsia may be present. If normal, then pre-eclampsia is ruled out.
Scans:
- Foetal heart beat → exclude still birth
- USS → intrauterine growth restriction, oligohydramnios, placental infarction/haematoma, increased uterine artery flow resistance.
How can pre-eclampsia be prevented in those at risk?
Aspirin (75-150mg) is given from 12 weeks gestation until birth → if single high-risk factor or >/2 moderate risk-factors are present.
How is gestational HTN without proteinuria managed?
- Treat for BP <135/85
- Dipstick testing → at least weekly
- Monitor blood tests weekly → FBC, LFTs, U&Es
- Foetal growth scans
- Admit to hospital if BP >160/110
How is confirmed pre-eclampsia managed?
- Labetalol → first line, nifedipine or methyldopa are alternatives.
- BP monitoring every 48hrs
- USS monitoring of foetus every 2 weeks
- VTE prophylaxis
How is pre-eclampsia managed during labour?
- IV magnesium sulphate → given during labour & in the 24hrs afterwards to prevent seizures.
- Fluid restriction → in severe pre-eclampsia/eclampsia to avoid fluid overload
- Planned early birth → if BP not controlled or complications occur. Corticosteroids given to help mature foetal lungs
What are the complications of pre-eclampsia?
- Multi-organ dysfunction → with progressive worsening to multi-organ failure
- Cardiovascular complications → MI, stroke
- ARDS, pulmonary oedema
- Placental abruption
- Intrauterine growth restriction
- Stillbirth, neonatal death
- Eclampsia
- HELLP syndrome
What is HELLP syndrome, and how is it managed?
- = a combination of features that occurs as a complication of (pre-)eclampsia:
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
- HELLP syndrome develops as a result of endothelial damage & consequent thrombi formation associated with pre-eclampsia.
- Blood film will show schistocytes
- Management:
- IV magnesium sulphate
- Antihypertensives
- Blood products
- Timely delivery
How does trichomonas vaginalis present? What are the key examination/investigations?
Up to 50% of TV are asymptomatic. Symptoms are often non-specific when they do occur:
- Vaginal discharge → frothy, thin, yellow/green, fishy smell
- Itching
- Dysuria
- Dyspareunia
- Vaginitis & ‘strawberry cervix’
- In men → balanitis, urethral discharge/itching, dysuria
Investigations
- Vaginal pH → >4.5 (normal is 3.5-4.5)
- Charcoal swab with microscopy
- NAAT
- Vulvo-vaginal (self-taken low vaginal)
- Urethral swab or first-catch urine is used in men.
How is trichomonas vaginalis managed?
- Screen for other STI’s
- Metronidazole 400bd for 7 days
- Treat sexual contacts
- GUM referral
What is bacterial vaginosis, and what is the pathophysiology?
= an overgrowth of anaerobic bacteria in the vagina.
- Bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia, & gonorrhoea.
Pathophysiology:
- Lactobacilli are the main component of the healthy vagina bacterial flora.
- These bacteria produce lactic acid which keeps the vaginal pH low.
- The acidic environment prevents other bacteria from overgrowing.
- Bacterial vaginosis occurs when there are reduce numbers of lactobacilli in the vagina → results in a raised pH.
- This more alkaline environment enables anaerobic bacteria to multiply.
How does bacterial vaginosis present?
- 50% of women with BV are asymptomatic
- Fishy-smelling watery grey/white vaginal discharge → key symptom to remember
- No itching, irritation, pain → if they are present could indicate an alternate cause or co-occuring infection
What are the two key investigations for bacterial vaginosis?
- Vaginal pH → raised at >4.5
- Charcoal vaginal swab for microscopy → taking during speculum examination or self-taken
- Clue cells
How is bacterial vaginosis managed?
Asymptomatic BV → treatment is not usually required
- As this is not an STI, it will not be passed on to their partner
Advise on healthy genital washing → 3 month relapse rate is high if no changes are made to this.
Metronidazole 400mg bd for 7 days:
- Given orally or by vaginal gel
- Vital that they do not drink whilst on metronidazole due to side effects
How does cervical cancer present, and what are the main differentials?
Presenting Symptoms:
- Abnormal vaginal bleeding → intermenstrual, post-coital, post-menopausal
- Vaginal discharge → blood-stained, mucoid, purulent
- Pelvic pain, dyspareunia
Speculum Examination:
- Inflammation, bleeding, ulceration, visible tumour on inspection.
Differential Diagnoses:
- Cervicitis → inflamed, friable, commonly caused by chlamydia
- Ectropion → red cervix
- Endometrial cancer → may present with abnormal vaginal bleeding
What are the different types of miscarriage?
- Threatened → vaginal bleeding with a closed cervical os & an USS confirms a viable intrauterine pregnancy.
- Inevitable → vaginal bleeding with/without abdominal cramping & open cervical os.
- Incomplete → vaginal bleeding, open cervical os, retained products of conception (RPOC) remain in the uterus after the miscarriage.
- Complete → full miscarriage has occurred, there are no RPOC left in the uterus, & cervical os is closed.
- Missed → No symptoms have occurred, but the foetus is no longer alive.
- Anembryonic → a type of missed miscarriage, where gestational sac is present, but contains no embryo.
