Obstetrics and Gynaecology 2 Flashcards
Define Post-Partum Haemorrhage
What are the RCOG classifications?
PPH is bleeding from the genital tract in excess of 500 mls within 24 hours of the birth of a baby.
Minor: 500 - 1000 ml
moderate: 1000 - 2000 ml
severe: 2000 ml
What are the main causes of Post Partum Haemorrhage?
The four T's Tone Tissue Trauma Thrombin
Uterine atony accounts for 80% of cases of major post partum haemorrhage.
Others include retained or morbidly adherent placental tissue, uterine and genital tract trauma, surgical haemorrhage, or coagulopathy secondary to abruption, sepsis, pre-eclampsia or amniotic fluid embolus.
What is primary dysmenorrhoea?
What is secondary dysmenorrhoea?
Primary Dysmenorrhoea occurs in females with no pelvic pathology (50% of women 10% severe) usually coincides with the start of menstruation
Secondary occurs in association with some form of pelvic pathology
What features make primary dysmenorrhoea likely?
- Menstrual pain starting 6-12 months after menarche, once cycles are regular
- Pain starts shortly before the onset of menstruation, and last for up to 72 hours, improving as the menses progresses.
3. Non-gynaecological symptoms such as: nausea, vomiting, migraine, bloating, emotional symptoms are present.
- Other gynaecological symptoms are not present.
- Pelvic examination is normal.
What is the normal treatment for primary dysmenorrhoea
N.B. what is treatment pathway after initial treatment?
What is not recommended?
Offer NSAIDS such as:
ibuprofen, naproxen or mefenamic acid unless contraindicated.
Be aware mefanamic acid is more likely to cause seizures in O.D. (also be aware there is a low therapeutic window)
Paracetamol if NSAIDs not tolerated or in addition to.
If the women doesn’t wish to concieve consider
3-6 months trial of hormonal contraception.
Monophasic COCP
Oral - desogestrel 75 mg
Parenteral (depo-provera, nexplanon)
Intrauertine progestogen only (Mirena)
Consider also
local application of heat
Transcutaneous electrical nerve stimulation - to a high frequency.
RCOG guidelines recommend that women with cyclic pain should be offered a therapeutic trial of hormonal treatment for a period of 3 to 6 months before having a diagnostic laparoscopy - to look for endometriosis.
Weak opioids are not recommended.
Neither are herbal, dietary, acupuncture, acupressure, spinal manipulation, behavioural therapy and exercise - due to lack of good quality evidence.
List some causes of secondary dysmenorrhoea and their indications
(4/5)
- Endometriosis/Adenomyosis - cyclical or chronic pelvic pain, frequently occurring prior to menstruation and accompanied by heavy menstrual bleeding and deep dysparenunia. Rectal pain or bleeding may indicate recto-vaginal endometriosis.
- Fibroids (leiomyomas) - Lower abdominal pain, frequently accompanied by heavy menstrual bleeding; a pelvic mass may be identified on examination.
- Pelvic inflammatory disease - lower abdominal pain and tenderness that may be accompanied by dyspareunia, abnormal vaginal bleeding, and abnormal vaginal discharge. In acute infection, fever may be present
- Intrauterine device insertion (IUD) 3 - 6 months previously usually. Pain may be accompanied by longer and heavier periods, often with intermenstrual bleeding or spotting. -Consider removal and alternative.
- Also consider ovarian tumours.
One line description of dysmenorrhoea
Painful menstruation, associated with high prostaglandin levels in the endometrium causing contraction and uterine ischaemia.
What is endometriosis?
Where do you classically find it?
The presence and growth of endometrial-like tissue outside the uterus which induces a chronic, inflammatory reaction.
Affecting 1-2% of women
It is estrogen dependent, and therefor mostly effects their productive years.
N.B. if it is within the myometrium itself it is called adenomyosis
It can occur throughout the pelvis, particularly the uterosacral ligaments, and on or behind the ovaries. Accumulated blood is dark brown and can form a chocolate cyst or endometrioma on the ovaries.
What are the symptoms of endometriosis? How can they be classified?
Gynaecological: Dysmenorrhoea Non-cyclical pelvic pain deep dysparenunia infertility fatigue in the presence of any of the above
Non-gynaecological cyclical symptoms: dyschezia (difficult of painful defecation) dysuria haematuria rectal bleeding shoulder pain
also consider IBS and PID
What are some investigations for use in endometriosis?
