Obstetrics and Gynaecology Flashcards
What should be suspected in a patient that presents with hyperemesis, irregular 1st trimester vaginal bleeding, uterus large for dates, vaginal passage of vesicles with products of conception, and positive serum hCG? How to diagnose and treat it?
Gestational trophoblastic disease should be suspected. GTD covers a spectrum of diseases caused by overgrowth of the placenta, ranging from molar pregnancies to malignant conditions such as choriocarcinoma.
USG shows findings of a complete mole - “snowstorm” appearance of mixed echogenity, representing hydropic villi and intrauterine haemorrhage, and large theca lutein cysts
Management
- surgical evacuation: histological examination of products of conception is essential to confirm diagnosis
- 2-weekly serum and urine samples until hCG concentrations are normal
In hydatiform mole, hCG levels are raised excessively. It’s important to measure hCG levels after surgical evacuation, when they are expected to return to normal. If they don’t go down or they plateau, chemotherapy is indicated. That’s why it’s important to not get pregnant during management of GTD
What are the features and management of HELLP syndrome?
HELLP syndrome is a serious complication seen in about 5% of cases of severe pre-eclampsia, which manifests as
H - haemolysis
EL - elevated liver enzymes
LP - low platelet count
The syndrome is usually self-limiting, but permanent liver or renal damage may occur. Eclampsia may co-exist.
Features
- epigastric or RUQ pain and tenderness
- nausea and vomiting
- “tea-coloured” urina due to haemolysis
- increased BP and other features of pre-eclampsia
Investigations: liver function test, renal function test, blood count
Management
- urgent delivery
- magnesium sulfate for eclampsia
How to treat menorrhagia?
- Levonorgestrel-releasing intrauterine system
- Tranexamic acid or NSAIDs or combined oral contraceptives
- Norethisterona (15mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progesterons
If contraception is desired, consider Mirena, COCP and injected long-acting progestogens
- tranexamic acid + NSAIDs if menorrhagia + dysmenorrhoea
- NSAIDs + COCP if dysmenorrhoea is problematic
- mefenamic acid if dysmenorrhoeae in a young girl
How to treat constipation in pregnancy?
1st. ispaghula husk
2nd. lactulose
What is the gold standard investigation of endometriosis, and who isn’t it performed everytime?
Gold-standard investigation for endometriosis is laparoscopy (treatment is often done too during this procedure by ablating endometriosis lesions if they are found).
Medical management is usually tried first, prior to any surgical methods
- NSAIDs to treat pain
- COCP
- Levonorgestrel intrauterine system
This means in the majority of cases, we wouldn’t perform a gold standard laparoscopy to diagnose the condition first, but rather attempt to treat it medically with NSAIDs and hormonal therapy. If the symptoms improve with medical therapy, there mat not be a need for laparoscopy, and we would treat on the basis of suspected endometriosis.
How to manage a 6 week presumed pregnancy that presents with one episode of vaginal bleeding that already stopped, and in which the US shows no fetal heart activity?
No need to perform a hCG since the US confirmed the pregnancy.
If the crown rump length is less than 7mm, or gestational sac diameter is less than 25mm: rescan in 7 days since it may still be too early to see a heartbeat. A fetal heartbeatcan usually be seen at 5 weeks gestation but some may be seen later.
If the crown rump length is more than 7mm, or gestational sac diameter is more than 25 mm, we would expect the fetus to be big enough to see cardiac activity. If this is not seen, it’s likely a non-viable pregnancy. The diagnosis of miscarriage using 1 US scan is never 100% accurate. For that reason, we always get a second opinion or repeat the scan in a weeks time.
When would a pregnant woman receive oral and IV aciclovir following exposure to chickenpox? And when is IVIG given to the baby?
If the woman has no history of immunity (previous infection or varicella vaccines) with a negative serology IgG test, they will get oral aciclovir.
If they develop a rash, they will get oral or IV aciclovir, depending on the severity.
If the mother develops a chicken pox rash between 7 days before and 7 days after birth, there’s a risk of neonatal varicella, which may be fatal to the newborn child, so IVIG is given to the neonate
Varicella-zoster immunoglobulin are only given to pregnant women if they have not been immune to VZV and oral acyclovir is contraindicated, and they have had significant exposure but haven’t developed any symptoms yet
How to diagnose menopause?
