Obs & Gynae Flashcards
Uterine causes of abnormal bleeding
Endometrial cancer (PMB)
Fibroid (menorrhagia)
Polyps
Endometriosis
Adenomyosis
(painful, cyclical)
PID
(discharge, pain +/- fever)
Causes of abnormal mestruation
Reproductive tract:
- pregnancy related
- uterine lesions
- cervical lesions
- iatrogenic
Systemic:
- coagualopathy
- hypothyroidism
- cirrhosis
Dysfunctional uterine bleeding (DUB)
Cervical causes of abnormal bleeding
Generally present with PCB
- erosion (aka ectropion)
- trauma
- cervicitis (more likely discharge)
- polyp
- cancer
Pregnancy related causes of abnormal bleeding
hCG is first line investigation of abnormal bleeding
Miscarriage (irregular, IMB)
- cramping pain
Ectopic (irregular, IMB)
- severe pain and tenderness
Gestational trophoblastic disease
Implantation bleeding (spotting)
Investigation of abnormal vaginal bleeding
Bloods
- anaemia?
- clotting probs?
- TFT
Pregnancy test
VE
- lower genital tract / cervical lesion?
- swab
TV TA US
- growth in uterus?
- if > 4mm inc thickness do hysteroscopy and biopsy
Menorrhagia differentials
DFPTC
DUB (no organic pathology) Fibroids Polyp Thyroid Clot: von Willebrand's
(IMB: cancer, pregnancy, contracep; PCB: cervix; PMB: A.V., cancer; pain: endometriosis)
What to ask about in menorrhagia history
Cycle pattern (duration of bleed) Number towels/tampons used per day Other bleeding (IMB, PCB) Impact on lifestyle Duration of problem
Other symptoms, especially: Dysparenunia Pain Bleeding from other sites Discharge Thyroid sx
Obstetrics Contraceptive history Smear PGH (inc surgery) Sexual history
Drugs
Smoking
Investigations menorrhagia
Abdominal and bimanual pelvic exam
FBC to assess need iron
TFT to see if hypothyroid
Consider clotting studies
If suspect cancer or fail to respond to treatment after 3 months:
- TV TA US (more than 4mm growth)
- endometrial biopsy with hysteroscopy if USS abnormal
Management of menorrhagia
No structural probs (or only small fibroids): medical
- Marena IUD
- COCP
- Tranexamic acid
- pro uterine haemostasis (antifibrinolytic)
- Mefenamic acid (if pain)
- nsaid (anti prostoglandin)
Structural problems present: Surgery
- GnRH agonist prior to surgery (need ‘add back’ hormones if >6month)
- ablation
- embolisation (fibroid)
- myomectomy (fibroid)
- hysterectomy
Fibroids
intramural (70%), subserosal, submucosal
Affect 20% by 40yrs - reproductive years Mainly asymptomatic Presentation - menorrhagia - pelvic mass/bloating - infertility - urinary Sx - frequency, retention - dystocia in labour Red degeneration in pregnancy - pain fever vomiting
Management of fibroids
Surgery: hysterectomy, myomectomy, uterine artery embolisation
Medical: GnRH agonists
Treatment menorrhagia compatible w conception
Antifibrinolytics- eg tranexamic acid.
- CI thromboembolytic disease
NSAID (anti prostaglandins) - mefenamic acid.
- helpful if dysmenorrhea also.
- CI peptic ulcers
Both taken during bleeding
Treat menorrhagia with no poss of conception
Danazol
- expensive and effective however
- associated with androgenic side effects,
- inhibits ovulation but unreliably so not lisenced as contraceptive
COCP
- effective, CI in some women
Mirena coil
- very effective, reduce fibroid volume, similar satisfaction ratings to hysterectomy
- SE: irregular menses for first 3-6 months after insertion
Surgical treatment- if family complete.
- endometrial resection by laser, diathermy, ablation
- embolisation of fibroid
- hysterectomy
Primary amenorrhoea details
Absence of menstruation by 16 years
1-2%
Familial?
