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
Exams for intermenstrual bleeding
S&S:
• Tampon in vagina - establish if bleeding is from vagina and nowhere else
• High BMI - RF for endometrial cancer
• PV exam
Ix of intermenstrual bleeding
Ix:
• Infection screen
• Pregnancy test
• TVUS for structural abnormalities
Post coital bleeding causes
Cause:
1. Infection 2. Cervical ectropion 3. Polyps 4. Vaginal or cervical cancer
Define menopause
12 months of secondary amenorrhoea
S&S of menopause
S&S: • Menstrual irregularity • Hot flushes and sweats • Dyspareunia, vaginal discomfort and dryness • Recurrent UTIs • Sleep disturbance • Mood changes • Loss of libido
Tx of menopause. Risks and benefits
Tx:
• HRT:
○ Used in early menopause
○ Tx of women where risk:benefit ratio is favourable
○ Benefits - reduces menopause sx + osteoporosis risk
○ Risks - VTE, stroke, breast cancer
Postmenopausal bleeding causes
Causes:
1. Vaginal atrophy 2. HRT 3. Endometrial hyperplasia 4. Endometrial cancer 5. Polyps 6. Cervical cancer
Endometrial Ca RFs
Endometrial cancer RFs: • Oestrogen only HRT • Age • PCOS • Early menarche and late menopause
Ix of postmenopausal bleeding
Ix: • Trans vaginal USS ○ Endometrial thickness should be thinner than premenopause. If thick, suspect endometrial CA. • Endometrial biopsy • Hysteroscopy
What is meigs syndrome. S&S and tx
3 features:
• Ascites
• Benign ovarian tumour
• Pleural Effusion
S&S:
• Affects 40+ women
• Rare
Tx:
• Drain fluid and remove tumour
Epi of fibroid
Epi:
• Common in 30-50y
• FHx
• Obesity increases risk
S&S of fibroids
H&E:
• Heavy or painful periods - dysmenorrhoea and menorrhagia
• Swelling in abdomen
• Constipation or urinary urgency due to compression of fibroid
• Dyspareunia - Bleeding during or after sex. If growing in cervix or near vagina
Ix and tx of fibroids
Ix:
• Abdo USS
• TV exam
Tx:
• Observation
• Medication to reduce bleeding - see DUB tx (COCP, mirena coil)
• Shrink fibroids - GnRH analogue for 6 months. Gives sx similar to going through menopause.
• Surgery - Hysterectomy, myomectomy to retain fertility. GnRH analogue given pre surgery to shrink fibroid
Define endometriosis and adenomyosis
Endo - endometrial tissue outside of uterus
Adeno - Endometrial tissue in myometrium
S&S of endometriosis
S&S - related to menstrual cycle: • Dysmenorrhoea • Menorrhagia • Dyspareunia • Lower abdo pain • Intermenstrual bleeding • Reduced fertility
Ix of endometrriuosis. What might you see?
Chocolate cysts:
• Large patches of endometriosis form cysts which bleed when you have a period
• Cysts fill with dark blood giving a chocolate appearance
Ix:
• Confirmed via laparascopy
Tx of endometriosis
Tx:
• Analgesics - paracetemol, NSAIDs, codeine
• COCP
• Mirena coil
• GnRH analogues
• Laparascopic surgery to remove large patches
S&S of adenomyosis
S&S: • Dysmenorrhoea • Dyspareunia • Menorrhagia • Infertility possible • Examination - uterus symmetrically enlarged and tender.