- women with 45 yo or above - symptoms and changes in menstrual pattern
- women with less than 45 yo - two FSH taken 4-8 weeks apart
FSH more than 40 U/L is elevated
Women with premature ovarian failure also have low estradiol (less than 50 pmol/L)
A transvaginal US may be considered for women with atypical symptoms of menopause, which would involve heavy irregular bleeding, to investigate endometrial thickness and exclude endometrial cancer
Early menopause is used for women who go through their menopause between 40-45 years
How should an ectopic pregnancy be managed?
If haemodynamically stable - laparoscopic salpingectomy or salpingostomy
If haemodynamically unstable - laparotomy (open salpingectomy or salpingostomy)
Methotrexate would be used if there’s a suboptimal fall or rise in bHCG in a patient who is not in significant pain. It can only be given if the patient meets all the criteria below:
- not in significant pain
- haemodynamically stable
- adnexal mass smaller than 35mm with no fetal heart visible
- no intrauterine pregnancy
- serum hCG less than 5000 UI/L (ideally less than 1500 UI/L)
- able to return for follow-up
(methotrexate will unlikely be the answer since there are so many criteria to meet)
What to suspect in a patient that presents with ascites, pleural effusion (exsudate), fatigue and pelvic pain?
Meigs’ syndrome, that has benign ovarian tumour, ascites and pleural effusion as key features. It’s a diagnose of exclusion, and symptoms resolve after removal of the ovarian mass.
What are the values of haemoglobin that define anaemia in pregnancy?
Hb levels of
< 110 g/L in the 1st trimester
< 105 g/L in 2nd and 3rd trimesters
< 100 g/L in the postpartum period
What organisms usually cause PID and how should it be treated?
Causative organisms
- Chlamydia trachomatis - most common cause
- Neisseria gonorrhoeae
Management
- outpatient: ceftriaxone 500mg IM single dose + doxycycline (or ofloxacin) 100mg PO twice daily + metronidazole 400mg PO twice daily for 14 days
- inpatient: ceftriaxone 2g IV daily + dexycycline 100mg IV twice daily followed by doxycycline 100mg PO twice daily + metronidazole 400mg PO twice daily for 14 days
- IU devices may be left in if mild case of PID; but removal of IUD should be considered and may be associated with better short term clinical outcomes
If just cervicitis (Chlamydia): doxycycline 100mg PO twice daily for 7 days + azithromycin 1g PO single dose followed by 500mg PO once daily for 2 days
If just cervicitis (Neisseria gonorrhoeae)
- ceftriaxone 1g IM single dose
How should premature ovarian failure be managed?
Hormone replacement therapy until at least the average age of menopause, which is 51 years old
How to differentiate cervicitis from PID?
PID
- sexually active with multiple partners
- menstrual irregularities
- lower abdominal pain
- deep dyspareunia
Cervicitis
- presents with discharge
- can ascend to cause PID
- no menstrual irregularities or lower abdominal pain
What are the indications for a colposcopy?
- abnormal cervical cytology on cervical screening - most common reason
- women with symptoms of cervical cancer (postcoital bleeding or persistent vaginal discharge with infection ruled out)
- cervical polyps that cause bleeding
- ectropion that causes postcoital bleeding
No matter what, if there’s an unexplained bleeding that lasts more than 6-8 weeks, refer to colposcopy
Cervical smears are never the answer for symptomatic women
What are the 3 types of HRT and its indications?
Women who need treatment for vasomotor symptoms postmenopausally should be given HRT for up to 5 years.
