Obstetrics Flashcards
Clinical features of an ectopic pregnancy
Pain- pelvic or lower abdominal classically, can be referred to shoulder tip \+/- Vaginal bleeding Vaginal discharge- brown 'prune juice' History of amenorrhoea Haemodynamically unstable Signs of peritonitis
Differentials of an ectopic pregnancy
Miscarriage Ovarian cyst accident- torsion, cyst haemorrhage or rupture Acute PID UTI Appendicitis Diverticulitis
Investigations for ectopic pregnancy
HINT: When should a laparoscopy be offered?
Pregnancy test for urinary beta HCG
+ then transvaginal USS
MRI second line
If pregnancy of unknown origin (cannot be identified on USS) then 48 hours later beta HCG
Should double if early intrauterine
Half if miscarriage
>1500 then ectopic until proven otherwise- diagnostic laparoscopy
Management of an ectopic pregnancy
If haemodynamically unstable then (haemorrhage protocol), ABCDE
Expectant/ conservative- PUL, stable, minimal or no symptoms
Medical- IM methotrexate (offered first line), monitor beta HCG levels (<1500), unruptured ectopic with a small adnexal mass
Surgical- laparoscopic salpingectomy (if no contralateral tubal damage), significant pain, mass >35mm, fetal heartbeat on USS, serum HCG >5000
Anti-D immunoglobulin
Follow up to see serum HCG decreasing at acceptable rate
`Up to what age is an early medical abortion (EMA)? Where can this be done?
10/40
Home or clinic
After this until 12 weeks the medical abortion must be done in a clinic
Medical abortion management up to 12/40
Mifepristone- anti-progesterone orally
Vaginal misoprostol- prostaglandin analogue to cause uterine contraction to expel
What to expect from an EMA
Dizziness Flushing Diarrhoea Nausea Period like cramping Vaginal bleeding, may be heavy with clots up to 2/52
Medical abortion management 12/40+
Inpatient stay
Mifepristone followed by 3 hourly misoprostol
Feticide recommended in late second trimester- digoxin or potassium chloride
Surgical abortion options
Vacuum aspiration up to 14/40
Dilation and evacuation 14/40+ (with forceps as well as the vacuum aspiration)
Differentials for continued bleeding after medical or surgical abortion
Retained products of conception- persistent pain and/or bleeding
Infection- endometritis
Contraception
Failure of procedure- uterine perforation
Signs of endometritis
Pain Bleeding Deep dyspareunia Vaginal discharge Fever Cervical motion tenderness
Management of endometritis
Sepsis 6 if systemically unwell
(H) ABCDE if haemodynamically unstable
Broad spectrum antibiotics
Empty uterus if indicated
Signs of tubal rupture and intra-abdominal bleeding
Pallor Tachycardia Hypotension Shock or collapse Shoulder tip pain (from diaphragmatic irritation due to intraperitoneal blood) Vomiting and diarrhoea
What should ALWAYS be checking in a bleeding obstetric history?
Rhesus status
Vaginal bleeding and slight abdominal discomfort 30/40 pregnant differentials
Placenta praevia Placental abruption Endometritis Haemorrhage Trauma Vasa praevia Early labour
Vaginal bleeding and slight abdominal discomfort 30/40
Investigations
History
General examination for signs of haemodynamic compromise
Urine dip
FBC, LFTs, U&Es
Transabdominal ultrasound- looking for placenta
CTG- Fetal heart rate and situation
Speculum examination- trying to localise the cause of bleeding
Factors associated with recurrent miscarriages
Antiphospholipid syndrome DM and thyroid disease PCOS Anatomical malformations- uterine or cervical, fibroids, Asherman's syndrome Infection Lifestyle Advancing maternal age Inherited thrombophilia- factor V leiden
Investigating recurrent miscarriage
Blood tests- antiphospholipid antibodies (anticardiolipin, lupus anticoagulant and glycoprotein B2)
Karotyping
Imaging- pelvic USS
Clinical features of placental abruption
Painful vaginal bleeding (may not be visible if concealed)
Woody hard uterus and may be pain on palpation
May be haemodynamically unstable
Triad of vasa praevia
Vaginal bleeding
Rupture of membranes
Fetal compromise (rapid deterioration due to loss of fetal blood from the umbilical cord vessels)
Investigations for placental abruption
FBC, clotting profile
Kleihauer test- to determine amount of anti-D required
Group and save- if unknown
Cross match
U&Es, LFTs- HELLP
Ultrasound scan- poor negative predictive value though
Management of placental abruption
Conservative- marginal abruption no compromise
Induction of labour