TV USS to diagnose or exclude an ovarian ednometrioma
TV USS is useful for identifying or ruling out rectal endometriosis
Laproscopy with histology
What are the treatments for endometriosis?
Remember how are they categorised?
Medical treatments
In primary care: Depending on the women’s preferences.
- Pain relief via NSAIDS - ibuprofen, naproxen or mefenamic acid (though more dangerous in overdose)
+/- paracetamol or alone - If the women doesn’t wish to conceive then a 3-6 month trial of hormone contraceptive
a) COCP 3 months of conventional and then tricycling or continuous use if this is in adequate (taking 3 boxes after each other to stop withdrawal bleeds)
b) oral desogestrel (POP) depot, subdermal implant (nexplanon) and IUS Mirena. after discussion of the advantages and disadvantages.
C) non-contraceptive progestogens - medroxyprogesterone or norethisterone
- combination of the above
In secondary care:
- Gondadotrophin-releasing hormone (GnRH) analogues - initially stimulate then inhibiti secretion due to pituitary downregulation followed by anovulation, markedly reduced oestrogen and amenorrhoea, inducing a reversible menopause
N.B. Add back HRT should be initiated to reduce post menopausal symptoms and bone mineral density loss. (otherwise only 6 months, with HRT 2 years+)
Surgical treatments:
- Excision or ablation of endometriosis deposits
- laparoscopic - diathermy, laser ablation or excision of deposits, ovarian cystectomy
- radical surgery - total abdominal hysterectomy and slapingo-oopherectomy. BSO
What is the aetiology of endometriosis?
Clinically what is good to remember?
Whats the prevalence?
The most popular theory is the retrograde menstruation theory.
Though more distant foci may result from mechanical, lymphatic or blood-borne spread.
Affected women do have an impaired immune system and evidence of neuro and angiogenic activity causing pain. Genetic linkage suggests a degree of inheritence.
Remember there is little correlation between severity of symptoms and severity of apparent disease on laparoscopy.
1 in 10 women of reproductive age in the UK.
What is chronic pelvic pain? What is important?
An intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.
It is a symptom not a diagnosis!
N.B. CPP presents to primary care as frequently as migraine or low-back pain. Affecting approx 15% of adult women. Carrying a heavy social and economic price.
Possible causes of Chronic Pelvic Pain
- Endometriosis/Adenomyosis _ with cyclical pain
- Irritable Bowel Syndrome
- Interstitial Cystitis (painful bladder syndrome)
- Psychological factors are important as depression and sleep disorders are common. A number give history of childhood and/or ongoing sexual or physical abuse.
- Dense vascular adhesions (caused by endometriosis, previous surgery or previous infection)
- Musculoskeletal pain -trigger points and spasm of the pelvic floor - Rx botulinum injx
? Pelvic congestion syndrome or myofascial syndrome.
What is important to cover in the Chronic Pelvic Pain consultation?
the Woman’s ICE
Ideas about the pain
Concerns
Expectations
What examinations in Chronic Pelvic Pain are important?
Abdominal and Pelvic - identify focal tenderness, enlargement, distortion or tethering or prolapse. +/- trigger points.
What investigations are important in Chronic Pelvic Pain?
- Screen for infection - Chlamydia, Gonorrhoea, Bacterial Vaginosis and Trichomonas Vaginalis.
Transvaginal Scanning
to idenitify and assess adnexal masses
MRI and TVS for adenomyosis
Does a positive endocervical sample diagnose PID?
No. It supports it.
Equally a negative result does not rule out the diagnosis of PID.
PID is best managed with a GUM physician.
What symptoms would prompt a CA125
More than 12 times per month of (3x per week)
- Bloating
- Early satiety
- Pelvic pain
- Urinary urgency or frequency
- Over 50 new symptoms of IBS
RCOG guidelines
Chronic Pelvic Pain treatments?
1) if cyclical trial endometriosis treatment of 3-6 months of hormonal treatment before diagnostic laparoscopy + biopsy _ this can also be effective for non-endometriosis related cyclical pain.
2) IBS treat with antispasmodics + modify the diet.
3) offer analgesia (NSAIDS +/- paracetamol