Hypothalamic dysfunction (stress, wt, exercise) 30%
- low FSH
- T: the Pill
Gonadal failure: Turner’s Syndrome (45 xo) 35%
- high FSH
- streak gonads (fibrous tissue instead of ovary)
- no breast development
- T: the Pill
Anatomical outflow obstruction
- vaginal agenesis
- imperforate hymen
- transverse vaginal septum
Testicular feminization syndrome
- 46 XY (genetically male) but insensitive to androgens
- so male genitalia never develops (testes never descend)
- female phenotype
Causes primary amenorrhoea
Familial late puberty
Hypothalamic
- stress, exercise, weight loss
Has she got normal external secondary sexual characteristics?
Are internal genitalia normal?
Turners syndrome
- Webbed neck, shield chest, short, cubitus valgus
Testicular feminization
Reproductive outflow tract disorders
- imperforate hymen
Causes secondary amenorrhoea
Pregnancy
Hypothalamic
- exercise, weight loss, stress,
Pituitary disorders
- adenomas eg prolactinoma,
- pituitary necrosis eg Sheehan’s syndrome (rare)
Ovarian causes
- PCOS (US:cysts, high LH, low FSH)
- tumours
- ovarian failure (premature menopause)
Secondary amenorrhoea details
Absence of menstruation for >6months after prev regular cycles
Pregnancy
Hypothalamic 35%
- stress, weight, exercise
- treat with the Pill to increase oestrogen
PCOS 30%
- low FSH, high LH
- assoc w obesity, hirsuitism, acne, infertility
- treat with the Pill to increase suppress LH, raise oestrogen
—–with these two causes you get withdrawal bleed after a week of progestin, showing normal uterine lining (unless severe hypothalamic dysfunction)
Pituitary disease
- tumour or apoplexy causing low Gn’s
- prolactin (macroadenoma)
- Sheehan’s
Premature ovarian failure (like menopause)
- FSH levels high
- HRT
Secondary amenorrhoea - history
Full menstrual history
- menarche
- normal cycle, previous probs
Could you be pregnant?
- sexually active?
- contraception (progesterone can cause amenorrhea)
Noticed weight loss or gain?
- intentional?
Tumour symptoms (galactorrhoe, headache)
PCOS symptoms
- hair growth, acne, weight gain
Stress, emotional issues
Rest of gynae history
- family history of gynae probs
- prev gynae history
- smear
- obstetric
- drugs
- smoking
Amenorrhoea investigations
Pregnancy test
Serum LH + testosterone (increased in PCOS)
FSH (very high in premature menopause)
Prolactin (increased by stress, prolactinomas, some drugs)
can give progesterone withdrawal test if further investigation required
Causes dysmenorrhoea and pelvic pain
Primary Endometriosis/adenomyosis Fibroids (menorr) PID Ovarian disease
Primary painful periods
- no organic pathology
- excessive prostaglandins > painful uterine contractions
- ‘pelvic congestion’
- manage in primary care - mefenemic acid
Not settled? > Secondary
US may show:
- fibroids
- adenomyosis
- ovarian cyst
Infection screen
- PID
Finally, laparoscopy may be needed to find
- endometriosis
Treatment dysmenorrhoea
NSAIDs- mefenamic acid, naproxen, ibuprofen (vs prostaglandin synthesis)
COCP
Mirena coil
Ovarian cyst and torsion presentation
intermittent, unilateral dull ache
w/ intercourse
torsion:
sudden unilateral lower abdo pain
may be brought on by exercise
w/ nausea and vom
ovarian cyst types
physiological cysts - common in reprod age
- follicular (common)
- corpus luteum
benign tumours
germ line - dermoid cyst = teratoma
- common under 30 yrs
epithelial - serous or mucinous cystadenoma
stromal - fibroma
(Meigs = fibroma + ascites + pl eff)
Causes postcoital bleeding
Cervical
- trauma
- polyps
- carcinoma
- cervicitis (w discharge)
- erosion
Vaginal cancer/infection
Features of polycystic ovarian syndrome (PCOS)
- Hypo-androgenism, oligo-ovulation, polycystic ovaries
- Acne, hirsutism, obesity >40% clinically obese
- Acanthosis nigricans (darkened skin on neck, skin flexures)
- Oligomenorrhoea/amenorrhoea -from anovulation
Subfertility (75% difficulty conceiving)
Recurrent miscarriage
Long term risks PCOS
Ovarian and endometrial cancer risk
- unopposed oestrogen
Diabetes, especially if also obese
MI, stroke, IHD
Hypertension
Diagnosis PCOS
Diagnosis of exclusion Usually have increased LH:FSH Increased testosterone Increased fasting insulin 5 or more ovarian follicles on USS
Treatment PCOS
Detect + treat diabetes, hypertension, hyperlipidaemia
Encourage weight loss + exercise
Clomifene if trying to conceive (induces ovulation)
Combined pill if not trying to conceive- will control bleeding + reduce risk of unopposed oestrogen on endometrium (risk endometrial carcinoma)
Treat hirsutism with cyproterone acetate (androgen receptor antagonist)- in Dianette COCP
Causes postmenopausal bleeding
Endometrial carcinoma (PMB is endometrial carcinoma until proven otherwise) - unopposed estrogen?
