Obs & Gynae 3 Flashcards
Give 4 principles of care to consider when investigating + managing infertility.
- See both partners together
- Explanation + written advice
- Psychological effects of fertility problems
- relationship difficulties
- support groups
- counselling - Seen by specialist team
What initial advice should be given to couples trying to conceive?
- Inform effect of age
- Preconception advice: folic acid, smoking cessation
- Refer after 1 year -> early referral if female over 35yrs, or if there is a known / suspected problem.
List some reproductive disorders associated with obesity.
- PCOS
- Infertility
- Miscarriage
- Obstetric complications
What investigations might you request when investigating a couple for infertility?
- Ovulation / ovarian function
- Semen quality
- Tubal potency (+ uterus_
Which 3 hormones are measured in ‘Ovarian Reserve Testing’?
- FSH
- AFC (Antral Follicle Count)
- Antimullerian Hormone (AMH)
What is the diagnostic criteria for PCOS?
Rotterdam Criteria: 2 out of 3
- Anovulation / oligo/amenorrhoea
- PCOS on scan (TVS)
- Raised androgens: clinical or biochemical -> exclude adrenal cause
What treatment measures may be used for PCOS?
- Normalise weight
- Clomifene (or Tamoxifen)
(but may increase risk of ovarian cancer if used for more than 12 months) - Metformin
> less effective than clomifene alone
> less effective in obese
> may help if clomifene resistant
> GI side effects
Tubal disease may be a cause of infertility. What are the causes of tubal disease?
- Infections: Chlamydia, Gonorrhoea
- Endometriosis
- Surgical: adhesions, sterilisation
Does medical treatment of endometriosis improve the chances of pregnancy?
Medical treatment of minimal or mild endometriosis does not improve chances of pregnancy.
What are the risks of IVF?
- Multiple pregnancy
- Miscarriage
- Ectopic
- ? Fetal abnormality
- Ovarian hyperstimulation syndrome
- Egg collection = risky
- Longer term: ? Ovarian Ca.
List some patient factors affecting the success of IVF.
- Age
- Cause of infertility
- Previous pregnancies
- Duration of infertility
- Number of previous attempts
- Specific medical conditions
- Environmental factors
Increased maternal age confers increased risk on the pregnancy. Give examples of why the pregnancy is higher risk.
Increased risks of:
- Hypertension
- Diabetes
- IUGR
- Operative Delivery
- Thromboembolism
- Maternal death
What is the role of uterine abnormalities in pregnancy?
- Associations with infertility / miscarriage
- Exact role is not clear
- Abnormalities:
> adhesions
> polyps
> fibroids
> septate uterus
With regards to IVF, the chance of pregnancy decreases with 4 factors. Name these 4 factors.
- Maternal age
- Successive cycles
- Obesity
- Environmental factors (smoking, alcohol, caffeine)
At what age does breast cancer screening take place?
Females, aged 50 - 70 years
How often are women above 50yrs invited for breast screening?
3 yearly
What assessment is carried out in the fast track breast cancer clinics?
Triple Assessment:
- Physical Examination
- Mammogram (USS)
- Biopsy
What scoring system is used for each of the investigations for breast cancer, and what should you look for in the scores?
P = Physical Exam (1-5)
M = Mammogram (1-5)
B = Biopsy (1-5)
* Look for concordance in the results.
Which nodes should you check when conducting a physical examination for breast cancer?
- Axillary
- Supra-clavicular
- Sub-clavicular
List some pre-existing medical disorders in pregnancy.
- Asthma
- Epilepsy
- Hypertension
- Diabetes
- Thyroid disease
List some pregnancy-specific medical disorders seen in pregnancy.
- Pre-eclampsia / Eclampsia
- Thromboembolism
- Gestational Diabetes Mellitus (GDM)
- Obstetric Cholestasis
- Acute Fatty Liver Disease
What are the key issues regarding management of medical disorders in pregnancy?