Emergency delivery if mother or fetal compromise- C/section
ANTI-D within 72 if rhesus negative
Clinical features of placenta praevia
Classically painless vaginal bleeding
Useful questions to ask regarding antepartum haemorrhage
How much bleeding and timescale (how many pads) Details of the blood Could the waters have broken Provoked or not Abdo pain Fetal movements normal Risk factors for abruption
Differentials for antepartum haemorrhage
Placental abruption
Placenta praevia
Vasa previa
Uterine rupture
Local genital causes- polyps, carcinoma, ectropion
Traumatic
Infections- candida, bacterial vaginosis, chlamydia
Placenta praevia management
Minor or major USS scans at 36 and 32 weeks respectively
Planned C-section at 38 weeks
ABCDE if significant haemorrhage
Give anti-D within 72 hours of onset of bleeding if rhesus negative
High risk factors for pre-eclampsia
Chronic HTN
previous pregnancy HTN, pre or eclampsia
CKD
DM
Autoimmune diseases- SLE, antiphospholipid syndrome
Prophylaxis for pre-eclampsia
75mg daily aspirin if 1 high risk factor or 2 moderate risk factors
From 12 weeks
Clinical features of pre-eclampsia
Including criteria
HTN on two occasions
Significant proteinuria
In a women >20 weeks pregnant
Headaches, blurred vision, halos, photopsia, epigastric pain, sudden onset oedema, hyperreflexia
Complications of pre-eclampsia
HELLP syndrome Eclampsia DIC AKI ARDS HTN post-partum Cerebrovascular haemorrhage Death
Fetal- growth restriction, placental abruption, death
Pregnancy induced hypertension
New onset after 20 weeks gestation
Management of pre-eclampsia
Monitoring of maternal and fetal wellbeing- regular blood pressure check, urinalysis, blood tests, fetal growth scans and cardiotocography
Venous thromboembolism prevention- low molecular weight heparin
Antihypertensives- labetalol (1) or nifedipine (2) or methyldopa
Delivery- the definitive cure
Monitor mother until 24 hours post-partum
To diagnose hyperemesis gravidarum
More than 5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalances
Management of hyperemesis gravidarum
Mild- community, oral antiemetics, oral hydration, dietary advice, reassurance
Moderate- ambulatory daycare- IV fluids, parenteral antiemetics and thiamine
Severe- inpatient care
Fetal complications of gestational diabetes
Macrosomia Organomegaly Erythropoiesis Polyhydramnios Increased rates of pre-term delivery
Gestational diabetes plasma glucose tests
Fasting >5.6mmol/L
2hr post-prandial >7.8mmol/L
Management of gestational diabetes
Patient education and careful monitoring and control of BM
Consultant lead care
Metformin (1) Sulphonylurea (2)
Insulin if fasting glucose >7.0mmol/L at diagnosis
Aim to deliver 37-38 weeks
What is the definition of a major PPH?
> 1000ml of blood loss within 24 hours of delivery
Causes of primary post-partum haemorrhage
Tone- uterine atony- inadequate contraction
Tissue- retention, preventing uterine contraction
Trauma- vaginal or cervical tears- instrumental, episiotomy, C-section
Thrombin- vascular abnormalities (abruption, HTN, pre-eclampsia) or coagulopathies (von Willebrand’s disease, haemophilia, ITP, DIC, HELLP)
Clinical features of PPH
PV bleeding
May be signs of hypovolaemia
May be signs of local trauma
Management of PPH
HINT: TRIM
Teamwork
Resuscitation- ABCDE Protect airway 15L of 100% via non-rebreathe Cap refill, HR, BP and ECG monitoring, two large 14G cannulas, give cross matched blood, up to 2L of warmed crystalloid and 1-2L of warmed colloids until blood available Monitor GCS Expose to identify bleeding sources
Investigations and monitoring- every 15 mins, consider catheter and central line insertion
Measures to arrest bleeding
Atony- Bimanual compression, pharmacological management, surgical intrauterine balloon tamponade
Hysterectomy always last resort
Repair of any trauma
Administration of oxytocin to remove placenta, or manual removal
Correction of coagulation abnormalities with haematology team advice
Obstetric history
Previous obstetric history - gestation period - mode of delivery - gender - birth weight - complications (any assistance required) - who was involved in the care - miscarriages/ terminations/ gestation periods of these/ ectopics GRAVIDITY and PARITY
Current pregnancy Gestational age and EDD Use of folate Singleton or multiple Any screening- any fetal anomalies Placenta position Amniotic fluid index
Gynaecological history