Ix and Tx of adenomyosis
Ix:
• MRI
• Histology
Tx:
• GnRH analogues
• Hysterectomy
RFs of endometrial cancer
RFs: • Increased exposure to oestrogen • Obesity • Diabetes • PCOS • COCP lowers risk
S&S of endometrial cancer
S&S: • Post menopause bleeding • Postcoital bleeding • Intermenstrual bleeding • Dyspareunia • Lower abdo pain
Ix of endometrial cancer. Tx
Ix: • Vaginal exam • Uterine USS • Endometrial biopsy • Hysteroscopy • Staging CT if confirmed cancer
Tx:
• Surgical excision
• Hysterectomy with bilateral oophrectomy
• Radiotherapy
S&S of cervical carcinoma
S&S:
• Vaginal discharge
• Bleeding - post defecation, micturition or post coital
• Vaginal discomfort
• Late sx - painless haematuria, chronic urinary frequency, Painless fresh rectal bleeding, altered bowel habit
• Bulk in pelvis
Ix and tx of cervical carcinoma
Ix: • STI screen • Colposcopy to visualise cervix • FBC, LFTs, U&Es • CT CAP if mets
Tx: • Surgical excision • Hysterectomy • Radiotherapy • Chemotherapy
RFs of ovarian carcinoma
RFs: • Age • Smoking • Obesity • HRT • FHx
S&S of ovarian carcinoma. Differentials
S&S:
• Early is vague - abdo discomfort, distension, bloating
• Pelvic or abdo mass associated with pain
• Ascites
Differentials: • Fibroids • Benign ovarian tumour • Cyst • Endometriosis
Ix and tx of ovarian carcinoma
Ix:
• Abdo pelvis USS
• CT CAP
• CA 125
Tx:
• Surgical
• Chemo + radio
S&S of vulval carcinoma and tx
Tx:
• Wide local excision +/- lymph node dissection
• Chemoradiotherapy
S&S: • Itching • Bleeding • Vulval lesion • Inguinal lymphadenopathy
S&S of benign ovarian tumour
S&S: • Asymptomatic • Dull ache in lower abdo or low back • Torsion - more likely if tumour • Dyspareunia • Pressure affects on bladder, or venous system
Ix and tx of benign ovarian tumour
Ix: • Pregnancy test • FBC - infection, hemorrhage • USS • CT if USS not definitive
Tx:
• Small cysts with no sx - watchful waiting
• Medium cysts - yearly USS to monitor
• Larger cysts - surgery
PCOS S&S
S&S: • Infertility • Irregular periods or no periods • Hirsutism • Acne • Thinning of scalp hair • Weight gain • LT - diabetes, HTN, hypercholesterolemia
PCOS Ix and Tx
Ix: • Testosterone bloods • LH bloods - higher in PCOS • USS of pelvic organs ovaries • Impaired glucose tolerance test for diabetes
Tx: • Lose weight • Acne tx • Clomifene to ovulate and increase fertility • Metformin not universally recommended
PID causative organisms
Causative organisms:
• Chlamydia trachomatis - most common
• N gonorrhoea
PID S&S
S&S: • Lower abdo pain • Fever • Deep dyspareunia • Dysuria Cervical excitation
PID Ix and tx
Ix: • Chlamydia and gonorrhoea screen • FBC • CRP • MSU • Blood cultures • Pelvic USS
Tx:
• oral ofloxacin + oral metronidazole
• Contact tracing
Cx of PID
Cx:
• Infertility
• Chronic pelvic pain
• Ectopic pregnancy
Define stress and urge incontinence
• Overactive bladder/urge incontinence - detrusor overactivity
Stress incontinence - Small leaks when coughing or laughing
Ix of urinary incont
Ix:
• Bladder diary for minimum 3 days
• Vaginal exam to exclude prolapse
Urine dipstick and culture
Tx of stress and urge incont
Tx - stress:
• Pelvic floor muscle training
• Surgery - retropubic mid urethral tape
Tx - urge:
• Bladder retraining
• Antimuscarinic eg oxybutynin - not in frail elderly
S&S of pelvic prolapse
S&S:
• Feeling of something coming down
• Pain in vagina, abdomen or back
• Dyspareunia
• Worse after long periods of standing, better on lying down
• Urethrocystocele - incontinence, urgency, Incomplete emptying, retention
Rectocele or enterocele - Incontinence, urgency, incomplete emptying
RFs for pelvic prolapse
RFs: • Age • Difficult or protracted Childbirth • Increased pressure in abdomen eg obesity or chronic cough Gyne surgery