- Be familiar with normal physiological changes of pregnancy
- Preconception assessment
- What is the effect of pregnancy on the Medical condition?
- What is the effect of the medical condition on the pregnant woman and her baby? (incl. impact of maternal medication).
Describe some steps which might be taken prior to conception to maximise the chance of a healthy pregnancy in a woman who has a disease.
- Optimise disease control
- Rationalise drug therapy to minimise effects on baby -> alter medication to drugs ‘safe’ in pregnancy
- Advise on risks to mum + baby
- Agree a plan of care -> MDT
- Effective contraception until ready to conceive.
What effect might pregnancy have on a pre-existing condition?
- May cause condition to worsen eg. mitral stenosis
- Some conditions improve in pregnancy eg. Rheumatoid Arthritis.
What effect might a pre-existing medical condition have on the health of baby + mum?
- Increased risk of pregnancy complications eg. HTN -> pre-eclampsia
- May have detrimental effects on the baby either:
i) directly: eg. teratogenic drug effects
ii) indirectly: eg. premature delivery
What considerations should be made for the delivery of a pregnancy where mum has a pre-existing conditions?
- ‘Safest’ mode of delivery
- Neonatal support
- Anaesthetic expertise
- HDU / ITU facilities
- Ongoing care postpartum -> maternal condition may initially deteriorate.
i. Which type of anaemia is most common in pregnancy? ii. Why?
iii. What are the implications of this anaemia for the baby?
i. Iron deficiency anaemia, followed by folate deficiency anaemia
ii. Pregnancy is associated with a 2-3 fold increase in requirement for iron and a 10-20 fold increase in folate requirements
iii. Iron deficiency is associated with low birthweight and preterm delivery.
Describe the physiological respiratory changes seen in pregnancy.
- Increased metabolic rate + increased oxygen consumption
- Increased minute ventilation due to increase in tidal volume
- Arterial pO2 increases; pCO2 decreases
- Mild compensated respiratory alkalosis is normal in pregnancy.
Pregnancy may exacerbate asthma. With regards to trimesters, when is this most likely to occur?
Risk of asthma exacerbation is most likely in the 3rd trimester
What are the effects of asthma on the foetus during pregnancy?
- Risk of fetal growth restriction due to inadequate placental perfusion
- Premature delivery: usually due to deterioration in maternal condition
Which drugs can be used for Asthma in pregnancy?
- Short acting b2 agonist
- Long acting b2 agonist
- Inhaled steroids
- Theophyllines
- Steroid tablets (in severe asthma)
- Leukotriene antagonist can be used
What are the physiological changes experienced by the cardiac system during pregnancy?
Cardiac output rises by 40% (mainly due to increased stroke volume)
CO = SV x HR
What considerations should you have when managing cardiac disease in a pregnant woman?
- Prediction + prevention of heart failure
- Anticoagulation -> if mechanical heart valves
- Drug therapy: may need to alter / add medication
- Monitor fetal growth and well being -> scan
- Timing and mode of delivery
- Postpartum complications -> cardiac failure
How does Obstetric Cholestasis present?
- Usually in 3rd trimester
- itchy palms of hands + soles of feet
- NO RASH *
- Abnormal LFTs:
Raised AST, ALT + Bile acid
If a woman presents with obstetric cholestasis, what are the risks to the baby? What does this risk relate to?
Risk: stillbirth, premature labour
Relates to: the level of bile acid (higher bile acid = increased risk)
What is the treatment for Obstetric Cholestasis?
What is the effect of this treatment?
- Ursodeoxycolic acid
- Appears to be associated with improved biochemical abnormalities (bile acid level + LFTs)
- treatment has not been shown to reduce fetal complications.
When does Obstetric Cholestasis tend to resolve?
After delivery.
Hyperthyroidism is uncommon during pregnancy and usually improves after the 1st trimester.
