Obs + Gynae Flashcards
what is the management of PPROM at 30 weeks
The patient is 30 weeks pregnant and therefore it is better to prolong the gestation as much as possible. Referral/discussion with obstetrics registrar/consultant. · Initial mx: admit patient for observations for 24 hours (due to increased chance of going into labour) observations to look for ?infection, bloods such as FBC + CRP for infection – monitor for signs of chorioamnionitis, advise patient to avoid sexual intercourse and watch out for signs of infection e.g. take temperature everyday ·
Medical management: o Prophylactic erythromycin 250 mg QDS for 10 days
Corticosteroids
Aim expectant management until 34 weeks
MgSO4 - neuro protective for baby?
Advice against sex due to infection risk
PROM mx
CTG
speculum - clear liquor in fluid
reassure mum
If contractions - deliver
risk factors for placental abruption
smoking old cocaine pre-eclampsia multiparity trauma
how do you investigate abruption
abdo US to rule out placenta praevia first
clotting studies for DIC
CTG
Avoid vaginal exam
mx of abruption
A-E Counsel mum - keep calm haem stable Hb - blood not fluid - tx hypovolaemia O2 Hb above 100 Monitor UO Transexamic acid? Stable IV access CTG BDZ <36 weeks anti-D foetus in distress - C/S Maintain BP during C/S no foetal distress can induce for vaginal delivery if both stable Risk of DIC Baby dead induce and deliver vaginally
IM oxytocin following C/S
eczema
lichenification
ecsorations
hypo and hyper pigmentation
eczema managemnet
psych - stress improve it
food allergies in kids = control ]
bathing showers better than baths
soap free cleanser
avoid wool and synthetic fibre
protect skin from dust and detergent
stress reduction
avoid scratching
mittens
emollients first line - big quantities, after bath, thick layer, 30 mins before steroids
Prescribe in pumps not pots - stop dipping fingers in
topical steroids - lowest strength possible
antihistamines at night - warn about sedation
tx secondary infecton - fluclox
immunosuppresant is las line
what are the differentials for PAD?
spinal stenosis arthritis venous claudication smptomatic baker cyst venous insufficiency DVT nerve root compression
what ix should you do in pAD
Ankle brachial plexus
gold standard test for diagnosis = CT angiogram
doppler
whta is the management of chronic pad?
aggressive risk factor modification including BP, lipids, dm and smoking cessation
advice mild to moderate cases to keep walking to improve sx and may have a structured exercise programme
antiplatelet therapy recommended to all
annual follow up visits to monitor coronary, cerebrovascualr and leg ischaemic sx
symptomatic relief can be given with vasodilators such as Naftidrofuryl
referral to vasc surgery for revsacularisation if critical - monitor patency long term
what is the mx of acute limb ischameia
medical emergency - any decrease in limb perfusion urgent hx and exam urgent referal to vascular surgery emergency ABPI or duplex US once diagnosis made - systemic anticoag unless contra - pain relief - paracetamol and opoid if non viable limb = amputation if viable limb - revascularisation e.g. percutanoeus catheter directed thrombolytic therapy
what are the differentials for psoraisis
lichen planus eczema SLE pityriasis rosea seborrheic dermatitis
what is the mx of psorasis
the aim of therapy is to gain control of the disease process and achieve/maintain remission. And aim to achieve no impact on QoL.
topical tx are mainstay of tx - creams, ointments and lotions if limited start with topical corticosteroids and/or Vit D analogue (calcipotriol).
Topical tars and dithranol are no longer used as much
Systemic therapy - phototherapy, conventional systemic therapy e.g. methotrexate, ciclosporin and biological therapy
while explaining the risks e.g. etanercept
counsil pt on condition, psycosocial implications screening for depression and anxiety, psoriatic arthritis and mention of CV disease risk
how does management of guttate psoriasis differ to plaque psorasis?
1st line is phototherapy and initiate tx under specialist
what is the mx of osteoporosis?
Non-pharmacological: Educate about the diagnosis and supplement with written information, stop smoking, reduce alcohol intake, wean down or stop causative medications like steroids, regular exercise such as swimming and walking, utilise an MDT approach to tackle falls risk factors (reduce polypharmacy, physiotherapy, occupational therapy, social services assessment, optician review, hearing aid assessment), offer hip protectors.
Medical: Ensure calcium and vitamin D replete, bisphosphonates (eg: alendronate), denosumab (monoclonal antibody that acts as a RANKL inhibitor and thereby reduces osteoclast activity given subcutaneously every 6 months), strontium ranelate (looks a bit like calcium so taken up into bones etc), raloxifene (secondary prevention only, if bisphosphonate not tolerated or contraindicated; selective oestrogen receptor modulator, reduces breast cancer risk but increases VTE risk), teriparatide (parathyroid hormone peptides).