Endometrial hyperplasia, or polyps
Cervical malignancy
- esp post- coital
Atrophic vaginitis
- spotting
- assoc w dryness, dyspareunia
Investigations postmenopausal bleeding
Full Hx, pelvic exam, cervical smear
USS- if endometrial thickness <3mm endometrial carcinoma risk is low
if >3mm (or 5mm if on HRT) – endometrial biopsy with/without hysteroscopy
Endometrial cancer presentation
Generally post menopausal women (75%, with 20% between 40yrs and menopause)
PMB (= endometrial cancer until proved otherwise)
- initially slight, infrequent
75% present at stage one - confined to uterus
Pain/discomfort is late feature
Premenopausal women get IMB or irregular periods
Endometrial cancer risk factors
Nulliparous/low parity
Late menopause
(COCP is protective)
FH - ovarian/breast/colon
Diabetes
PCOS
Obesity
Endometrial hyperplasia
Endometrial cancer prognosis
If confined to uterus (stage 1) = 80% 5 year survival
Endometrial hyperplasia
Due to prolonged unopposed oestrogen stimulation
With or without ‘cytological atypia’
- without is benign, with has 20% risk of progression
Presentation: abnormal uterine bleeding (esp PMB)
Bacterial vaginosis
Non puritic
Fishy white/grey vaginal discharge - homogenous
Discharge will raise ph of vagina >4.5
Clue cells
If pregnant - risk of prem labour/miscarriage
Treatment bacterial vaginosis
Metronidazole 400mg bd 7 days
Candidiasis
Intense puritis
Vulvovaginal erythema
Non smelly thick ‘cottage cheese’ like discharge
pH<4.5
Treatment candidiasis
Topical clotrimazole or oral fluconazole
Trichomoniasis
Protozoan infection - seen on wet film (not hvs)
Std
Profuse smelly discharge - green/yellow
May get post coital bleeding
Strawberry cervix (red petechiae), erythema
pH>4.5
Treatment trichimoiasis
Metronidazole 400bd 7days
Gonorrhoea
Profuse odourless creamy discharge
Non irritating
diplococcus
Can progress to acute salpingitis or disseminated infection - fever, pelvic pain..
Treatment gonorrhoea
Ceftriaxone 500mg im and 1g azithro
Or cefixime 400mg po and 1g azithro
(Single doses)
Chlamydia
Most common std Often asymptomatic Purulent mucoid discharge Pcb Vaginitis
In pregnancy - risk of neonatal conjunctivitis
Diag - endocervical swab
Treatment chlamydia
Oral doxycycline 100mg bd 7 days
or azithromycin 1g (single dose)
partner notification last 6 months (treat then test)
-unless symptomatic man: last 4 weeks
Genital warts
Caused by hpv (usually 6, 11)
Warts may be dotted about or confluent
Treatment genital warts
Cryotherapy
Syphilis
Systemic disease
Painless solitary genital ulcer plus rash
Treatment syphilis
IM benzathine penicillin
Genital herpes
Herpes simplex virus type 1 or 2 (most type 2)
Genital ulcers
Burning pain and puritis
Latent and active phases
Treatment genital herpes
Acyclovir
STI counselling
Ask about sexual partners - need to contact
Talk about risk of PID and long term sequelae
Risk of TOA (tubuloovarian abcess)
Unopposed oestrogen
Obesity
- due to conversion of androgens
Tamoxifen
- has oestrogenic effect on uterus
PCOS
Oestrogen HRT (without progestins)
Uterine sarcoma
5% of uterine cancers
Rare, aggressive
Cervical cancer: risk & epidemiology
Sexually active women
Mean age 52 years
Higher risk: early first coitus, numerous partners.