Oestrogen-only HRT
- used in women who have had a hysterectomy or an IU system in situ
Sequential (cyclical) combined HRT
- used in peri-menopausal women who are still menstruating or are within 12 months of their last period
- sequential combined HRT is where oestrogen is taken every day, and progestogen is taken sequentially (usually for the last 14 days of menstrual cycle) to induce a bleed
- patients are often switched to continuous combined HRT after 12 months
Continuous combined HRT
- used in menopausal women (who had thei last period more than 12 months ago)
- oestrogen and progestogen doses are taken daily
- the rationale is to prevent endometrial hyperplasia which could lead to endometrial cancer, if only oestrogen preparation is used
Smoking is not a contraindication of HRT, but it should be given as transdermal HRT, which doesn’t increase the risk of DVT
Irregular breakthrough bleeding or spotting is common in the first 4-6 months of treatment with a continuous combined HRT. Reassurance is all that’s required. Only investigate further if bleeding persists beyond 6 months, bleeding becomes abnormally heavy, or bleeding occurs after a period of amenorrhoea while on HRT
Which exam should always be ordered in a postmenopausal woman that presents with vaginal bleeding?
Transvaginal US to determine endometrial thickness, as there’s a risk of endometrial cancer.
If the endometrium is thick, hysteroscopy with endometrial biopsy should be arranged.
Atrophic vaginitis could also cause postmenopausal bleeding or postcoital bleeding (most common cause), but it’s important to rule out cancer.
How to manage first episode and recurrent genital herpes in pregnancy?
First episode
- first and second trimesters: aciclovir 400mg 3x/day for 5 days followed by supressive aciclovir 400mg 3x/day from 36 weeks of gestation to reduce the risk of HSV lesions at term (and hence, the need for delivery by c-section)
- third trimester: aciclovir 400mg 3x/day for 5 days followed by supressive aciclovir 400mg 3x/day until delivery. C-section should be recommended due to the high risk of neonatal transmission during vaginal delivery
Recurrent episodes
- inform that the risk of neonatal herpes is low, even if lesions are present at the time of vaginal delivery
- aciclovir 400mg 3x/day should be considered from 36 weeks of gestation
What is the main hormone to confirm ovulation?
Mid-luteal phase progesterone. The sample should be done 7 days before an expected period
How should pelvic organ prolapse be managed?
Non-surgical management
- if evidence of vaginal atrophy - vaginal oestrogen
- if POP-Q stage 1 or 2 - consider pelvic floor muscle training as first-line (stage 2 is prolapse at the level of the introitus)
- any stage + symptoms - vaginal pessary
Surgical management: women who didn’t improve or declided non-surgical
What is the only safe mode of contraception for patients with migraine with aura?
Copper IU device.
COCP - UKMEC 4 - ABSOLUTE CONTRAINDICATION
Mirena IUD - UKMEC 2
progesteron-only methods (pill, injectables, implants) - UKMEC 2
What constitutes chronic hypertension, gestational hypertension, pre-eclampsia, severe pre-eclampsia, eclampsia, and HELLP syndrome?
Chronic hypertension
- PA over 140/90 before 20 weeks of gestation
Gestational hypertension
- new PA over 140/90 after 20 weeks of gestation w/o significant proteinuria
Pre-eclampsia
- gestational hypertension with proteinuria
- proteinuria can be: equal to or above 0.3g in 24-hour urine; equal to or above 30mg/mmol in protein/creatinine ratio; or equal to or above 8 mg/mmol ACR
Severe pre-eclampsia
- pre-eclampsia with BP over 160/110
or
- pre-eclampsia + recurring headaches, visual scotoma, epigastric pain, rising creatinine, rising liver transaminases or falling platelets
Eclampsia
- pre-eclampsia + seizures
Seizure control: 4g magnesium sulphate over 5 minutes
HELLP syndrome
- severe form of pre-eclampsia associated with Haemolysis, Elevated Liver enzymer, and Low Platelets
What vaccines are offered to pregnant women in the UK?
Influenza and pertussis (combined with polio, diphteria and tetanus) vaccines.
What should be suspected in a patient that presents with RIF pain, vomit, fever, USG showing ovarian cyst with reduced or normal vascularity?
What is the most appropriate action for AE doctor?
Ovarian torsion.
Refer to gynaecology on-call.
Suspect in every patient that seems to have PID, but presents without vaginal discharge.
What test should be ordered in a patient with vaginal discharge and post-coital bleeding?
Vulvovaginal swab for NAATs for chlamydia or Neisseria gonorrhoeae.