Tx of pelvic prolapse
Tx:
• Watchful waiting
• Lifestyle - lose weight, stop smoking (chronic cough)
• Pelvic floor exercises
• Vaginal pessary
Surgery - hysterectomy, vaginal mesh (chronic pain)
Ovarian torsion S&S and ix and tx
Ix:
• Pelvic USS
S&S:
• Sudden onset sharp unilateral lower abdo pain
• N&V
tx - laparascopy and fixation of ovary
Define primary and secondary amenorrhoea
Primary - menses not occurred by age 14 in absence of secondary sexual characteristics or by 16 if secondary characteristics developing
Secondary - Menses stopped after starting for 6 consecutive months
Causes of primary amenorrhoea
Primary causes:
• Secondary char present:
○ Constitutional delay - no abnormality, just late
○ Genitourinary malformation - malformations of genitals eg absence of uterus or vagina
○ Testicular feminisation - XY but insensitive to androgens
○ Hyperprolactinaemia - hypothyroidism and drugs
○ Pregnancy
• Secondary absent:
○ Ovarian failure eg Turner syndrome
○ Hypothalamic failure due to underweight
Causes of secondary amenorrhoea
Secondary amenorrhoea causes: • Pregnancy • Premature ovarian failure • Depot and implant contraception • Loss of weight • Thyroid disease • PCOS Cushings
Ix of amenorrhoea
Ix: • Examine for signs of excess androgen - hirsutism, balding, acne • TFTs • Pregnancy test • VE • Prolactin • Total testosterone • Pelvic USS - if pt underage avoid VE • Karyotyping if suspect turners
Pathology of ovarian hyperstimulation syndrome
Pathology:
• Ovaries form many follicles following increase in hCG
• Vasoactive mediators released from hyperstimulated ovaries result in capillary permeability
• Fluid shift into 3rd space compartments eg ascites and pleural effusion
S&S of OHS
S&S: • Can be mild to severe • Bloating - due to ovarian size or ascites • Pleural effusion • Hypercoagulability
Ix and RFs of OHS
Ix: • USS of ovaries • FBC - haemoconcentration • U&E • Coagulation screen • LFTs • CXR
RFs:
• PCOS - use of clomifene
• Age under 30
Low BMI
Tx of OHS
Tx: • Analgesia • Anti-emetics • Colloid IV if clinically dehydrated • Aspiration of 3rd space fluid
Commonest cause of vulval swelling
bartholins abscess
S&S of bartholins abscess tx
S&S: • Pain • Swelling • Dyspareunia • Unilateral vulval swelling • Tender to palpation if abscess
Tx - incision and drainage
S&S and tx of atropic vaginitis
S&S - vaginal soreness, dyspareunia, vagina looks pale and dry
Tx - topical oestrogens or HRT
S&S and Tx of vulval dystrophy. Types
S&S - itching and soreness on outside
Hypoplastic (lichen sclerosis):
• 45-60y
• Skin looks atrophic +/- white plaques
Hyperplastic:
• Multiple symmetrical thickened hyperkeratotoic lesions on vulva
Tx - Topical steroids
S&S and tx of vaginal intraepithelial neoplasia
• S&S - post coital bleeding, abnormal discharge
Tx - local ablation
Ix of pelvic pain
• Pregnancy teest
• High vaginal swab
• FBCs, CRP
Pelvic USS
Gyne acute causes of pelvic pain
Ectopic, PID, endometriosis, torsion, dysmenorrhoea, ovarian cyst
Gyne chronic causes of pelvic pain
Endometriosis, adhesions, fibroids, prolapse, cyst, PID
Non gyne causes of acute pelvic pain
Appendicitis, colitis, diverticulitis, renal stones
Chronic non gyne causes of pelvic pain
IBS, nerve entrapment
Define endometritis, S&S
S&S: • Fever • Lower abdo pain • Uterine tenderness • Purulent discharge
Infection of endometrium occurring usually after surgery (IUCD) or childbirth
Ix and tx of endometritis
Ix:
• High vaginal swabs
• Endocervical swabs
Tx:
• Doxy + metronidazole
When is normal labour
Between wk 37 to 42
Give stages of labour and explain
Stage 1 - dilation of cervix up to 10cm. Water break. Lasts 12 hrs
Stage 2 - Passive stage no urge to push. Active stage urge to push. Baby born.