HPV is causative agent in majority of cases (16,18,39)
SMOKING
Cervical cancer screening
25 to 49 (every 3 years)
50 to 64 (every 5 years)
Look for dyskaryosis or CIN (abnormal cells)
Refer for colposcopy +/- biopsy
HPV and cervical cancer
Look out for symptoms
- irreg bleeding (especially post coital), pain, discomfort
Prevention: 2 measures
- vaccinate vs HPV (6,11,16,18)
- screen all women from 25 (earlier too many false positives)
Cervical intraepithelial neoplasia - CIN
Precursor to cancer Starts at transitional zone Detected on Pap smear film Stage 1 - 3 Refer for colposcopy and biopsy
CIN treatment
BORDELINE
- repeat smear in 6 months
- or test sample for hpv 16,18,39
DYSKARIOSIS
Loop electrosurgical excision procedure (LEEP)
- removes affected tissue
Cryotherapy/ ablation may also be used to destroy lesion
Cervical cancer stages
1: Confined to cervix
Treatment: biopsy/excision, simple hysterectomy
2: surrounding
T: radical hysterect
3: further local inv to lower vag/pelvis
T: chemoradio
4: bladder, rectum, mets
Palliative
Ovarian cancer: risk and protective factors
Mean age 60
Risk:
- FAMILY HISTORY
- low parity
Protective:
- multiparous
- breast feeding
- COCP
Presentation of ovarian cancer
75% present late (stages 3/4)
- already peritoneal spread
Highest mortality for gynae-oncology
Abdominal distension ‘bloating’
Feeling full/ loss of appetite
Urinary symptoms
Ascites or mass on examination
Do serum CA125 levels
Do TV TA US
Hereditary link in ovarian cancer
5-10% have hereditary link
If 2 relatives (1st or 2nd degree) have had ovarian cancer or pre-menopausal breast cancer: REFER for genetic counselling
Associated with BRCA 1 and BRCA 2 mutations
Offer prophylactic BSO (at 35 or once family finished)
- reduces risk of both ovarian and breast ca
Management of ovarian cancer
Surgery
- TAH, BSO
- exploratory laparotomy
- peritoneal wash/biopsy
- lymph nodes
- omentectomy
Chemo: Carboplatin
Surveillance: CA125
80% relapse: second chemo or palliation
Vulval cancer
5% of gynae cancers
Mean age 65
Risk: poor personal hygiene
Present: pruritis, lump, 70% labia major
Refer for biopsy
Can also get VIN (precancerous), melanoma and pagets disease
Vaginal cancer
Very rare as primary
Secondary to cervical is most common form
Radiotherapy
Gestational trophoblastic disease
Hydatidiform moles
- complete
- partial
Gestational trophoblastic neoplasia
- choriocarcinoma
- placental-site trophoblastic tumour
Hydatidiform moles
“Abnormal form of pregnancy, with implantation of non-viable fertilised egg, resulting in growth of a mass from the placenta which may or may not contain fetal tissue”
Risk
- maternal age > 35
- prior GTD
- long term Pill
Partial vs complete hydatidiform moles
Partial
- growth contain malformed fetal tissue
- leads to missed abortion by 10-15 weeks - needs evacuation
- hCG normal or marginally raised
Complete (more common)
- from fertilized ovum containing no DNA
- no fetal tissue (just grape-like vesicles)
- presents with abnormal bleeding
- may get anaemia, hyperemesis, preeclampsia (irritable, htn, dizzy)
- hCG++, enlarged uterus
Hydatidiform mole mx
FBC - anaemia?
