Obs Gyne Flashcards
Red flags of Breast lumps
• Hard lump with fixation +/- skin tethering
• Phx of Breast CA
• Lump getting bigger
• Eczematous skin not responsive to topical tx
• Bloody nipple discharge
• Unilateral discharge
Nipple inversion
Explain Screening program of breast CA
Women 50-70:
2 view mammography every 3 years
High risk women <50:
• If FHx of breast cancer
• 40-49 - annual 2 view mammography
• Genetic mutation of BRCA1/2 - annual MRI from 30y+
Tx of mild/moderate cyclical breast pain
• Diet - reduce caffeine and sat fat
• Simple analgesia
Changing/stopping contraceptives
Tx of non cyclical breast pain - well localised and generalised
• Well localised - consider ill fitting bras, breast abscess, cyst, mastitis, CA
Generalised - consider lung disease, nerve root pain
Give epi, S&S, Ix, and Tx of fibroadenoma
Epidemiology:
Peak 16-24
S&S:
Discrete, firm, non tender and highly mobile
Ix:
• Mammogram
• USS
FNAC
Tx:
Refer for confirmation
Patho of sclerosing adenosis
Overproliferation of duct lobules. Results in pain and small firm nodules.
S&S, epi, tx, ix of phyllodes tumour
Epi:
40-50 peak
S&S:
Lump forms grows large and quickly
Ix:
USS, mamography, FNAC
Tx:
Wide surgical excision
hx and S&S of fat necrosis. Ix and tx?
S&S:
• Hx of injury and bruising
Scarring results in firm lump in breast
ix - uss, mammography, FNAC
tx - none needed once confirmed
Breast cyst Ix and S&S
S&S:
Firm round lump not fixed and no skin tethering
1st cyst - urgent referral to exclude CA
hx of cysts - FNAC and referral if blood stained or non resolving
Galactocoele patho
Patho - obstruction of lactiferous duct results in cyst containing milk
S&S and tx of galactocoele
S&S:
• Cyst on examination
Occurs whilst or shortly after lactation
Tx:
Aspiration
Duct ectasia patho and S&S
• Occurs around menopause
• Ducts become blocked and secretions stagnate
Discharge which may be blood stained +/- breast lump +/- nipple retraction +/- breast pain
duct ectasia ix and tx
Ix:
Urgent referral to exclude CA
Tx:
• Self resolving
Surgery may be needed to confirm diagnosis
Breast abscess hx and S&S. tx?
Hx:
• Usually occurs in lactating breast following mastitis
Presents as gradual onset pain in one breast segment with hot tender swelling of area.
tx - aspiration
RFs of breast CA
Age, denser boobs, obesity, alcohol, smoking, FHx, HRT, Genetics
S&S of breast ca
Presentation: • Breast lump - 90% • Nipple skin changes - 10% • Painful lump - 21%, pain alone 1% Nipple discharge - 3%
Ix and tx of breast cancer. cx of ix?
Ix:
• Lymph node biopsy
Can result in lymphoedema
Tx:
• Tamoxifen - if oestrogen receptor +ve
• Aromatase inhibitors eg anastrozole - blocks synthesis of oestrogen for oestrogen +ve
• Herceptin - Monoclonal Ab directed at HER2
Surgical, axillary lymph node clearance
Emergency contraception options and when they can be used?
Copper IUCD - <5 days
Levonorgestrel - 1.5mg PO. <3days OTC.
Progesterone receptor modulator - <5 days oral
Contraindications COCP?
Venous disease, arterial disease, liver disease, cancer, drug interactions
If missed 1 pill of COCP what do? Missed 2+ pills?
Missed doses:
• If 1 pill missed - take ASAP even if 2 in 1 day. Continue
If 2+ pills missed - Take most recent missed pill even if 2 in 1 day. Leave earlier missed pills and use barrier contraceptives for next 7 days.
Define antepartum hemorrhage, miscarriage, and PPH
APH - Bleeding from uterus after 24th week
Miscarriage - Bleeding <24 wks
PPH - Bleeding after birth of baby
Causes of APH
• Placenta praevia
• Placental abruption
Local infection
S&S of APH
• Pain (suggests abruption) • Painless (suggests placenta praevia) • Failure of fetal head to engage with praevia • Signs of fetal distress Signs of shock if severe bleeding.