Stage 3 - placenta expelled. circa 15 mins.
What tx for delay in stage 1 labour?
Delay in stage 1:
• Can induce labour by rupturing membranes
• Offer oxytocin
• If neither work, consider C section
Tx for delay in stage 2 labour
Delay in stage 2:
• Oxytocin drip
• If not, C section
Tx for delay in stage 3 labour and reduce PPH
syntometrine IM
Indications to induce labour
• IUGR
• Prolonged pregnancy - Post 41 weeks
• HTN and pre-eclampsia
Time of delivery in best interests of baby - eg requires cardiac surgery
Contraindications to induction of labour
Severe placenta praevia, transverse fetal lie, cervix unripe
Methods to induce labour
• Membrane sweep
• Prostaglandin gel
Oxytocin with/without artificial rupture of membranes
S&S and RFs of PROM
S&S:
“Popping” sensation with continuous watery liquid draining
RFs of PPROM:
• Smoking
• Previous preterm delivery
Vaginal bleeding at any time of pregnancy
Ix for PROM
Ix:
• Seeing amniotic fluid pooling in vagina after 30 mins of lying down
• USS
DON’T EXAMINE VAGINA - increases risk of ascending infection, early signs of which are fetal tachycardia and mild increase in maternal temp
Cx of PROM
Cx:
• PPROM - Prematurity, sepsis, pulmonary hypoplasia
• Umbilical cord prolapse
Placental abruption
Tx of PROM
Tx: • Hospital admission • PPROM - erythromycin • Antenatal steroids if preterm Women shouldn’t exceed 96 hours following ROM as infection risk increases
Complications of C section
Complications: • Post partum hemorrhage • Bladder injury • Lung aspiration • Pulmonary embolus • Infection
Indications for c section
Indications: • Malpresentation eg breech • Placenta Praevia • Cephalopelvic disproportion • Pre-eclampsia • Fetal distress • Failed induction of labour Maternal request IS NOT an indication
Indications for assisted delivery
Indications: • HTN • Tired and need help • Fetal distress • Premature baby • Breech delivery
Cx of assisted delivery
Cx:
• Episiotomy may be needed
• Injury to anatomical structures
• Shoulder dystocia
S&S of placental abruption
S&S:
• Painful vaginal bleeding. Placenta praevia is painless
• Hard palpable uterus due to retroplacental blood tracking into myometrium.