Clotting - look out for DIC
CXR - look out for trophoblastic emboli
Cross match blood
Under GA - evacuate by dilation, suction & curettage (w oxytocin vs blood loss)
Anti D if needed
Then monitor hcg for up to 2 years to ensure return to norm
Emergency contraception
Levonorgestrel pill within 72 hours
Or IUD within 5 days
- still 99.9% effective
Follow up in 3 weeks
COCP
Take on first day of cycle: 3 weeks active, 1 week placebo (or no pill) - bleed
Can back-to-back to control timing of bleed
If miss a day, take when remember
If miss 2+ days - use condoms for 7 days
- use condoms anyway vs STI
Prevents ovulation, thin lining, thicken mucus
Pros
- over 99% effective
- protect vs colon, ovarian, endometrial cancer
- help vs painful, heavy periods
- can help vs acne
Pill contraindications
Breast feeding (or 6 weeks postpartum)
FH or PH breast cancer, VTE, migraine
Smoker over 40
Pill pros and cons
Cons
- compliance
- contraindications
Pros
- safe effective
- acne
- periods
- cancer
vs COCP
Pros
- over 99% effective
- protect vs colon, ovarian, endometrial cancer
- help vs painful, heavy periods
- can help vs acne
Cons
- must take daily
- breast cancer risk (and cervical)
- SE: headaches, mood, breast tender, nausea
(can change type of pill for less oestrogenic effects)
- HTN
Contraindications
- breast feeding
- migraine w aura
- thromboembolic disease (stroke/ihd)
- FH breast cancer
- smoker over 35 (compounds arterial risk)
- htn
“Mini Pill”
cerazette
Progesterone only
Creates mucus plug in cervix
Less effective than COCP (still around 99%)
Take at same time each day (or within 12hr window). No break for bleed.
If miss 12hour window use condoms for 48hrs
Use if COCP doesn’t suit or is contraindicated
Commonly periods can be irregular/unpredictable - spotting (1/3 none/light, 1/3 same, 1/3 heavier)
Also breast tenderness, libido change, acne
Implant
Subdermal implant
3 (implanon) or 5 years (norplant)
Prevents ovulation
One of most effective
Irregular or no periods
Uncomfortable removal
Delay in return to normal
Mini pill pros and cons
Pros
- no contraindications
Cons
- compliance
- irregular bleeding
- breast tender, acne, mood
Depo-injection
IM injection every 12weeks
Slow release progesterone
Prevents ovulation
One of most effective
Irregular vaginal bleeding (1/3)
Amenorrhoea (1/3)
Osteoporotic link - avoid if pre-existing, and in adolescents
SE: Weight gain, reduced libido
Can take a while (up to 12 months) to return to normal cycle
Injections or implants pros and cons
Pros
- v v effective
- compliance easy
Cons
- irregular bleeding
- delay in return to normal fertility
Condoms
93% effective
Protect vs STI’s
Mirena IUD
Long term but reversible
Hormone release in uterus - vs implantation
Risk of infection, perforation
- swabs before
Helps vs heavy, painful periods
Mirena pros and cons
Pros
- extremely effective
- long term easy compliance
- periods
- no delay to fertility
Cons
- small procedural risk - swabs before
- ectopic (tiny)
Intra-uterine coil
5 or 10 years
Prevents fertilisation and implantation
Reversible - can remove at any point
Risk of introducing infection to uterus
Risk of perforation
Can get heavy, painful periods
Sterilisation
Consider as irreversible
- must have finished family
Male more effective than female
Vasectomy - takes up to 12 to be fully effective - need two consecutive blank samples
Sterilisation
Female
- surgery - laparoscopy
- ectopic
- less effective than mirena
Male
- very effective
- day case
- risk pain, swelling, infection
- 12 weeks to work - take semen samples
Infertility
Sperm (25% - 40%)
Tubules - PID, surgery
Endometriosis
Amen causes
- hypothal
- pcos
- ov fail (early menop)
- pituitary
Cause often unknown
Common minor problems to expect in pregnancy
70% get morning sickness Reflux Urinary frequency Lower back pain Candida vaginalis Constipation
Haematological changes in pregnancy
Plasma volume up 40%
No. of RBC’s up 20% (more if take iron supplement)
But overall, HCT falls (haemodilution)
Increase in clotting
CV and respiratory changes in pregnancy
CO up 40%
BP falls initially then returns to normal later
Increase in tidal volume
Renal changes in pregnancy
50% increase GFR
Decrease in serum creatinine/urea
Glycosuria common (does not mean diabetes)
Insulin in pregnancy
Insulin resistance due to placental hormones
Should increase production to prevent hyperglycaemia
Antenatal counselling
Any concerns?