Ix of APH
• Always admit for assessment, even if small bleed
• No VE until praevia ruled out
• USS
• Resus if severe bleed
• Blood tests - FBC (Initial Hb may not reflect sudden blood loss), G&S, X match, clotting studies
• Fetal monitoring
Maternal corticosteroids if at risk of preterm birth
Placenta Praevia S&S, RFs, Ix. What must you never do if suspected?
S&S: • No pain • Uterus non tender • Lie and presentation may be abnormal • Small PV bleeds before large
RFs:
• Multiparity
• Multiple pregnancy
Previous C section
Ix:
• Usually picked up at 20 wk abdo scan
If suspect - TV scan
RFs for GBS?
RFs for GBS: • Premature • Prolonged rupture of membranes • Previous sibling GBS infection Maternal pyrexia
Define early and late miscarriage
Loss of pregnancy <24 wks gestation
Early <12 wks. Late 13-24 wks.
Classify - threatened, inevitable, incomplete, complete, missed, recurrent miscarriages
Classification:
• Threatened miscarriage - Mild bleeding. Closed cervical os
• Inevitable miscarriage - Heavy bleeding and clots. Open cervical os.
• Incomplete miscarriage - POC partially expelled.
• Complete miscarriage - POC completely expelled.
• Missed miscarriage - Fetus is dead but retained.
Recurrent miscarriage - 3+ consecutive miscarriages
Common causes of miscarriage
• Most iatrogenic - COCP • Abnormal fetal development • Poorly controlled diabetes • Poorly controlled thyroid disease • PCOS • Antiphospholipid syndrome Uterine abnormality
RFs for miscarriage
• Age • Smoking • Alcohol • Low BMI Drugs
S&S and differntials of miscarriage
S&S:
Bleeding and vaginal pain worse than period
Differentials:
• Ectopic pregnancy
• Implantation bleed
Cervical polyp
Ix and tx of miscarriage
Ix:
• TV USS
• Serum hCG
Tx:
• Early miscarriage - conservative with urine hCG in 7-14 days
• Medical - Vaginal misoprostol
• Surgical:
○ Indications- persistent excessive bleeding, infected POC
Vacuum aspiration under local - risk of cervical tears and perforation
Define pre-eclampsia
HTN + proteinuria seen after 20 weeks gestation
What does pre-eclampsia dispose to?
• Fetal prematurity and growth retardation
• Eclampsia
• Hemorrhage - placental abruption
Cardiac and multi organ failure
RFs of Pre-eclampsia, Ix
RFs: • >40y • Nulliparity • BMI >30 • DM • Hx of pre-eclampsia • Pre-existing vascular disease eg HTN or renal disease
Ix:
• Urinalysis
• Frequent monitoring of FBCs, LFTs, U&E
Clotting studies if severe pre-eclampsia
S&S of severe pre-eclampsia
S&S of severe pre-eclampsia: • HTN >170/110 • Proteinuria ++/+++ • Headache • Visual disturbance • Papilloedema • RUQ pain • Hyperreflexia HELLP syndrome
What is HELLP syndrome?
HELLP syndrome - serious pre-eclampsia:
• H - Hemolysis (anemia)
• EL - Elevated LFTs
LP - Low Platelets
Tx of pre-eclampsia
Tx:
• Oral labetalol
• Delivery of baby is definitive cure
○ Not offered pre 34 weeks unless refractory to tx
Prevention - aspirin and calcium if high risk of pre-eclampsia
Tx of eclampsia
Eclampsia Tx: • A-E assessment • Mg sulfate IV • IV labetalol to reduce risk of further seizures Fetal delivery definitive tx
RFs of hyperemesis gravidarum?
RFs:
• Multiple pregnancies
• Hyperthyroidism
Obesity
Tx of hyperemesis gravidarum, when usually occurs?