PC- type and site of symptoms, timing (cyclical, continuous/intermittent), exacerbating and relieving factors, previous episodes + treatment, other symptoms
PV bleeding- intermenstrual, post-coital, post-menopausal
SOCRATES
Vaginal discharge- colour, consistency, amount, smell
Menstrual history- frequency, duration, volume
Other symptoms- dyspareunia, vulval itching, skin changes, infertility- assisted conception, investigations
PMH- pregnancies, deliveries, complications
Cervical smear
Surgical history
Previous gynae problems or STIs
DH- allergies, contraception, HRT, recent abx, any other (recreational or OTC)
FH- Breast/ cervical/ ovarian/ endometrial cancer
DM, bleeding disorders
Causes of post-coital bleeding
Cervical ectropion
Infection
Vaginitis
Malignancy
Causes of intermenstrual bleeding
Infection Malignancy Fibroids Endometriosis Pregnancy Hormonal contraception
Causes of post-menopausal bleeding
Malignancy
Vaginal atropy
HRT use
Clinical features of uterine fibroids
Majority asymptomatic Pressure symptoms +/- abdo distension- constipation, urinary retention Menorrhagia Subfertility Red degeneration- acute pelvic pain
Investigations for uterine fibroids
Routine bloods if unclear what the diagnosis is
Pelvic ultrasound
Management of uterine fibroids
Medical- tranexamic or mefenamic acid
Hormonal contraception to control menorrhagia- COCP, POP and Mirena IUS
GnRH analogues, progesterone receptor modulators
Surgical- hysteroscopy and transcervical resection of fibroid
Myomectomy- to preserve uterus
Uterine artery embolisation
Last resort hysterectomy
Clinical features of endometriosis
Cyclical pelvic pain
Dysmenorrhoea, dyspareunia, dysuria, subfertility
O/E, general tenderness, may be nodularity
Differentials of endometriosis
PID
Ectopic pregnancy
Fibroids
IBS
Investigating endometriosis
Pelvic USS
Gold standard is laparoscopy- chocolate cysts, adhesions, peritoneal deposits
Management of endometriosis
Pain- NSAIDs
Medical- Ovulation suppression for 6 months can cause atrophy of the lesions- COCP, progesterone agonist or Mirena coil
Surgical- excision, fulgaration (destruction with diathermy), laser ablation
Risk factors for endometrial cancer
Early menarche/ late menopause Low parity PCOS- due to oligomenorrhoea HRT with oestrogen alone Tamoxifen use Increasing age Obesity Hereditary factors that predispose to cancer- Lynch syndrome
Clinical features of endometrial cancer
Post-menopausal bleeding - 75-90% present like this
Clear or white vaginal discharge
Abdo pain or weight loss if advanced
Investigations for endometrial cancer
Transvaginal ultrasound
if >4mm then endometrial biopsy
If high risk case then hysteroscopy with biopsy
FIGO staging
Management of endometrial cancer
MDT and supportive therapy
Stage dependent
Hysterectomy and bilateral salpingo-oophorectomy even at stage 1, any larger and radical with radiotherapy and chemotherapy
Hyperplasia or atypia may precede malignancy and should be treated and surveyed
Causes of heavy menstrual bleeding
Polyp Adenomyosis Leiomyoma (fibroids) Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not classified
Investigating heavy menstrual bleeding
FBC, TFT, other hormones if suspicious (prolactin)
Coag screen and test for von Willebrand’s disease
USS pelvis- transvaginal
Smear up to date
High vaginal and endocervical swabs for infection
Pipelle endometrial biopsy
If pathology identified or inconclusive- hysteroscopy and endometrial biopsy
Management of heavy menstrual bleeding
Mirena coil if contraception needed
Tranexamic acid or mefenamic acid if not
COCP or POP
Surgical- endometrial ablation or hysterectomy
Two most common hormonal abnormalities in PCOS
Excess luteinising hormone- generating too many androgens
Insulin resistance
Clinical features of PCOS
Oligomenorrhoea or amenorrhoea Infertility Hirsutism/ acne/ acanthosis nigricans/ male pattern baldness Obesity Chronic pelvic pain Depression
Differentials for PCOS
Hypothyroidism
Hyperprolactinaemia
Cushing’s disease
Investigating PCOS
Blood tests- raised testosterone, raised LH, normal FSH, low progesterone, TFTs, serum prolactin, oral glucose tolerance test
Imaging- pelvic USS- transvaginal
Managing PCOS
Weight management through lifestyle changes
Induction of bleeds through COCP use to protect the endometrium from hyperplasia
Infertility- clomifene +/- metformin
Anti-androgen medication- spironolactone can lower levels