Obstetric Hx
Health probs and FH
Smoking and drinking
Early advice
- folic acid
- lifestyle - smoking and drinking
- Vit D
- avoid certain foods
Appointments < 10 Hb variants 8-12 - HIV, hep B (transmit) - syphillis, rubella (disable) - rh and blood group 10-14 and 16 Down's screening 18-20 Fetal anomaly
Nutrition in pregnancy
Avoid uncooked meat/fish/eggs - toxoplasmosis (also cat litter) Avoid soft cheese - listeria Avoid alcohol (no clear safe level) Supplements - folic acid, Vit D, iron(?)
Folic acid
All should take 400 micrograms daily when trying to conceive and up to 12 weeks.
Higher dose of 5mg if diabetic, coeliac, obese, previous neural tube defects
Alcohol in pregnancy
Developmental delay Behaviour problems Growth retardation Learning difficulties Facies
Smoking in pregnancy
Small baby
- infection and trauma
Miscarriage
Still birth
SIDS
Respiratory probs eg. Asthma
Problems with diabetes in pregnancy
Mum
- HTN/preeclampsia
- UTI
- future DM
MISCARRIAGE
Risk of deformities - detailed scan
Big baby/sac
- preterm
- difficult labour
Neonatal
- hypoglycaemia
- RDS
Assessment of miscarriage
LMP, normal cycle, other bleeds
Amount of bleeding
- heavy suggests incomplete
- minimal brown loss - missed?
Pain
- minimal pain in threatened
- severe pain, preceding bleed more chac of ectopic
- shoulder tip pain? Ectopic
Examine
- cv status - shock?
- abdo exam (v tender in ectopic)
- VE: cervical excitation? Cervix open?
Causes of bleed in early pregnancy
Ectopic
Miscarriage
Lower genital tract lesion
Implantation bleed
Types of miscarriage
Nb pain precedes bleeding - ectopic more likely
Threatened
- bleeding but cervix close and poc remain
- 25% progress to inevitable
Inevitable
- dilated cervix
- considerable bleeding
- abdo pain
- passed products (complete or incomplete)
Incomplete
- some products retained despite inevitable miscarriage
- need evacuation
- US shows whether products retained
Missed (later on than threatened)
- fetal death but remains in utero
- no/little bleeding
- closed cervix
- small uterus for age
- fetal heart/movements absent
Complications of miscarriage
Bleed
Infection
Psycho
Rhesus sensitivity
Miscarriage management
US
Pregnancy test
90% have surgical evacuation for retained products
- prevent risk of infection and continued bleeding
Expectant management can be considered
- esp with incomplete
- should have 24 hour access
- follow up scan (2 weeks)
Medical miscarriage
- misoprostol and mifepristone
- inc pain and bleeding
Surgical
- STI swab first
- suction curettage
Causes of antenatal haemorrhage (post 24 weeks)
Lower genital tract lesion (polyps/erosion) Early labour Placenta previa (20%) Placental abruption (30%) Vasa previa (rare)
Ectopic
Period of ammenorhea (often about 6 weeks)
Onset of pain and bleeding
+/- vomitting
O/e
- lower abdo tender, peritonism?
- adenexa tender (+ mass?),
- cervical excitation
- -> check bp stable
Serial hcg measures
- raised but not doubling within 48hrs (as in norm preg)
TV TA US
- locate mass?