What are the - i) maternal; and ii) fetal / neonatal - risks (during pregnancy) of hyperthyroidism?
Maternal: Thyroid crisis with cardiac failure
Fetal / Neonatal: Thyrotoxicosis due to transfer of thyroid stimulating antibodies
Give an example of an anti-thyroid drugs. What complication may this drug cause?
Propylthiouracil: May cause maternal liver failure
Carbimazole: Causes fetal abnormalities
If a pregnant woman is hypothyroid + this is not treated, what is she at risk of?
- Early fetal loss
- Impaired neurodevelopment of baby
What treatment should a hypothyroid woman be given?
- Adequate replacement of thyroxine (esp. in the 1st trimester)
What is the pathophysiology of Type 1 diabetes?
Autoimmune destruction of beta cells of islets of Langerhans in the pancreas.
What is the pathophysiology of Type 2 diabetes?
- Characterised by insulin resistance
- Genetic component is stronger than for type 1
- Incidence increases with age and degree of obesity
What is the pathophysiology of gestational diabetes?
- Carbohydrate intolerance first recognised in pregnancy
- Risk of developing Type 2 Diabetes within 10 - 15 years.
How should you manage Diabetes pre-conception?
- HbA1c < 48mmol / l
- Folic acid 5mg
- Stop ACEi + Statins
- Retinal screening
- Renal function and microalbuminuria
What are the maternal complications of diabetes?
- DKA
- Hypoglycaemia (common)
- Progression of retinopathy
- Pre-eclampsia
- Premature labour
What are the fetal complications of diabetes?
- Miscarriage
- Macrosomia + shoulder dystocia
- Fetal abnormality
- Stillbirth
- Neonatal hypoglycaemia, respiratory distress, hypocalcaemia, polycycaemia
What can the fetal complications of diabetes largely be attributed to?
- Maternal hyperglycaemia
- Excessive glucose transfer across the placenta and secondary fetal hyperinsulinaemia
Which medications for diabetic control are safe to use in pregnancy?
- Insulin: basal bolus regime
- Metformin
- Glibenclamide
(All other hypoglycaemics are contraindicated) - Statins + ACEi are contraindicated
What is the change in renal output in a healthy pregnant woman?
50% increase in renal blood flow and GFR in a pregnancy with healthy kidneys.
Serum creatinine, Urate and Albumin.
Why are pregnant women more susceptible to acute pyelonephritis?
Pelvicaliceal system + ureters dilate, predisposing to ascending infection and acute pyelonephritis.
What are the maternal complications of chronic renal disease during pregnancy?
- Severe hypertension
- Deterioration in renal function
- Pre-eclampsia
- Caesarean section
What are the fetal complications of chronic renal disease during pregnancy?
- Premature delivery
- Growth restriction
- Still birth
- Abnormalities due to maternal drug therapy
What things should you consider in your risk assessment of a woman’s pre-pregnancy renal status?
- MDT care
- Close monitoring of renal function + BP during pregnancy
- Regular assessment of fetal growth and wellbeing
What are risks of epilepsy for the mother?
- Increase in seizure frequency
- Sudden Unexpected Death in Epilepsy (SUDEP)
> more common in patients who do not take their prescribed anticonvulsants
What are the risks of epilepsy for the foetus?
- Fetal abnormality
> all anticonvulsants are associated with a risk of fetal abnormalities (esp. Sodium Valproate) - Inheritance of epilepsy
- Risk of fetal hypoxia associated with maternal seizures
Describe the management of epilepsy in pregnancy.
- Preconception assessment: high folic acid
- Once pregnant: offer screening for fetal anomalies
- Control seizures
- Plan for delivery: pain relief, avoid prolonged labour
- Postpartum support
What factors increase a woman’s risk of thromboembolism during / post pregnancy?