A high vaginal swab would be ordered if suspected vaginosis, trichomonas, group B strep and yeast infections; or if the patient had recurrent symptoms, treatment failure, pregnancy, postpartum, post-abortion or post-instrumentation.
A 65 yo patient is diagnosed with breast cancer and was givan tamoxifen. Which symptom would be the most alarming and why?
Vaginal bleeding, since tamoxifen is a risk factor for endometrial carcinoma.
What is the safest contraception for patient with history of DVT?
IU copper device - UKMEC 1.
Other methods:
Mirena - UKMEC 2
Progesteron-only implants - UKMEC 2
Depo-provera injections - UKMEC 2
Progesteron only pill - UKMEC 2
If the patient also suffers from menorrhagia, Mirena would be the best option despite being UKMEC 2, because IU copper devic would be UKMEC 2 in this case, and the Mirena coil would benefit the heavy bleeding.
- history of DVT + no menorrhagia - IUCD
- history of DVT + menorrhagia - Mirena coil
Which antihypertensive drug should be prescribed in pregnancy? Which of those are safe for breastfeeding?
- start with labetalol (except if asthmatic patient)
- if labetalol not suitable, pick nifedipine
- if none suitable, pick methyldopa (increased risk of postnatal depression)
All three are safe for breastfeeding.
All ARB and ACEI are unsafe for pregnancy.
What should be suspected in a patient with ascites and a pelvic abdominal mass? Which exams should be ordered? What are the risk and protective factors?
Ovarian cancer, which need urgent referral to gynecology team.
Exams: CA-125 + USG
Risk factors
- increasing age
- gene mutations (BRCA1/ BRCA2)
- family history of ovarian cancer
- nulliparity
- tocacco smoking
- obesity
Protective factors
- COCP
- pregnancy
What should be suspected in a pregnant patient what presents with abdominal pain, a tender/hard uterus and fetal distress seen on CTG?
Placental abruption.
Premature separation of a normally placed placnta, resulting in maternal haemorrhage behind the placenta or lost through cervix. Management is resuscitation and delivery if presence of fetal distress or maternal compromise.
How to treat ITU in pregnancy?
1st choice: nitrofurantoin, unless at term
2nd: cefalexin (no need to worry about patient’s trimester, can be used to treat both lower and upper UTI)
3rd: amoxicillin (or if cultures available)
trimethoprim can lead to neural tube defects in the 1st trimester
What are the stages of labour?
Stage 1
- from onset of true labour to when the cervix is fully dilated
- divided into latent and active phase
- latent phase - begins with onset of regular contractions and ends with the acceleration of cervical dilation
- active phase - begins with cervical dilation acceleration, usually at 4cm, ends with complete cervical dilation
Stage 2
- from full dilation to delivery of the fetus
Stage 3
- from delivery of the fetus to when the placenta and membranes have been completely delivered
How to diagnose and treat polycystic ovarian syndrome?
Diagnosis - Rotterdam criteria (must have 2 out of three)
- US - polycystic ovaries (either 20 or more follicles or increased ovarian volume)
- oligo-ovulation or anovulation
- clinical and or/biochemical signs of hyperandrogenism (elevated free androgen of more than 5)
Management
- general: weight loss
- menstrual irregularities: COCP, cyclical progestogen or levonorgestrel intrauterine system
- infertility: weight loss to achieve spontaneous ovulation, clomifere citrate, then consider adding metformin (not first line, don’t pick in the exam), gonadotropins or consider laparoscopic ovarian drilling
What are the rules for COCP missed pills?
If one pill is missed (at any time in the cicle)
- take the last pill as soon as possible, even if it means taking 2 at once
- continue with the rest of the pack as usual
- no additional contraceptive protection needed
If 2 or more pills missed
- take the last pill as soon as possible, even if it means taking 2 at once
- the woman should abstain from UPSI until she has taken pills for 7 days in a row
- if missed in week 1 + UPSI in the free interval or in week 1 = emergency contraception
- if missed in week 2 = no need for emergency contraception
- if missed in week 3 = no need for emergency contraception but the woman should omit the pill-free interval and start the new pack of pills in the day after finishing the current pack
General tips
- if you took more than 1 week on COCP, no need for emergency contraception even if missed 2 pills
- if taking POP, you only need emergency contracepcion if UPSI ocurred after the missed pill and within 48 hours of restarting POP
In which scenarios are COCP unlikely to be appropriate?