- up to half cannot = preg of unknown location
Mx laparotomy
Anti d if rh negative
Risk: pid, prev ectopic, prev abortion, tubal surgery
Consequences - red fertility
Complications of diabetes in pregnancy
Maternal HTN/preeclampsia (mainly assoc w/ pre gestational diabetes)
- risk of having sustained diabetes
Fetal - macrosomia (injury/caesarean)
- congenital abnormalities 2-3 x risk (esp cardiac, cns, skeletal)
- spontaneous abortion
- premature delivery
- neonatal hypoglycaemia
Gestational diabetes
screening if
- obese
- prev big baby
- prev gdm, fh dm
- ethnic - black/asian
Ix: ogtt around 24 weeks
(earlier if prev gdm 16w)
management
- diet and exercise sufficient
- metformin if nec
- check bp and proteinuria closely
- check BM 6 weeks post partum
Diagnosis of gestational diabetes
24-28 weeks
Fasting glucose > 7mmol/L
Glucose tolerance test >11.1mmol/L
Management of diabetes in pregnancy
Preconception
- folic acid 5mg
- tight control
- eyes and kidney checks
DISH Non-drug - weight, diet, exercise Insulin (metformin also allowed) Regular blood glucose monitoring - plus antenatal monitoring of renal function and retinopathy Glucagon for hypos - may be masked
Detailed anomaly scan around 18 weeks
Offer caesarean/induction at 38 weeks
Sliding scale and dextrose intrapartum
Feed baby asap (and do BM)
Follow up
GDM screening
Obese
Previous macrosomic baby or GDM
FH DM
Ethnicity
24-28 weeks OGTT
OGTT > 11.1
Random > 7
New onset
Diagnosis of pre-eclampsia
After 20 weeks
New onset HTN (>140/90)
New proteinuria (>300mg over 24hrs)
+/- non-dependant oedema (hand/face swelling)
Presentation
- headache
- alter vision
- peripheral oedema
Management of pre-eclampsia
Prophylactic Aspirin if high risk
Monitor BP, proteinuria regularly
1) BP control
- labetalol
- ! avoid ACE-i and diuretics
2) Delivery
- If mild wait, expectant management (ie wait until 35 weeks)
- If any ‘severe’ symptoms deliver baby asap (generally caesarean)
Management of eclampsia
Magnesium Sulphate (monitor for toxicity - resp rate, reflexes) Treat concurrent HTN
Features of ‘severe’ pre-eclampsia
Headache / blurred vision RUQ pain BP > 160/110 HELLP Pulmonary oedema Seizures (eclampsia) IUGR (fetus)
Strong risk factors for pre-eclampsia
HTN in previous pregnancy Chronic kidney disease Autoimmune disease (SLE, antiphospholipid syndrome etc) Diabetes (1 or 2) Chronic HTN ---> offer low dose aspirin to prevent
mod: Nulliparous African Young or old First time/short time with partner Family history
Serious complications of pre-eclampsia
Eclampsia + cerebral haemorrhage HELLP DIC Placental abruption (with severe haemorrhage due to thrombocytopenia) Still birth
Miscarriage
Fetal loss before 24 weeks (majority before 13)
10 - 20 % of pregnancies affected
Majority not known about - within 2 weeks
Bleeding (heavier more clots than normal menses)
Cramping pain
Placenta previa
Painless bleed soft uterus
1-4 stages (proximity/occlusion of os)
Do not examine
US
Admit from 34 weeks
Deliver by caesarean from 37
Risk of PPH
Placenta previa
Painless vaginal bleeding
Soft, non-tender uterus
Major: complete, partial
Minor: marginal, low-lying
If seen on US in early preg, 90% resolve by 32 weeks
Placental abruption
Separation of placenta from uterine wall
80% revealed 20% concealed
Abdominal pain (+/- back ache)
Uterine hardness and tenderness
Vaginal bleeding
Fetal distress
Risk factors for placenta previa
Multiparous/older mum
Smoking
Previous previa
Previous caesarean
Management of placenta previa
If suspected (painless bleed) do not do VE unless excluded by US
If confirmed, monitor up to 34 weeks then admit
Mostly deliver by caesarean at 38 weeks
Earlier delivery if fetal distress or major hemorrhage
Need cross matched blood - high risk of PPH
Abruption
Pain bleed hard tender uterus
Fetal distress
Mx - stabilise w blood
Baby - US and deliver
Risk: HTN, smoke, coke, trauma
- anomaly, old, multp,previous
Breech
3-4%
Frank (bum first legs by ears)
complete (cross legged)
footling
US
Risk
- prem, previous, pp, polyhyd.