• Shock out of keeping with visible loss
• Constant pain
• Tender tense uterus
• Fetal heart absent or distressed
• DO NOT PERFORM VE AS MAY BE PRAEVIA
Tx of placental abruption
Tx:
• Fluid resuscitation
• Urgent delivery when baby stable
S&S of breech position
S&S:
• Subcostal tenderness
• Ballotable head in fundus area
Fetal heartbeat loudest above umbilicus
Ix for breech and Cx of vaginal delivery
Cx of vaginal delivery:
• PROM
• Cord prolapse
Fetal head entrapment
Ix:
USS if breech persisting post 35 wks
Tx of Breech position
Tx: • Pre 32-35 wks - no tx necessary • 36 weeks offer - ○ External cephalic version - lifting of fetal bottom with one hand and pushing head with other. Contra is abnormal CTG, ruptured membranes. C Section
Non pharm Analgesia in labour
Non pharm:
• Massage
• Temperature
Transcutaneous electrical nerve stimulation
Pharmaceutical analgesia in labour
Oral:
• Pethidine
Nitrous oxide and oxygen:
• Entonox - Gas and air
Epidural analgesia:
• Highly effective
Local analgesia:
• Pudendal nerve block
• Perineal nerve infiltration
Side effects of epidural analgesia
May cause dizziness, shivering, hypotension, or delay 2nd stage of labour
Causes of polyhydramnios
Amniotic fluid produced by fetal kidneys and maternal plasma. Absorbed by fetus’ GI system and swallowing. Therefore polyhydramnios can be cause by:
• Fetal swallowing problem - eg atresia of upper GI, fetal hypoxia, neuromuscular abnormalities
• Excess Fetal urination - eg. fetal hyperglycaemia caused by GDM
Lack of Absorption via GI system
S&S and ix of polyhydramnios
S&S:
• Presents as uterus large for date
• Fetal parts difficult to palpate
Ix:
• USS
Oligohydramnios causes
Fetal causes:
• Chromosomal abnormalities
• IUGR
• Fetal demise
Placental causes:
• Abruption
Maternal causes: • Dehydration • HTN • Pre-eclampsia • Diabetes
Ix of oligohydramnidos
Ix:
• BP and BM
• Test for SLE
• USS
Types of prolapsed cord
Overt cord Prolapse:
• If presenting part of fetus doesn’t fit pelvis snugly after membrane rupture, there is a risk that the umbilical cord can slip past fetus and become compressed
This compromises fetal circulation and is an emergency
Occult cord prolapse:
Umbilical cord lies alongside presenting part
S&S and RFs of prolapsed cord
RFs: • Prematurity • Breech • Oblique, transverse and unstable lie • Low lying placenta
S&S:
• VE can see overt cord prolapses
• Abdo exam - ill fitting presenting part alert to possibility of prolapse
• Variable fetal heart rate decelerations
• Fetal Bradycardia if complete compression
Tx of prolapsed cord
Tx: • Overt prolapse: ○ O2 to woman ○ Place women in knee chest position and push fetus away from prolapsed cord ○ Immediate C section • Occult prolapse: ○ Woman in left lateral position ○ If fetal heart remains abnormal - C section
Causes of shoulder dystocia
3Ps - Power, passenger, pelvis
• Power (uterus) - Unco-ordinated contractions from primigravid mothers
• Passenger (fetus) - Lie of fetus, Macrosomia
Pelvis - Oval brim
Cx of shoulder dystocia
Cx: • Brachial plexus injuries • Pneumothorax • PPH • Cervical tears
RFs and Tx of shoulder dystocia
RFs: • GDM • Fetal macrosomia • Maternal obesity • Prolonged labour • Previous shoulder dystocia
Tx:
• Prevention:
○ Offer C section if GDM and fetal macrosomia
• Stop mother pushing. McRoberts maneuver. Episiotomy
Patho of foetal hydrops
Patho:
• Abnormal fluid accumulation in 2+ fetal compartments
• Eg ascites, pleural effusion, pericardial effusion, skin oedema
Either immune (rhesus blood related) or non immune. Immune 90% of cases
Causes of foetal hydrops
Causes:
• Haem - haem disease of newborn, Alpha thalassaemia, fetal hemorrhage
• Cardiac - Aortic stenosis, coarctation of aorta
Infective - TORCH syndrome
Ix for foetal hydrops and tx
Ix: • Indirect Coombs test • USS of fetus + placenta • Echo for fetal arrhythmia • Fetal karyotyping
Tx:
• Inform parents to help decide if pregnancy should be continued
• Complicated tx..
Ix for small for age babies
Ix:
• Symphysis fundal height charts - serial measurements reveal little to no growth week on week.
