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.