- multiparous, multiple preg
- abnormal uterus, fetus
Complications
- prem
- cord prolapse
- fetal and maternal injury
Breech management
37 weeks exteral cephalic version
- w epidural, tocolytic, US fetal monitoring
Diff if twins, fibroids
Risk membranes>labour,
- abruption, fetal distress
50-70% success
Or delivery by caesarean
PPH
Atonic
- risk twins, macro, poly
- prevented by giving oxytocin injection
Coagualopathy
Accreta
Retained
Risk factor for abruption
HTN Trauma Smoking Cocaine Uterine anomaly (eg fibroid) Multiparous/older mum Previous abruption
Management of placental abruption
Bloods from mum
- assess clotting (risk of DIC)
- do crossmatch
Volume replacement - fluid, blood, FFP
US and fetal heart trace (CTG)
- if distress: caesarean
- no distress: monitor until 36 weeks, steroids (for fetal lungs)
Distocia
Power
- atonic
Passenger and passage
- cephalopelvic disproportion
- malpresentation
Mx
- syntometrin (oxytocin + ergometrin)
- position of mum
- caesarean
Cord prolapse
Fetal brady
Pulsatile cord palpable
Emergency
- replace cord manually
- caesarean
Risk- previous, malpres, pmature
Shoulder dystocia
Injury
- fractures of clavicle humerus skull
- neurological ie brachial plexus (c5-c8,t1)
- erbs palsy (5% permanent) ‘waiter tip’
Home delivery
Personal importance of labour
Control, relaxation, familiarity, less medicalised
3% of births nationally
Eligibility in discussion with consultant (no national guidelines)
CAPO
- conception probs?
- age?
- problems in pregnancy (bleed, breech, HTN, GDM)
- obstetric history (not good idea for first baby)
Downs screening
RISK
11-14 weeks Nuchal translucency
16 weeks Blood tests
Maternal age
DIAGNOSIS
Amniocentesis
- 1% miscarriage
DOWNS
- LD
- short
- heart defects
- duod atres
- facies
- hearing and vision
- coeliac, epilepsy, thyroid, leuk, dem
Breast feeding
Bond with baby
Baby’s health
- infection
- brain devel and growth
- less atopy
Cheap and convenient
Difficulties
- can be hard
- can be sore
Antenatal advice
First feed straight after delivery and on demand for first few days
Mum needs nutrition and rest
150ml per kg per day
4-6months weaning onto purée etc
6 months meals of finger food
12 chopped up proper food, proper milk
Mastitis
Erythema, hot, tender
Feel unwell
Continue breast feeding
- if ducts block can get spasmodic shooting pains
Can be complicated by abscess
T: augmentin
Massage, hot bath, cold cabbage leaves
Toxoplasmosis
Undercooked meat
Cat faeces
Mum gets general Sx - fatigue, myalgia, lymphadenopathy
Neonate gets chorioretinitis, seizures, organomegaly
Rubella
Antenatal screening is routine (for susceptibility)
Mum gets mild viral illness (inc rash, conjunctivitis, coryzal, lymphad)
Neonate gets mental defects, deafness, cataracts, heart defects
Herpes simplex
Mum gets systemic symptoms and genital lesion -which recurs after latent periods
Neonate gets skin/mouth lesions, possible sepsis, possible neurological probs (acute and long term)
Listeriosis
Causes neonatal sepsis
Mum gets flu-like illness
Soft cheeses
chickenpox exposure in pregnancy
first step: check varicella antibodies
if not immune give VZIg
if present with rash - give oral aciclovir
aim to prevent fetal varicella syndrome - skin, eye, neuro
Menopause
What?
Est/Prog levels fall
Egg production stops
Periods stop
Transition 2 years but variable
80% symptoms
50% disruptive
Transition changes
- irratic periods
- hot flushes
- night sweats
- sleep disturb
- mood
Long term changes
- osteoporosis
- skin/join tab
- urogenital
- dryness, dyspar, UTI, incont
urogenital prolaps
chronic pelvic pain seen in older women
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency
HRT
To help ease transition - generally only started now if early onset <45
- protects vs osteoporosis
Not for long term
- risk of breast cancer, stroke/CVD, clotting
- check for breast lumps
No uterus - estrogen only
Uterus - estrogen and progesterone (cont or cyclical)
Vasomotor - systemic (can use non hormonal first line - clomidene)
Urogenital - topical (gel, pessary)
Unopposed oestrogen
Obesity
- due to conversion of androgens
Tamoxifen
- has oestrogenic effect on uterus
PCOS
Oestrogen HRT (without progestins)
What to ask in history?
Obstetrics Any menstrual problems? Current contraception? Problems? Sexual history? - infections - partner
Family history of breast cancer?
Thromboembolic disease?
Liver disease?
Plans for future pregnancy - how soon?
Lifestyle - regular? hectic?
Hormone pill to temporarily stop periods if erratic
Norethisterone
- high levels of progesterone
- use if wedding holiday etc
puerperal pyrexia
temp >38 w/in 2 weeks of childbirth
usually due to endometritis
admit for iv abx