• Refer for USS
1st appt for prengnacy - when, what discuss, what do?
1st appt - Topics:
• Discuss lifestyle choices ie smoking, alcohol etc.
• Measurement of BP, weight, BMI, proteinuria
• Screen for:
○ Anaemia
○ Red cell allo-antibodies
○ Hep B, HIV, syphillis, Rubella, chlamydia
○ Sickle cell and thalassaemia
○ Gestational diabetes if RFs
• Screen neonate for:
○ Downs, edwards, and pataus done via nuchal translucency measurement
○ USS at 18 weeks for abnormalities
Causes of abnormal vaginal discharge
Causes of abnormal discharge: • Excess normal secretions • Bacterial vaginosis • Candida albicans • Cervicitis - chlamydial, herpetic, gonococcal • Trichomatis vaginalis
Qs to ask vaginal discharge
Hx:
• Sx - itchy, offensive, colour, duration, vulval soreness, abdo pain, menorrhagia, fever, bleeding
• Sexual hx - recent new partner, multiple partners, protection
• Medical hx - pregnancy, diabetes, abx
Ix of vaginal discharge
Ix:
• Check pH on pH paper - >4.5 BV or TV likely. <4.5 candida or physiological
• High vaginal swab for BV, TV, or candida
• Endocervical swab for gonorrhoea and chlamydia
• Viral swab for herpes
S&S and tx of bacteria vaginosis
S&S:
• Thin, fishy smelling, offensive discharge with no soreness
• pH secretions >4.5
Tx:
• Metronidazole
S&S, ix and tx of candidiasis
S&S:
• Superficial dyspareunia
• Pruritic vulvae
• Thick creamy discharge, non offensive
Ix:
• High vaginal swab
Tx:
• Oral flucanazole
S&S of chlamydia, tx and ix
Ix men:
• Urine testing for chlamydia
* Male - none, sometimes discharge, dysuria * Female - usually none, lower abdo pain, intermenstrual bleeding
Tx:
• Doxycycline
Ix female:
• Endocervical swab
S&S gonorrhoea
S&S - women: • Vaginal discharge • Lower abdo pain • PID Abscess of bartholins gland
S&S - men:
• Urethral discharge, dysuria, prostatitis
Rectal infection - anal discharge, discomfort
Tx of gonorrhoea
Tx:
• Ceftriaxone
• Contact tracing
Trichomonas vaginalis S&S`
Women - S&S: • Vaginal discharge - frothy, smelly, mucopurulent • Abdo pain • Dysuria • Vulvovaginal soreness/itching
Men - S&S:
• Dysuria
• Urethral discharge
Ix of trichomonas vaginalis
Ix: women
• pH >4.5
• High vaginal swab
Ix: men
• Urethral swab
• First void urine for culture
Tx of TV
Tx:
• Contact tracing
• Metronidazole
S&S of hep b and c
HBV and HCV - S&S: • Fever • Malaise • Dark urine • Pale stools • jaundice
Ix of hep b and C, and tx
Ix:
• LFTs
• Hepatitis serology
Tx of both: • Avoid alcohol • Acute illness - supportive • Chronic - interferon and lamivudine • Immunise (no vaccine for hep c)
Patho of chorioamnionitis
Patho:
• Acute inflammation of foetal amnion and chorion membranes
• Due to ascending infection
S&S and tx of chorioamnionitis
S&S:
• Uterine tenderness
• ROM with foul odour (can occur with intact membranes)
• Maternal signs of infection - tachycardic, pyrexia
Tx:
• Prompt delivery via C section
• IV abx
Obstetric cholestasis S&S and tx
S&S:
• Pruritis worse on palms, soles, and abdomen
Tx:
• Ursodeoxycholic acid
• Vit K supplement
How much folic acid do normal pregancies need? Epilepsy?
Take Folic acid 5mg in epileptic, normally 400 mcg