Surgical: Repair of fractures.
what ix do you do in pleural effusion
Bloods- FBC. U+E, LFT, CRP/ESR, LDH, clotting, amylase, lipid profile, TFTs, RF, ANA, ANCA, complement if suspicion of connective tissue disease
Blood cultures
Sputum gram stain, culture and sputum for AFBs
Pleural fluid analysis (USS guided aspiration):
Appearance (clear/straw, yellow/turbid, milky, blood)
Biochemistry: LDH, protein, pH, glucose, amylase, triglycerides, cholesterol
Microbiology: gram stain, cell count, culture, AFB culture
Cytology: for malignant cells
Immunology: Rheumatoid factor, ANA, complement
CXR, USS chest – loculated effusion, to insert drain/sample fluid
Contrast enhanced CT thorax: detect small effusions, look for the underlying cause
Bronchoscopy, thoracoscopy
Pleural biopsy
how do you manage PPH
resusitate
- high flow oxygen
- IV fluids through large bore, transfuse if major bleed
- FBC, blood group and coag
Identify cuase
Tx as uterine atony if tissue, trauma and thrombin are ruled out
- bimanual uterine compression
stepwise uterotonic therapy with concurrent TXA
- Pharmacological = oxytocin IV slow bolus, ergometrine
Surgery - ballon tamponade, uterine artery ligation, hysterectomy last line
if trauma repair laceration
thrombin - correct clotting abnormalities
Tissue - manual removal of placenta
menorrhagia first line requiring contraception
IUS
Dysmenorrhoea 1st line mx
Mefanamic acid
+ COCP if want contra
what is the mx of finding placenta praevia at the 20 week scan?
rescan at 34 weeks
no need to limit activity or intercourse unless they bleed
if still present at 34 weeks and grade I/II then scan every 2 weeks
final ultrasound at 36-37 weeks to determine the method of delivery
elective caesarean section for grades III/IV between 37-38 weeks
if grade I then a trial of vaginal delivery may be offered
if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
how do you manage placenta praevia with bleeding
consider degree of bleeding and whether woman is in labour, duration of pregnancy
Anti- D
if unknown location urgent US
If known location - stabilise mother and then fetal survival
COntinuous CTG if bleeding
IV access
Antifibrinolytic
crystalloid and blood prodcuts
Cross match
C/S usually required if major bleed - vaginal delivery if minor
what is the show?
prelabour passage of mucus plug
whta is the antenatal mx of placenta praevia
pelvic rest advice and seek medical attention if bleeding
some may resolve spontaneously
mother may rquire corticosteroids
if high risk - short cervix = hospitalisation
if preterm labour cant be arrested = C/S
what is the general mx for an antepartum bleed
IV fluids, raise legs and crossmatch
In in shock transfuse until BP is over 100
catheter to check outpit
Anti- D
If not stable - deliver baby
if stable after bleeding stops keep placenta praevia pts in until delivery, abruption pts can sometimes be discharged
menorrhagia mx first line not requiring contraception
transexamic acid
what are differentials for menorrhagia
PCOS uterine fibroids, endometrial polyp, hormonal contraception, endometrial malignancy, adenomyolysis
hypothryoidsim
cervical or ovarian cancer
what are the differentials for dysmenorrhoea
primary dysmenorrhoe PID endometriosis adenomyolysis fibroids uterine polpys ovarian cyst with haemorrhage ovarian torsion ashermanns syndrome
What ix do you do in PID?
WBC ESR,CRP
Vaginal or endocervical swabs send for chlamydia or gonorrhoea nucleic acid amplification
Urine - UTI and pregnancy
Can consider TV US
Screen for other STIs
Consider pelvic CT or MRI
Laproscopy
what is the mx of PID
triple therapy - Ceftriaxone IM, doxy nd metronidazole
If severe or signs of peritonitis or abscess give IV
screen and test sexual contacts
also analgesia
consider IUD but balance against risk of pregnancy
repeat testing in 3-6 weeks to ensure no recurrence
Rest is advised for those with severe disease - appropriate analgesia
avoiding unprotected sex
what are the risk factors for endometrial cancer
eostrogen only HRT oestrogen receptor agonists - tamoxifen Obesity nullipartiy late menopause
ix of endometrial cancer
transvaginal US
if over 4 mm do a pipelle biopsy
hysterescopy and biopsy
FBC anaemia
what staging is used in gynae cancers
FIGO staging
mx of endometrial cancer
open bilateral hystero-salpingo-oophorectomy for all pelvic lymph node clearance adjuvant radio or chemo based on the pts wishes consider palliative chemo egg harvest
what sx should you ask about in an ovarian malignancy
nausea, early satiety bladder - urinary freq ureters - recurrent uti bowel - constipation and obstruction back pain ascites - right pleural effusion DVT
what are the risks for ovarian cancer
oestrogen exposure - obesity, late menopause, HRT smoking
genetic
ix of ovarian cancer
tvus ca125 risk of malignancy score - >250 is high risk CT or MRI for preop and monitoring FBc, UE, LFT , coag ALP = liver mets laparotomy
what is the mx of ovarian cancer
surgical debulking and staging HSO, omentectomy and appendectomy retroperitoneal lymphadenopathy chemo - carboplatin + paclitaxel Radiotherapy Prophylactic surgery if hihg risk or braca
what are the possible signs of cervical cancer
non-menstrual bleeding including post coital bleeding
what are the risk factors for cervial cancer
3P-3S
- increased parity
- over 4 partners
- long pill use
- early first sex
- STDs including HIV
- smoking
what is the mx of cervical cancer
preventtion and vaccination
Surgery - cone biopsy is small or or radical hysterectomy
chemoradiotherapy
chemo - cisplatin
follow up = annual cervical screen if pt hasnt undergone surgeyr
if CIN1 can be managed by loop biopsy or laser