- Maternal age
- BMI
- Operative delivery
- Haematological changes in pregnancy predispose to VTE
You suspect a pregnant woman has a VTE. What investigation should you do for:
i) DVT?
ii) PE?
i) DVT: Doppler Ultrasound
ii) PE: VQ scan (Ventilation / Perfusion scan) or CTPA
A pregnant woman has a VTE.
i) What is the treatment of choice?
ii) Why is Warfarin not used as a therapy?
i) Treatment of choice: LMWH
ii) Warfarin crosses the placenta, and may cause fetal abnormalities and intracranial bleeding.
FGM definition
“All procedures involving partial or total removal of female external genitalia or other injury to the female organs for non-medical reasons. It involves damaging and removing normal, healthy female genital tissue, and hence interferes with the natural function of girls’ and women’s bodies”
WHO categories FGM into 4 main types. What are these?
1: Clitoridectomy: partial / total removal of the clitoris
2. Excision: partial / total removal of the clitoris + labia minora ± excision of labia majora
3. Infibulation: narrowing of vaginal orifice, with creation of a covering seal by cutting + appositioning the labia minora ± labia majora with or without excision of the clitoris.
4: All other harmful procedures to female genitalia for non-medical purposes.
Why does FGM occur?
- Preserves a girl’s chastity / virginity
- Part of being a woman
- Upholds family honour
- Cleanses + purifies the girl
- Fulfils a perceived religious requirement
- Gives the girl social acceptance, especially for marriage
What is the UK prevalence of FGM?
103,000 women aged 15 - 49 are living with FGM in England + Wales
Where are the FGM ‘hotspots’ in the UK?
- London
- Cardiff
- Manchester
- Sheffield
- Birmingham
- Milton Keynes
What is the law with regards to FGM?
FGM Act, 2003:
- Offence to perform FGM in England, Wales, NI
- Assist in the carrying out of FGM
- Assist a non-UK person to carry out FGM outside the UK or a UK national or permanent UK resident
- Under the Children’s Act 1989, local authorities can apply to the court for various orders to prevent a child being taken abroad for mutilation.
List 8 gynaecological complications of FGM.
- Dyspareunia
- Sexual dysfunction with anorgasmia
- Chronic pain
- Keloid scar formation
- Dysmenorrhoea
- Urinary outflow obstruction / recurrent UTIs
- PTSD
- Difficulty conceiving
List some obstetric complications of FGM.
- Fear of childbirth
- Increased likelihood of C-section, PPH, episiotomy, severe vaginal lacerations
- Extended hospital stay
Difficulties:
- performing vaginal examinations in labour
- applying fetal scalp electrodes
- performing fetal blood sampling
- catheterising the bladder
What are our responsibilities as doctors regarding FGM?
- Report all cases of FGM in the medical notes
- Ensure that families know that FGM is illegal.
What are the 4 most common problems in paediatric gynaecology?
- Amenorrhoea
- Precocious puberty
- Delayed puberty
- Menstrual disorders
What is a ‘normal’ menarche?
- Age 11-14
- Preceded by development of secondary sexual characteristics
- Peak height velocity
- Initial cycles anovulatory: pain free and often long gaps between
- Bleeds last 3 - 7 days, 21 - 45 day gaps
What is primary amenorrhoea?
What are the possible causes?
- No menses by age 16 in the presence of secondary sexual characteristics
- No menses by age 13 in the absence of secondary sexual characteristics
Possible causes:
- Hypothalamic-Pituitary-Ovarian Axis:
- Turner’s
- Premature Ovarian Failure
- Swyer syndrome - Anatomical
- Enzyme/Receptor:
- Congenital Adrenal Hyperplasia
What is ‘secondary amenorrhoea’?
What are the possible causes?
Cessation after onset of menses.
Possible causes:
- Weight loss
- Excessive exercise
- PCOS
What is ‘oligomenorrhoea’?
Menses more than 35 days apart.
What is ‘precocious puberty’?