8-12 weeks
Tx:
• Antihistamines - promethazine
IV hydration may be needed
S&S of ectopic
S&S:
• Usually around 6th week of pregnancy
• Pain on one side of Lower abdomen. Sharp, severe, gets worse over several days
• PV bleeding often. Darker bleed than normal
• Shoulder tip pain referred from diaphragm
Tube ruptures - shock
RFs of ectopic and Ix
RFs: • PID • Previous sterilisation • Endometriosis IUCD
Ix:
• Pregnancy test
• TV USS of pelvic organs
HCG blood - lower than normal
Tx of ectopic pre and post rupture
Tx:
• Ruptured - emergency surgery
• Pre rupture:
○ Salpingectomy or salpingotomy (partial fallopian tube removal)
○ Methotrexate
Wait and see - 50% of ectopics self resolve
3 causes of postpartum depression. When they start?
3 causes of depression post partum:
• Baby blues - Weepy, irritable starting 3rd day goes by 10th
• Postnatal depression - Starts in first 4 weeks after childbirth. Tx advised
Postnatal psychosis - severe mental illness
Diagnostic criteria of depression
Core symptoms for atleast 2 weeks.
• Anhedonia
• Low energy
Pervasive Low mood
D - depressed mood E - energy loss P - pleasure loss R - retarded movement E - eating less or more S - sleep S - suicidal ideation I - i'm a failure (low self confidence) O - only me to blame (guilt) N - no concentration
Mild - 4 sx. Moderate - <6 sx. Severe 7+
Postpartum psychosis S&S
Postpartum psychosis S&S: • Mood changes - low or high • Trouble sleeping • Paranoid thoughts • Hallucinations • Delusions • Loss of social inhibitions Lack of insight
Postpartum psychosis ix and tx
PPP Ix: • BM - hypoglyc • TFTs • Vitamin deficiencies CT head to rule out stroke
Tx - lithium, clozapine
S&S of fetal distress. Ix
S&S:
• Reduced movement felt by mother
• Slowing of growth of serial symphysis fundal height
Ix:
• Doppler USS of umbilical artery
• CTG
Fetal blood sampling during labour
RFs of fetal distress and tx
RFs: • Hx of stillbirth • IUGR • HTN • Obesity • Smoking • T2DM • Pre-eclampsia • Age
Tx:
Monitor for potential induction or C section
How do you interpret CTG?
Interpretation - DR C BRAVADO: • DR - Define Risk • C - Contractions • BRA - Baseline rate • V - Variability • A - Accelerations • D - Deceleration O - Overall impression
Pathology of gest diabetes
Patho:
• Any degree of glucose intolerance with its onset during pregnancy
• Pregnancy hormones decrease fasting glucose levels, increase fat deposition and increase appetite.
• Postprandial glucose concentrations increase as insulin resistance increases
This is usually countered by increased insulin. In GDM this is not so.
RFs of GDM. Ix
RFs:
• Age
• High BMI pre pregnancy
Smoking
Ix:
• Fasting glucose >5.6mmol
2 hour glucose post OGTT >7.8mmol
Tx of GDM and Cx
Tx:
• Glycaemic control below target levels
• Offer USS for fetal abnormalities at 20 wks
Fasting BM 10 wks after birth to exclude diabetes
Cx of GDM: • Increased birth weight • Preterm risk • Shoulder dystocia Pre-eclampsia
S&S of molar pregnancy . ix
S&S:
• Pregnancy sx - large for gestation age
Vaginal bleeding
Ix:
• High levels of hCG
USS
S&S of multiple pregnancy
S&S:
• Hyperemesis and exaggerated pregnancy sx
• Uterus palpable earlier than 12 weeks of gestation
• Large for dates uterine size
2+ fetal heart rates heard on auscultation
Causes of primary PPH
Primary Cause - 4 Ts:
• Tone - Uterine atony (most common), distended bladder
• Trauma - Laceration of uterus, cervix, or vagina
• Tissue - Retained placenta (2nd most common) or clots
Thrombin - Coagulopathy
Define primary and secondary PPH
Primary - Blood loss >500ml within 24 hours of delivery
Secondary - Abnormal bleeding 1 day to 6 wks post delivery
Causes of secondary PPH
Secondary cause:
• Infection
Retained products of conception (RPOC)
Tx of primary PPH
Tx:
• Resus
• A-E assessment
• Bloods - X match, G&S, U&E, FBC, Clotting, LFT
• Oxytocin IV
• Surgical - Balloon tamponade, hysterectomy
S&S of secondary PPH and ix
S&S: • Fever • Abdo pain • Offensive vaginal discharge • Bleeding • Dysuria
Ix: • Blood culture • FBC • MSU • High vaginal swab • USS
Retained placenta tx
Tx:
• IV oxytocin
Manual evacuation of placenta
pt wants abortion. What Ix?