- history of VTE or family history of VTE
- migraine with aura
- BMI more than 30
- smoker or ex-smoker
- history of breast cancer or carrier of gene mutations BRCA1/BRCA2
- hypertension (even if adequately controlled)
How to differentiate polycystic ovarian syndrome from premature ovarian failure?
PCOS
- normal FSH
- increased LH
- oestradiol normal
- prolactin normal
POF
- increased FSH (diagnostic criteria - elevated FSH level > 25 in 2 occasions > 4 weeks apart)
- increased LH
- decreased oestradiol
What should be suspected in a woman with 3 previous miscarriages, all in her first semester?
Antiphospholipid syndrome.
All women with recurrent first trimester miscarriage and all women with one or more second-trimester miscarriage should be screened before pregnancy for antiphospholipid antibodies.
Management
- aspirin 75mg + heparin to lower risk of further miscarriage
- cared by haematologists and obstetricians throughout pregnancy
What are the clinchers related to contraception (younger woman with menorrhagia, sexually active woman with menorrhagia and sickle cell disease, emergency contraception)?
Young woman, not sexually active (don’t require contraception)
- with menorrhagia only - IUS first line
- tranexamic acid - more useful for menorrhagia (after IUS)
- mefenamic acid - more useful for dysmenorrhoea
Sexually active woman (require contraception)
- menorrhagia/dysmenorrhoea or those suffering from fibroids which do not disturb the uterine cavity - IUS mirena (first-line), unless it’s a woman younger than 20 yo (UKMEC 2), then COCP, POP or implant would be more appropriate
- woman with sickle cell disease and menorrhagia - depo-provera IM (redices the frequency and severity of painful crises)
Emergency contraception
- within 72h of unprotected sex -levonelle pill
- within 120h of unprotected sex - IUCD or ellaOne pill
What is the recommended time to administer anti-D immunoglobulins to a previously non sensitised rhesus negative mother after delivery?
As soon as possible and always within 72 hours. If not possible, it can still be administered up to 10 days, as there may still be some protection offered during this time.
What are the hystological changes, symptoms and management of cervical ectropion?
Hystology changes: replacement of stratifies sequamous epithelium that normally lines ectocervix by columnar epithelium, just like in Barret’s oesophagus.
Usually assymptomatic, can cause post-coital bleeding or excessive non-purulent discharge.
Managed if symptoms are bothersome, including cautery with silver nitrate, diathermy and cryotherapy.
What should be suspected and how to manage a patient that presents with low lying placenta at 20 weeks US, and post coital bleeding?
Placenta praevia.
Management
- perform a speculum examination to check for vaginal wall or cervix lacerations that could also explain the bleeding
- arrange a routine US at 32 weeks to check if the placenta has migrated upwards
- advice the patient to avoid sexual intercourse
Never perform a digital cervical assessment!
How to manage stress incontinence and urge incontinence?
Stress incontinence
- pelvic floor exercise is the initial treatment of choice, at least 8 contractions performed 3x a day for at least 3 months
- surgical procedures (retropubic mid-urethral tape procedures may be required)
- duloxetine is used for those who are not surgical candidates
Urge incontinence
- bladder retraining (minimum of 6 weeks) - the idea is to gradually increase the intervals between voiding
- bladder stabilising drugs: antimuscarinic agents are first-line. NICE recommends oxybutinin, tolterodine or darifenacin
What are the routine blood tests performed at 10 weeks during pregnancy?
- blood group and antibodies
- rhesus status
- haemoglobinopathies
- syphilis
- hepatitis B status
- HIV
- full blood count looking for anaemia
How should a woman who presents with reduced fetal movements be managed?
1st: listen to fetal heart using a handheld doppler devide to exclude fetal death
2nd: perform a CTG (if beyong 28 weeks of gestation) to exclude fetal compromise