- Appearance of physical and hormonal signs of pubertal development at an earlier age than is considered normal
- Puberty before age 8 (girls); 9 (boys)
- Secretion of high-amplitude pulses of GnRH by the hypothalamus
What is the aetiology of ‘Central’ Precocious puberty?
- Gonadotrophin-dependent: maturation of the entire HPG axis
> spectrum of physical and hormonal changes of puberty
> may be associated with CNS abnormalities: trauma, tumours, hydrocephalus
What is the aetiology of ‘pseudo puberty’ with regards to precocious puberty?
- Gonadotrophin-independent
Possible causes:
- Congenital adrenal hyperplasia
- Adrenal tumours / ovarian tumours
- McCune-Albright syndrome
A girl presents in clinic with suspected delayed puberty. What investigations should you consider?
Baseline: - FBC - CRP - U+Es - LFTs to exclude anaemia, IBD, renal and liver disease
Bone profile:
- Alk phosp
- Coeliac antibodies
- TSH + Free T4
How might endometriosis present?
- Pain
- Increased CA125
- ?infertility
Describe the pain associated with endometriosis
- Cyclical pain
- Dysmenorrhoea
- Dyspareunia
In which patient group would you expect to see presentations of endometriosis?
- Younger women
- Low parity
What are the 2 main methods for reducing pain associated with endometriosis?
- Abolish cyclicity -> OCP, GnRH agonists
2. Glandular atrophy: Oral progestogens, Depo-Provera, Mirena
What risks might be associated with GnRH use?
Osteoporosis: give a little bit of oestrogen to lower this risk.
How is endometriosis diagnosed?
Laparoscopically
What is the management of endometriosis in secondary care?
Surgery:
- Ablation
- Excision
- Oophorectomy
- Pelvic clearance
Endometriosis and infertility are closely linked. Give some examples of how endometriosis might reduce fertility.
- Immune factors
- Oocyte toxicity
- Adhesions
- Tubal dysfunction
- Ovarian dysfunction
What population is adenomyosis usually found in?
- Older
- Multiparous
> tissue from placenta scars over + becomes painful - dull, nagging, constant pain
What pain is associated with adenomyosis?
- Cyclic pain
- Dysmenorrhoea
- Dyspareunia
- same as endometriosis!
What are fibroids?
- Benign uterine tumours
- Smooth muscle tumours
- Variable size + number
- Oestrogen dependent
What are the symptoms of uterine fibroids?
- Asymptomatic
- Heavy periods
- Anaemia
- Infertility
- Miscarriage
Summarise gynae conditions:
- Endometriosis
- Fibroids
- Adenomyosis
- Polyps
- Endometriosis:
- pain + infertility
- myomectomy for fertility preservation
- oestrogen dependent - Fibroids:
- pain + infertility + bleeding
- myomectomy for fertility preservation
- oestrogen dependent - Adenomyosis:
- Pain - Polyps:
- Bleeding + infertility
Define the ‘menopause’.
- Cessation of menstruation
- Average age: 51yrs
- Diagnosed after 12 months of amenorrhoea
- Onset of symptoms if hysterectomy
Define the ‘perimenopause’.
- Period leading up to the menopause
- Characterised by irregular periods + symptoms
eg. Hot flushes, mood swings, urogenital atrophy - if >45 years, do not measure FSH for diagnosis.
What general symptoms are characteristic of the menopause?
- Mood change / irritability
- Loss of memory / concentration
- Headaches, dry / itchy skin
- Joint pains
- Loss of confidence
- Lack of energy
Urogenital atrophy is a medium-term impact of the menopause. What symptoms accompany this?
- Dyspareunia
- Recurrent UTIs
- Post-menopausal bleeding*
- Note: this is a red flag symptoms!!!!
What are the 3 main long term impacts of the menopause?
- Osteoporosis:
- Menopause = significant RF for osteoporosis
- Effects reliably reversible with oestrogen - Cardiovascular disease:
- Adverse changes in lipid
- Increased prevalence with early menopause - Dementia:
- Increased prevalence with early menopause
*risk reduction strategies should start at the time of the menopause.