Ix: • Screen for chlamydia • Discuss future contraceptive needs • Risk of VTE Is smear due?
Tx to abort? Options available.
• Abx ppx - Metronidazole + doxy as 10% women develop genital tract infection post abortion
• Medical:
○ Mifepristone
• Surgical:
○ Vacuum aspiration up to 14 weeks
○ Dilatation and evacuation between 14-24 weeks
• Analgesia - NSAID
• Anti-D IgG to all non sensitised RhD -ve women
Explain the physiology of normal menstrual cycle. Normal menstrual loss?
Days 1-14 - follicular phase - FSH high and stimulates egg. Oestrogen produced by developing follicles
Day 14 - ovulation - egg released
Day 14-28 - luteal phase - Ruptured follicle forms corpus luteum and secretes prog and oestrogen.
Day 28 - menses - Corpus luteum degrades. Loss of oestrogen and prog causes necrosis of endometrium. Normal blood loss 20-60 mls. 80+ menorrhagia
hx to quantify menorrhagia
Questions to quantify:
• How many pads do you use?
• How many tampons?
• Flooding to clothes or bedding?
Causes of menorrhagia
Causes: 1. DUB 2. Fibroids - benign growths in uterine muscle 3. Endometriosis 4. Polyps 5. Infections 6. Endometrial carcinoma 7. PCOS 8. Hypothyroid Blood clotting disorders
S&S of menorrhagia. Ix. Tx.
S&S:
• Signs of anaemia
• Examine abdomen and PV
Ix: • FBC • TFTs • Clotting disorders • USS
Tx: • Mirena coil • Tranexamic acid • COCP • Hysterectomy
Primary and secondary causes of dysmenorrhoea
Primary - idiopathic cause. Thought to be due to excess prostaglandin release
Secondary: • Endometriosis • PID • Fibroids • Endometrial polyps • IUCD • Ovarian cysts
Ix and tx of primary dysmenorrhoea
Ix:
• Vaginal exam
• Pelvic USS
• Hysteroscopy
Tx - primary:
• Warmth - hot water bottle on abdo
• NSAIDs - blocks prostaglandins
• COCP
Red flags of dysmenorrhoea that indicate its not primary
Red flags - not sx of primary dysmenorrhoea: • Fever • Vaginal discharge • Sudden severe abdo pain • Dyspareunia • Intermenstrual bleeding • Postcoital bleeding
Define DUB
Patho:
• Excessive bleeding in absence of pregnancy, infection, trauma or tx
• Diagnosis of exclusion
Ix of DUB
Ix: • FBC to check if anaemic • USS to exclude fibroids • TFTs - hypothyroidism • Clotting studies - von willebrand disease
tx of DUB
Tx: • Mirena coil • Tranexamic acid - doesn’t reduce pain • COCP • Surgical - Uterine artery ablation and hysterectomy
Hx to ask of dyspareunia
Hx: • Superficial or deep? • Tightening of muscles - vaginismus • Recent or always? • Following childbirth? • Pain continues after sex? • Any hx of sexual abuse or rape? • FGM? • Menopause sx? • UTI sx?
Examination for Dyspareunia
S&S: • External genital exam. Look for: ○ Skin disease ○ Vaginal secretions ○ Infection ○ Scarring • VE - Be very careful and only when pt is ready.
Ix of dyspareunia
Ix:
• STI swab
• Dipstick urine - UTI
• Laparoscopy if adhesions suspected
Intermenstrual bleeding causes
Causes: • Pregnancy related - inc ectopic pregnancy • Vaginal causes: ○ Vaginitis ○ Infection • Cervical causes: ○ Cervical Polyps ○ Cervical ectropion • Uterine causes: ○ Fibroids ○ Polyps ○ Cancer • Missed OCPs • Breakthrough bleeding - Occurs when starting new contraceptive
Hx to ask in intermenstrual bleeding
Hx: • Menorrhagia? • LMP? • Timing of bleeding in menstrual cycle • Associated sx - abdo pain, fever, discharge • Pregnancy? • Sexual hx