How might the menopause be managed?
- Holistic approach
- Lifestyle advice
- Reduce modifiable risk factors
- Inform about options:
> hormonal eg. HRT, vaginal oestrogen
> Non-hormonal eg. clonidine
> Non-pharmaceutical eg. CBT
List 3 benefits of using HRT for menopausal symptoms
- Relief of menopausal symptoms
- Bone mineral density protection
- Possibly prevent long term morbidity
List 4 risks of using HRT for menopausal symptoms.
- Breast cancer
- VTE
- Cardiovascular disease
- Stroke
What is the relationship between breast cancer + HRT?
- Baseline risk varies from one woman to another
- HRT with oestrogen alone: little / no change in risk
- HRT + oestrogen + progesterone: increased risk
- Increased risk is related to treatment duration and reduces after stopping HRT.
If a woman is taking HRT and diagnosed with breast cancer, what action should you take?
- Discontinue HRT in women diagnosed with Br Ca.
- Do not routinely offer HRT to women with a Hx of Br Ca.
> HRT may, in exceptional cases, be offered to women with severe menopausal symptoms and with whom the associated risks have been discussed.
What’s the association between VTE and HRT ?
- Risk of VTE is increased by HRT
- High risk women (eg. strong FHx or thrombophilia) -> refer to haematologist for assessment before starting HRT.
What’s the association between HRT and Cardiovascular disease?
- HRT does not increase CV risk when started in women <60years
- Presence of CV risk factors is not a contraindication to HRT, as long as they are optimally managed.
Which form of HRT slightly increases the risk of stroke?
Oral HRT
What is the association between HRT and T2DM?
HRT is not generally associated with an adverse effect on blood glucose control.
Oral / transdermal HRT does not increase the risk of T2DM.
What are the principles behind prescribing HRT?
- Progesterone should be used for 12-14 days every 4 weeks or every 12 weeks
- Protects the endometrium from the stimulatory effects of unopposed oestrogen
- Mirena = licensed for HRT
- Tibolone or continuous combined: not suitable within 12 months of last menstrual period
- Risk of irregular bleeding
Who should have transdermal HRT?
- Gastric upset eg. Crohn’s
- Need for steady absorption eg. Migraine / Epilepsy
- Perceived increased risk of VTE
- Older women
- Medical conditions eg. Hypertension
- Patient choice
What is ‘Premature Ovarian Insufficiency’?
- Menopause < 40 yrs
- Natural / iatrogenic
- Causes:
> Chromosome abnormalities, Enzyme deficiencies, Autoimmune disease
> Surgery / Chemotherapy / Radiotherapy
How is a diagnosis of ‘Premature Ovarian Insufficiency’ made?
FSH > 25 IU/L
2 samples > 4 weeks apart + 4 months of amenorrhoea.
What is the treatment for premature ovarian insufficiency?
- Oestrogen replacement:
- HRT
- COCP - Androgen replacement
- Testosterone gel - Fertility:
- Donor egg
What is the European Menopause + Andropause Society’s position statement regarding hormone replacement (after a diagnosis of Premature Ovarian Insufficiency)?
- To help alleviate symptoms of oestrogen deficiency
- Minimise long term risks of oestrogen deficiency
- Induce secondary sexual characteristics in adolescents
- Continue at least until average age of the menopause (51 years).
What is the consensus statement from the BMS regarding HRT after Premature ovarian insufficiency has been diagnosed?
It is imperative that women with POI are encouraged to use HRT at least until the average age of the menopause.
Is contraception required around the time of the menopause?
Yes!
Fertile for 2 years if menopause < 50 years.
Fertile for 1 year if menopause > 50 years.
Which dose of oestrogen should you give for HRT?
Aim for the lowest effective dose.
* oestrogen should never be unopposed in a woman who has her uterus in situ *
